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This is to certify that the

dissertation entitled
THE RELATIONSHIP OF
LIFE CHANGE HISTORY
AND CONTROL OVER BIRTH
'10 POSTPARTUM BLUES

presented by

MARSHA F. WORBY I

has been accepted towards fulfillment
of the requirements for

Eh. D. «grain—WK

   

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GERALD J. BOSTWICK, Jr. .

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THE RELATIONSHIP OF
LIFE CHANGE HISTORY
AND CONTROL OVER BIRTH
TO POSTPARTUM BLUES

By

Marsha F. morby

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements

for the degree of

DOCTOR OF PHILOSOPHY

School of Social Work

1985

©1986

MARSHA , F. NORBY

All Rights Reserved

ABSTRACT

.THE RELATIONSHIP OF
LIFE CHANCE HISTORY
AND CONTROL OVER BIRTH
TO POSTPARTUM BLUES

By
Marsha F. worby

Postpartum blues occurs within the first few days postpartum
and is characterized by sadness, episodic weeping, irritability,
anxiety, and inablility to concentrate. In this culture the
syndrome is a common and expected emotional reaction following
childbirth. A review cfi’ the postpartum blues literature reveals
studies with biological, psychosocial, and crosscultural
perspectives.

This study explores the relationship of two variables to
postpartum blues. These variables are: a woman's sense of
control over her birthing experience; and a woman's life change
history (both before and during the woman's pregnancy).

This study views postpartum blues as a type of grief response
to the experience of loss related to physical, social and
psychological changes engendered by childbirth. Although often
unacknowledged and less intense, this experience parallels a
grief process.

The study sample consists of 71 women who delivered normal
infants in a community hospital setting which permitted a broad
range of birthing plans and interventions. All deliveries were
considered low risk including those done by cesarean section.

women in the study completed checklists and questionnaires
during the first four days postpartum and responded to telephone

follow-ups ten days post hospitalization. Ten of the women were

Marsha F. morby

interviewed.

Although the study's primary hypotheses were* not
statistically significant some important eumi unexpected findings
emerged. The incidence of postpartum blues in this sample was
lower than that reported in the literature. On the first and
third day postpartum, the study population did not differ from a
normal population CW1 self-report neasures cfi’ depressive affect.
On the second and fourth day, depressive affect was significantly
less than what might occur in a normal population.

women in this sample were able to associate symptoms of the
blues txn particular' concerns in their life situation, and to
their childbirth and postpartum experiences.

These findings suggest that postpartum blues is potentially
modifiable and that the current bias toward biological causation
requires ‘flthher evaluation. Clinical implications cfi' the
findings are discussed and suggestions regarding social work

practice are outlined.

TO MY MOTHER
AND MY DAUGHTERS

ii

ACKNOWLEDGEMENTS

This research was inspired tn/ the spirited creative teaching
of Brigitte Jordan and John Schneider. I am grateful for their
support and interest during early formulations of the study.

My thanks to Gerald Bostwick who gave valuable assistance as
chairperson of my committee and to Victor whiteman whose
expertise in empirical analysis was of great help.

My very special thanks to Martha Karson whose capacity to
provide energy, perspective, and kindness when enthusiasm waned,
made the completion of this enterprise possible.

And more thanks to Brigitte Jordan, who as a member of my
committee, contributed her organizational skills and critical
analysis to the shaping and reshaping of the project.

My deep appreciation to my Cleveland friends, Ann Schorr and
Mim Rosenthal for helping me to find my way in a new environment
and for teaching me new skills.

My gratitude also to the administrative, medical, nursing,
and floor staff of Booth Memorial Hospital of Cleveland who
together allowed me access to their setting and birthing mothers.
Captain Louise Bennett, Marsha Kuhar, Helen Bertosa, Paula
Ziegler, and Polly Sites all pmovided helpful ideas and support
for the project.

My deepest gratitude goes tx) the birthing mothers and their
families for allowing me to intrude on a most critical life
experience.

My sincere and loving appreciation to Laura, Eric, and Paula
worby who continually cheered their mother on to greater
fulfillment.

Finally, accolades to Cy, my .mgst caring, enduring, and

trusted friend.

iii

TABLE OF CONTENTS
Page
LIST OF TABLESOOOOOOOOOOOOOO0.00.00.00.00...OOOOOOOOOOOOOOVi

LIST OF APPENDICESOOOOOOOOOOOOO0.0.0.000...OOOOOOOOOOOOOOOVii

INTRODUCTIUNOO0.0...OOOCOCOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO1

CHAPTER
I. LITERATURE REVIEU...................................
ADJUSTMENT REACTIONS ASSOCIATED wITH CHILDBIRTH...
Psychotic Reactions........................
Postpartum Syndrome........................
Neurotic Oepression........................
POSTPARTUM BLUES..................................

Description-OOOOOOOOOOOOOOOOOOOOOOICOOOOOOI

«TEDUTUTDDD

Incidence.................................. 9

Early Investigations.......................TO
Psychosocial Studies.......................11
Biological Studies.........................13
Crosscultural Studies......................1a
Summary....................................19
POSTPARTUM BLUES: A BRIEF RESPONSE................19
Childbirth and Loss........................19
Mastery of Childbirth Experience...........22

Life Change................................25
HYPOTHESES.......................................27

II. METHOD

OVERVIEw.........................................3O
SETTING..........................................SO
SAMPLE...........................................31
PROCEDURE................. ........... ............32

iv

INSTRUMENTS
Postpartum Blues...........................34
Control Over Birth.........................37
Life Change History........................39
Time Period.............................42
Interview..................................42
The Birth Story.........................43

Critical Issues.........................43
pILDT STUDY...OOOOOOOIOOOOOOO...00.00.000.000000044

Revisions..................................44

III. ANALYSIS OF RESULTS
INTRODUCTION.....................................46
DESCRIPTION OF SAMPLE............................47
RESULTS OF HYPOTHESIS TESTS......................51
COMPARISON OF DACL NORMS AND SAMPLE DACL MEANS...SB
FOLLOw-UP DATA...................................SB
ADDITIONAL FINDINGS..............................59
QUALITATIVE DATA.................................BO
Blues Ouestionnaire........................6O
Interviews.................................64

IV. SUMMARY AND DISCUSSION
SUMMARY AND DISCUSSION...........................B7
INCIDENCE OF POSTPARTUM BLUES....................71
LIMITATIONS OF THE STUDY.........................72
SUGGESTIONS FOR FURTHER RESEARCH.................73
IMPLICATIONS FOR SOCIAL NORK.....................7S

APPENDICESOOO.OOOOOOOOOOOOOOOOOOOOOOOO00.0.0000000000000078

LIST OF REFERENCESOOOOOOOOOOOOC0.... ..... 0.00.00.00.00000112

GENERAL REFERENCES.......................................TZO

LIST OF TABLES

TABLE Page

I. AGE AND MARITAL STATUS.....................AB

II. EDUCATIONAL LEVEL OF NOMEN.................AB

III. OCCUPATION OF MOTHERS......................49

IV. COMPARISON OF TOTAL DISCHARGED
AND STUDY SAMPLE..................SO

V. COMPARING SAMPLE DACL MEANS
AND LUBIN MEANS...................S7

VI. T-TEST RESULTS FOR SAMPLE DACL
AND LUBIN MEANS...................58

vi

LIST OF APPENDICES

Appendix Page

A. Summary of Research Study for Hospital Committee...7B

B. Research Consent Form..............................BO

Co Demographic QUBStionnaireooooooooooooooooooooooo.0082

D. Postpartum Blues Measures

Depresssion Adjective Checklists................83

Blues questionnairBOOOOOOOOOOO0.00.00.00.000000087

E. Control Over Birth Ouestionnaire...................BB

F. Revised Life Events Ouestionnaire..................94

G. Semi-Structured Interview Schedule................1OZ

H. Illustrations of Interview Summaries..............104

vii

INTRODUCTION

In recent years there has been renewed interest in the
childbirth experience and its significance in affecting maternal
psychological health and early parent-child adjustment (Noble 8:
Hamilton, 1981; Oakley, 19BOa; Kitzinger 8: Davis, 1978; Bradley,
1983a). women are encouraged to exercise more control over the
manner of delivery; couples are invited to share childbirth
education and experience; and attention has been given to the
need to have mother and child available to each other immediately
following birth to encourage bonding (Klaus & Kennell, 1982).

Birthing and its related problems for women in this society
is still not well understood. The normal experience of
chilbearing and the postpartum have rarely been seen as a
legitimate research area (Bradley, 1983a; Leifer, 1977; Oakley,
1980b). Since the mild transient depression occurring within
three to five days postpartum occurs with such frequency in this
culture, it is often regarded as normal. Consequently, the
phenomenon has been neglected as a subject of investigation
(Stein, 1982). The syndrome, often called postpartum blues,
maternity blues, or third day tflues is characterized by episodic
weeping, irritability, anxiety, confusion, sadness, and worry.

Yalom, Lunde, Moos, and Hamburg (1968) found this dysphoria
perplexing, noting that it occurred after delivery at a time when
one might expect a woman to feel joyous. However, this apparent
paradox might be better understood if childbirth is seen as a
time of profound change for a woman, both intrapersonally and
interpersonally and that changes of such importance for an
individual generally involve simultaneous gains and losses.

The birth of a child confronts the birthing mother with
dramatic changes. Physically, the child previously within her
body is now outside and has the capacity for survival separate
from her. Psychologically, she needs to deal with this sudden

separation and the symbolic meaning it may hold for other

separations in her life. Additionally, the birthing process and
environment may precipitously convert her previous view of her
body as healthy and intact to that of an "unwell", "mutilated"
body.

Episiotomies, cesarean sections, and forceps deliveries have
painful aftermaths. The hospital experience may have required a
patient role of passivity and acceptance. For some women such a
change is contrary to their usual coping style. Socially, there
are all the role changes that becoming a mother implies in this
culture. A mother is expected to move from independence to, at
the least, an interdependent relationship with her infant; she is
expected to be adult; to act in ways that would put her infant's
needs before her own.

Oakley (1980a) discusses these losses and gains of childbirth
and points to the work of Marris (1974) who suggested that since
change may indeed stimulate feelings of loss, the response to
that change may be much like mourning and can be understood in
the same terms as any grief reaction. In this study I propose
that postpartum blues may be an expression of grief related to
loss.

Postpartum blues is a complicated phenomenon undoubtedly
influenced by biological, psychological, social and cultural
factors. There is agreement that it is common in this culture
and, in most instances, naturally resolves itself in a few days
to a few weeks. It is of interest and concern because knowing
more about the variables that influence this phenomenon will
increase our understanding of the childbirth experience for
women. For example, if we accept that physical, psychological,
and social changes related to childbirth may be experienced as
loss, then we might expect that a woman's sense of control over
the change experience (childbirth) might influence her reaction
to that experience (postpartum blues). In addition, we might
expect that previous traumatic life change events (such as death

of parents, separations, job loss), to influence a mother's

coping (postpartwn blues) wiU1 the life change event of
childbirth. Since raffective states during the early days and
weeks of the postpartum appear to influence mother-infant
attachment and interaction, (Sroufe & Waters, 1978; Cohn &
Tronick, 1983; Kumar, 1982) increased understanding of the
variables modifying postpartum blues would be of use.

The purpose of the proposed investigation is three fold; (1)
to explore the nature and extent of the relationship between a
woman's sense of control over her birthing experience and her
postpartum affective state; (2) to explore the nature and extent
of the relationship between life change history (both before and
during a women's pregnancy) to the postpartum affective state;
(3) to suggest ways for the helping professions to be more

effective and supportive to birthing mothers.

CHAPTER I
LITERATURE REVIEw

Adjustment Reactions Associated With Childbirth

 

The postpartum emotional reactions most often reviewed in the
obstetric or psychiatric literature include a range of
psychiatric disorders with depressive symptoms as a component.
waletsky (1981) places these adjustment disorders on 23 continuum
of depressive adjustment reactions associated with childbirth.
Psychotic reactions are set apart as having a particular
etiology. Of the others, neurotic depressions are at one end of

the continuum and the mildest, postpartum blues, at the other.

Psychotic Reactions

Psychotic reactions associated with childbirth may include
manic-depressive psychoses, manic psychoses, and schizophrenic
psychoses. The symptoms are similar to the nonpuerperal
psychoses (Herzog & Detre, 1976; Protheroe, 1969) and are marked
by intensity over a long period of time. They may include
symptoms of less serious illness such as crying, loss of energy,
impaired concentration and irritability. Additional symptoms
characteristic of the particular psychosis, however, such as
grandiosity, thought disorder, depressive delusions, or frantic
behavior, are also present.

The incidence of postpartum psychosis is reported 235
occurring in one or two of every thousand mothers (Pugh et al.,
1963; Paffenbarger, 1964; Kendell, Rennie, Clarke & Dean, 1981;
Brockington, Uinokur & Dean, 1982). The symptoms often begin
within a month of delivery.

Some investigators have attempted to separate psychotic from
non-psychotic reactions to childbirth by proposing dynamic

formulations arising out of cflinical experience. Markham (1961)

compared psychotic and non—psychotic reactions to childbirth. He
found that both groups of women experienced depressive reactions
which represented an affective response to the reactivation of
earlier conflicts under the impact of the stress of childbirth.
The dynamic forces related to the psychotic response, however,
involved conflicted symbiotic relationships to the maternal
figure; a passive hostility to the maternal figure; and inner
conflict around issues of castration. He suggests that in the
course of normal development, separation anxiety, 8 sense of loss
and some degree of oral deprivation are experienced as a part of
the childbirth stress response. This implies that some
depressive postpartum responses are normal or of different

etiology than the psychotic response.

Postpartum Syndrome

Another adjustment reaction on this continuum described by
Bieber and Bieber (1978) is called postpartum syndrome. These
are disturbances in previously health men and women which are
related to pregnancy, birth, or the postpartum. They may begin
during pregnancy or any time during the first year postpartum.
Acute anxiety, psychosomatic disorders, alcoholism and drug
abuse, changes in relationship with spouse, and disturbances at
work, present as symptoms. The incidence of this syndrome is
hard to establish since it is as yet not well defined and
symptoms as described may appear in either parent or within the

marital relationship.

Neurotic Depression

women with long standing emotional or personality
disturbances antedating pregnancy which worsen in the postpartum
period are often diagnosed as neurotically depressed. These

symptoms which become apparent withing six weeks of delivery and

may remain for six months or more, generally respond favorably to
a supportive environment (waletsky, 1981). Pitt's (1968)
criteria for puerperal neurotic depression included depressive
disabling symptoms developing after delivery and persisting for
more than two weeks. Oakley's (1980b) criteria included the
persitence of the depressed state after hospital discharge to
five months postpartum and the presence of two or more symptoms
(for example, poor concentration, extreme fatigue, anxiety,
irritability) for at least two weeks.

Kumar (1982), emphasizes the potential impact of social
variables affecting depressive reactions. He cites Oakley
(1980a) ufim) describes the "medicalization" cfi’ childbirth as a
process of depersonalization of the mother, turning her into an
object. with little opportunity' to have any Ineaningful dialogue
with her caregivers.

Arguments as to whether postpartum depression is an "illness"
or 1a "reaction to events" continue in the literature, and an
excellent summary of the issue is provided by Kumar (1982). In
this research I assume that the normal range of responses to
childbirth may be adversely affected by environmental events.
Persons with a predisposition to neurotic depression may be
particularly vulnerable to such stressful environmental events.

Incidence of neurotic postpartum depression averages 10% to
15%, (Kumar, 1982). Variations in the size of samples,
composition of the sample and the methods used to detect and
define postnatal depression has led to a reported incidence range
of 2.9% (Tod, 1954) to 16% (Meares, Grimwade & wood, 1975).

POSTPARTUM BLUES

The mildest adjustment reaction on the continuum is
postpartum blues which is described as a common transient mild
depression with the onset most likely within the first four days

of delivery (waletsky, 1981). The symptoms are benign and

self-limiting. Sporadic crying, possibly related to depressed
feelings, anxiety or worry is described as the most prominent
symptom. Irritability, fatigue, poor concentration, and mild
confusion are also part of the syndrome.

In her discussion of possible etiology, waletsky cites
Affonso (1977) who found the impaired memory of the birth
experience and a sense of detachment from the infant two or three
days postpartum was related to long labors, rapid labor, high
risk conditions, discrepancies between expectation of labor and
the actual experience, and labors in which medications were
administered. Klaus and Kennel (1982) suggest that mother-infant
separation, concern about ability to care for the infant and the
limiting of visitors to the mother may be factors in the
occurence of postpartum blues.

waletsky explains the symptoms as resulting from the large
hormonal changes occurring in the postpartum period. She points
to the work of Handley, Dunn, Cockshott & Gould (1977) who
correlated falling cortisol levels with maximal blues symptoms.
Also, she sees the work of Paschall and Newton (1976) as
supportive of this conclusion. They demonstrated that test
measures of neuroticism in women two to three days post delivery
are the same as the national norms. They reasoned that the
increased depressive symptomotology must therefore be related to
biological rather than psychological factors.

Attempts to propose a single major cause of a complex
phenomenon seem simplistic. To hypothesize the interaction (3f
psychological, socio-cultural, and biological variables would
seem more productive. A focused literature reviau of postpartum
blues is presented, followed by a proposal for an integrated

theory of its etiology.

Description

Investigators of postpartum blues describe it as a transient

mild postpartum depression occuring during the first week
postpartum. It is characterized by sporadic short-lived
tearfulness lasting a few minutes to a few hours often with no
obvious precipitating factor. Other related symptoms include
fatigue, irritability, distractability, feelings cfi’ depression, a
mild confusional state and anxiety and worry, especially about
personal health and that of the baby (Yalom, et al., 1968; Pitt,
1973, Hamilton, 1962; Davidson, 1972; Harris, 1981). In most
women the symptoms may last for a day or two and in some
instances for a week or more (Stein, 1982).

Stein (1982), in his comprehensive review states that since
neither women nor their attendants consider postpartum blues as
an illness, and since more than half the population at risk seems
subject to symptoms, it cannot be regarded as an illness. He
suggests instead that this common set of mental changes be
regarded as a normal reaction, which if better understood, might
provide new insights into more pathological reactions. Since
Stein seems to favor a biological explanation of the blues, he
may be implying that more pathological reactions may have
biological causes. However, the same argument could be made for
those supporting psychological or socio-cultural causations, or
some combination of all these explanations.

Others who regard postpartum blues as a normal response
suggest that prolonged postpartum blues might presage a more
severe disorder in 23 subsequent postpartwn period (Melges, 1968;
Paffenbarger, 1966; Butts, 1969, Thuwe, 1974). The Merck Manual,
(Berkow, Ed., 1982) a widely consulted medical handbook prized
for its clinical utility, describes "blues" as a common
depression usually appearing within 24 hours of delivery and
ending after 72 hours. The handbook notes that if the depression
lasts longer than 72 hours or is associated with lack of interest
if) the infant, suicidal or homicidal thousghts, Tmallucinations,
or psychotic behavior, it is pathologic.

The duration of symptoms, their intensity and their range

distinguishes the normal response of postpartum blues from more
pathological responses. The problem reserchers have had to
confront lies in espablishing where one begins and the other
ends. The possibility of neurotic or psychotit: symptoms
overlapping those of postpartum blues, especially in the early

postpartum period, would also have to considered.

Incidence

Yalom and associates (1968) state that because of the lack of
consensual definition of the syndrome, incidence rates vary
widely, with estimates ranging from 5% to 80%. A common estimate
is that postpartum blues occurs in 50-60% of mothers at some time
during the first ten days. postpartum. Davidson (1972) reports
60% among Jamaican women, and Macfalrane (1977) reports
depressive symptoms in at least 80% of women delvering in
hospitals. Kane, Harman, Keeler & Ewing 1968) report 64% of new
mothers with minor emotional disturbancei which do not require
require psychiatric intervention. Butts (1969) reports that
medical personnel expect periods of depression following
childbirth in normal mothers.

Kruckman, Craig, Svendsen, Acsmann-Finch and Stewart (1980)
using a broad definition of postpartum blues and depression
suggest that 85% of women of western culture experience this
reaction and note that women of non-western culture experience it
rarely, if at all. The implication is that socio-cultural
factors influencing pregnancy and the birthing system affect
depressive responses to childbier. It is not clear whether the
studies they reviewed were careful about searching out what may
be depressive equivalents iI1 a non-western culture. Ftur example,
physical complaints or hyperactivity may be ways that depression
is expressed.

In summary, although there is disagreement about incidence,

there is agreement that in this culture postpartum blues is

1O

commonplace and that it is expected to occur in more that 50% of
all birthing women. Current childbirth preparation literature in
this culture does not ignore this transient emotional disturbance
occurring a few days postpartum. It is described as an expected

mild depressive state which resolves without treatment.

Early Investigators

Speculation about mild postpartum dysphorias appeared in the
medical literature in 1875 when Savage described "milk fever" and
suggested that emphasis be placed on the relationship of the
symptoms to lactation (Savage, 1875). He described women becoming
excited, sleepless, and incoherent about two days after delivery
and ‘reported that ‘the disturbance seemed to resolve about the
fourth day postpartum. Hippocrates in the 4th century B.C.
cautioned that a bleeding nipple of a woman recently delivered of
a child was an ominous sign pointing to the onset of possible
mania (as reported in Herzog & Detre, 1976). No attempt is made
in these early observations to separate mild and the mroe intense
pathological symptoms.

Hamilton (1962) in reviewing the early literature cites
Manton (1892) ammj Siegenthaler (1898) 1Mx) reported observations
of a high incidence of mild and transitory confusion after
childbirth. Moloney (1952) described the syndrome as including
symptoms of fatigue, despondency, tearfulness, and inability to
think clearly. He suggested more careful attention to physical
comfort and emotional support of birthing women.

In an early effort to study the range of symptoms of the
blues, Hamilton (1962) interviewed ten nurses specializing in the
home care of newborn infants and their mothers and listed eight
symptoms in order of frequency with which they were mentioned.
This list is still utilized in current research. It includes:
lack of energy and fatigability, episodes of crying, anxiety and

fear, confusion, headaches, insomnia, worry about physical

11

symptoms and status, and engative attitudes especially towards
husbands.

Hamilton concluded that these symptoms might be related to
the early symptoms of serious psychiatric illness and invited
consideration of psychobiological mechanisms that might be
related to hormonal changes.

Research efforts continued to concentrate on creating
chdcklists of symptoms. Such methodological problems as the
timing of the data collection and the issue of whether the
symptoms were present before childbirth, made comparability
difficult (Stein, 1982).

Attempts to distinguish other postpartlm1 reaction from ‘Uwe
blues and to understand more about their relationship or
nonrelationship with one another continues to be of interest to
researchers. The intensity, range, and duration of symptoms, the
time of onset in the postpartum, the possible differences in
etiology, are all areas of ongoing research and discussion.

Researchers of postpartum blues have attempted to find
correlates of the blues in three major areas: psychosocial,

biological, and crosscultural.
Psychosocial Studies

Stein (1982) in his summary of the literature notes. that
although clinical correlates of the blues have been found (for
example, first child, breast feeding difficulties, anxiety during
first trimester), few of the findings have been reported in more
than one study. An exception is the association between blues
and mental symptoms in late preganacy (Davidson, 1972; Nott,
1976; Harris, 1980).

Yalom and associates (1968) and Nott (1976) found increased
incidence of the blues among the primiparous subjects. Other
studies did not confirm these findings (Pitt, 1973; Ballinger,
Buckley, Naylor 8: Stansfield, 1979). Stein (1982) also reports

12

that no obstetric variable has been found to correlate with the
blues. These variables, however, are typically physiological
measures (fetal position, blood loss, lacerations sustained,
length of each stage of labor, type of delivery). The experience
of the birth is generally rated as easy, average, or difficult
by the attending physician. Little attention is given to the
mother's perception of obstetrical variables which might be of
inportance. In this regard, Bradley (1983b) found that although
type of birth did not affect postpartum affective state,
satisfaction with the birth experience did seem to influence the
degree of depression in the hospital.

The Yalom and associates study (1968) is one of the most
extensive in the area of postpartum blues and its results are
often cited. Of particular interest in the study were
observations concerning postpartum crying. The most frequent
constellation of factors centered around what the authors
described as increased vulnerability or hypersensitivity to
possible rejections. Examples included doctors paying little
attention on rounds or leaving the woman alone too long in the
labor room, and husbands arriving late to visit. Loneliness was
poorly tolerated and several women wept at the departure of
roommates, husbands, or visitors.

One subject wept of distress at the loss of control over her
interpersonal environment and her sense of helplessness; another
wept with relief that an anticipated painful labor and delivery
were over. (Her first delivery involved spinal anaesthesia
followed by a severe spinal headache). Other reasons given
included doubts about the capacity to mother; difficult
interaction with the obstetrician, and dissatisfaction with the
baby.

Although many women were puzzled by what they felt to be an
exaggerated response to these issues, there seems to reason to
suspect that aspects of the birthing system might have been

experienced as unsupportive and hence stimulated this sense of

13

sadness or anger. (There is evidence that women are socialized
not to express anger and therefore crying may be a compensatory
equivalent).

Macfarlane, et al. (1978) and Gordon (1978) suggest that home
deliveries are associated with much less, if any, postpartum
blues. Proximity to family and new infant were seen as
contributing to increased self-confidence. The problem with
comparing hospital and home birth populations is that choice of
environment might select a very different sample the latter
having more self-confidence as an aspect of their emotional

style.
Biological Studies

Researchers viewing postpartum blues as a normal behavioral
response to childbirth often support hormonal changes as a major
determinant. In females, times of stress often coincide with
endocrine fluctuation. Menarche, pregnancy, childbirth, and
menopause are times in the life cycle when there are marked
changes in the circulating steroid hormones. Following
childbirth, estrogen, progesterone, and prolactin dramatically
fall (UJaletsky, 1981). Since the onset of depression seems to
coincide with this drop, a hormonal cause is postulated (Dalton,
1971; Meares, Grimnade & wood, 1976; Paykel, Emms, Fletcher &
Rassaby, 1980).

Nott, Franklin, Armigage & Gelder (1976), in a study which
attempted to correlate hormone findings and clinical findings in
normal pregnant women, failed to produce evidence supporting
hormone imbalance having relationship to postpartum affective
disturbance. Yalom and associates (1968) took postpartum blood
samples daily to test for changing hormone levels. Although the
findings were not available at the time the report was written,
the authors postulate a psychoendocrine profile suggesting that

women with early menarche (in combination with other variables)

14

are likely to become depressed postpartum.

Stein (1982) offers an extensive review of research in the
area of biological changes and their relationship to postpartum
blues. Although he feels that the hypothesis has merit, he
believes that the lack of definition of posptartlm1 blues. will
make metabolic studies of the blues unlikely to generate results
that can be meaningfully compared.

In addition, when a group cfi'researchers found indication of
a theoretical associatiLWI between postpartlm1 blues and lowered
free tryptophan (Handley, et al. 1977; Paykel, et al, 1980;
Stein, et al, 1976) it could not be verified. An attempt to
confirm the result by providing prospective trial fo L-tryptophan
for multiparous women after delivery did not reduce the blues
(Harris, 1980).

weissman aflmj Klerman (1977) after' extensive review of the
literature note that the psychiatric reactions of the postpartum
are almost all of a depressive nature and conclude that women are
indeed at greater risk for depressive disorders in the postpartum
period. They add, however, that if any specific endocrine
abnormality is involved, the mechanism is not understood. Thus
far, research has not demonstrated a significant relationship

between postpartum blues and hormonal state (Gelder, 1978;
Steiner, 1971).

Crosscultural Studies

Some researchers interested in supporting a biological
determinant for the blues have theorized that if the symptoms;
also occur in radically different non-western populations, it
might indicate that the symptoms are not likely to be culturally
or socially determined (Harris, 1981).

Harris (1980,1981) studied Maternity Blues in an East African
population of Tanzanian multiparous mothers. He selected a

sample of fifty mothers excluding subjects with socioeconomic

15

problems, the unmarried or unhappily married, and persons who
were ill or had previous abnormal pregnancies and (abnormal
deliveries. All subjects delivered their babies in a hospital
setting. Those delivering at home were excluded from the sample.

Harris reported that 38 (76%) mothers in the sample
experienced postpartum blues which, according to him,
demonstrated that blues is indeed a crosscultural phenomenon. He
concludes also that its expression may be culturally related. He
explains that eight of the subjects with blues showecl somatic:
symptoms without tearfulness and that somatization of stress in
East Africa is characteristic.

Limitations cited by the author are issues of language and
the difficulty implicit in asking questions which are relevant
to another culture. what is not mentioned is a limitation but
which is potentially quite important, is that the sample: was
drawn from a population using a western clinic and hospital
facility. The traditional birthing in contrast to the western
styled hospital system is not described and the impact of the
birthing experience (although normal from a medical view), is not
addressed.

Davidson's (1972) prospective study of 55 Jamaican women
attempted to relate levels of anxiety and depression during
pregnancy to attitude toward pregnancy, and to obstetrical,
psychosexual and sociological factors. During the eleven days
postpartunl 60.4% were found to experience some emotional upset
on days one to three). In this culture, Davidson saw
the symptoms or "form" of the blues as similar to what was
generally reported in western cultures.

He concluded, however, that the symptoms had special meaning
for this population. The symptoms seemed related to higher
parity and Davidson concluded that poor economic and social
conditions led to intense emotional stress around having larger
families. Hence, the birth of still another child to an already

large family increased the potential for postpartum blues.

II I!
_;L

16

Kruckman and associates (1980) in their review of
crosscultural studies note the rarity with which postpartum blues
is discussed in the literature. They suggest that male
domination in the discipline of anthropology prevented
observation of childbirth and its traditions. Typically only
females are given access. A lack of conscious awareness of the
existence of a range of postpartum emotional reactions may have
resulted. Also there has been a problem in defining symptoms of
the postpartum period, making relevant literature hard to locate.

Kruckman and associates (1980) report that Stephenson
(Stephenson, Huxel 8: Harui-lflalsh, 1978), a female research,
specifically addressed the issue of postpartum depressive
reactions and did not find its existence crossculturally.
Kruckman‘s group after a two year search of the literature
concluded that postpartum blues and depression did not appear in
the literature because it simply did not exist. The literature
review, however, did reveal great differences in the social
structures and support systems available to alleviate stress and
anxiety in the birthing mother.

How can this be explained? These authors suggest that unlike
western cultures, childbearing did not remove the woman and
isolate her from her work and her community. New families are
more likely to settle near families of origin. Powerful support
systems which include extended family, ritual participation, and
the practice of midwifery are available to the birthing mother
and her infant. There is continuity of know support in a known
environment. This contrasts with the high mobility of western
culture which may weaken family ties and support groups. It
constrasts also with a birthing system that depends on high
technology and the services of person unknown to the birthing
mother.

In a personal communication to the author, Jordan suggests
still another reason why postpartum blues does not appear in

crosscultural literature. She has observed that the first week

17

postpartum tends to be highly ritualized with strong prescriptors
regarding the mother's seclusion and activities. She suggests
that culturally appropriate behavior may mask occurrence of the
blues. For example, her work in Yucatan, revealed that all women
act depressed in the postpartum making it hard to distinguish who
was indeed depressed and who was not.

Jordan (1983) in her study of birth in four cultures
describes birth as a biosocial phenomenon involving a universal
physiological process associated with socio-cultural practices
which differ in each society. She indicates that birth is
universally considered a significant life crisis event and that
in order to deal with it, people create a set of internally
consistent and interdependent practices and beliefs designed to
cope Iwith its problematic aspects. Jordan suggests that birth
practices in a given society tend to become "packaged into
relatively uniform, systematic, standardized, ritualized, and
even morally required routine" (Jordan, 1983, p.2).

The most common childbirth system in the United States is
physician attended and managed by a hospital trained staff.
Having once entered the system a series of interventions take
place. The hospital systan rather than the patient controls the
technical decisions made. The birthing woman is regarded as an
ill person whose capacities to participate in decision making
with competence is compromised and therefore devalued.

Viewing the birthing woman is ill (as opposed to well, which
is a more common view in other cultures) has great impact. A set
of culturally defined expectations of the sick person are in
place which reciprocally allow the physician, nurse, and other
health professions to fulfill their role. Parsons (1951) has
contributed the classic description of the "sick role" in this
culture. An individual who is sick is not responsible for the
condition; is exempt from normal social role obligations; is
obligated to get well; is obligated to look for and accept

technically competent professional help. This model may best

18

relate to persons with acute illness. Expectations of "sick
role" behavior, however, may complicate pregnancy and childbirth.
The wish to participate actively in medical decisions, for
instance, may be met with resentment and criticism. Similarly,
the 'wish to have the birthing mother and family be the major'
managers of the condition, may lead to conflict.

Patients are expected to gfive tdghly personal information to
strangers; the patient is expected to believe in the competence
of strangers and regard them as potentially more helpful than a
family member; they are expected to control emotion so that it
does not interfere with professional care; they are expected to
follow medical advise (Mumford, 1977). Dependency and compliance
are rewarded.

Usual patterns of behavior are altered dramatically for the
"ill person" in the hospital setting. Carlson (1978b) includes
such areas as affiliation, (visitors are limited); achievement,
(achievement goals are set aside due to lack of supplies or
energy); aggression, (verbal and physical means of expression are
often prohibited); dependency, (often increased because cf
illness and lack of information); elimination, (often have little
privacy); ingestion, (usually eat alone enmj with minimal food
choice); restoration, (rest is limited with many disruptions of
hospital routine); sexual, (modified and curtailed). The area of
personal control over environment might be added to this list.

All of these "requirements" potentially intensify the sense
of change for the birthing woman; and, since change and feelings
of loss are connected, it is of interest to know how patients
manage the loss emotionally. Davidson (1972) notes that a blues
reaction is also the sequel to other events in hospitals
unrelated to birthing, such as surgery. He adds that the very

act of admission to a hospital in itself could act as a stressor.

19

Summary

In summary, it may be stated that issues related to the
birthing system in this culture affect the emotional response of
women to childbirth. Issues identified include: the loss of
independent status that being a patient implies; the presence of
technologically rather than humanistically orientecl environment;
the deprivation of choice and control over one's situation; the
lack of sufficient contact with important others, including the
baby. These circumastance may stimulate or at least a
psychologically vulnerable birthing mother.

Most problematic in this perspective is the lack of a
theoretical framework that is broad enough to encompass what we
have learned from the biological, psychosocial and cultural
approaches. The theoretical framework of loss and grief proves a
helpful integrating model. A discussion of its applicability
follows.

POSTPARTUM BLUES: A GRIEF RESPONSE

Childbirth and Loss

The similarity of symptoms of postpartum and normal grief is
striking. A sense of anxiety, mood variability,
distractability, crying, fatigue, mild confusion, sadness and a
sense of loneliness characterize both. In discussions of the
grief process, Lindemann (1944), Parkes (1972), Marris (1974),
and Schneider (1984) descrflme a phase of numbness with obsessive
memories of the circumstance of the loss (usually death). A
comparable situation often occurs immediately after birth: there
is frequently a sense of numbness and disbelief followed by a
need txJ review the circumstance of the birth :01 considerable
detail (Affonso,1977).

Grief, in this discussion, is considered a complex

20

combination of numerous emotions experienced at the time of loss,
(Zisook 8: DeVaul, 1983) and loss is defined as a state of being
deprived of, or of being without something one has had. The most
profound loss and its associated grief, is the loss of a
significant relationship or loved person. Other loss, such as
loss of possesions stimulate variable intensity of grief
depending on the nature of symbolic emotional attachment. Loss
may also involve a loss of some aspect of the self, physical or
psychological.

Life changes have loss as an implicit component (Schneider,
1984). Change implies leaving one set of circumstances and
embracing another set. This shift is an emotional process.
Grieving the loss of the old is a part of that process.
Schneider also suggests that loss is ImJt easily recognized in
this culture and that grieving is commonplace and may account for
many puzzling emotional responses and somatic complaints. It is
strking in this regard, that postpartum blues is also
commonplace.

In this culture, childbirth is expected to be associated with
gain, joy and achievement. The losses are rarely acknowledged.
Yalom and associates (1968, p.16), in their paper on postpartum
blues. note, for example, that the "dysphoria curiously occurs
after delivery at 23 thme when one would expect to feel joyous."
Women are not encouraged to reflect on their ambivalence or sense
of loss regarding their changed situation.

If childbirth is regarded as signifying a life change, then
the losses are multiple and obvious. There are, to begin with
ienormous ‘rapid physical changes. The levels of female sexual
lwormones. undergo rapid physical changes. There is also blood
loss, trauma to the birth canal, and at times, the painful
aftermath of episiotomy, spinal anaesthetic, or cesarean section.
lflost. dramatic of' course, is the change ‘from having ‘the fetus
tuithin the body to having an infant "in hand". capable of

separate survival. The obvious life change of the infant

21

requires the mother to confront a life change for herself.

Psychologically, the mother may feel a loss of "apart of
herself" when she loses the special attention she felt she
received during her pregnancy. The state of pregnancy is
evidence of a fertile female who has a growing fetus within her.
This has special meaning both intrapsychically and socially. A
major developmental change is begun in pregnancy and culminates
in childbirth. In this culture it may be described as a
developmental transition involving a move from an adolescent
emancipation from her own mother to the realization that she must
now face a role of nurturant mother herself. This change
involves the negotiation of a series of developmental tasks which
may need to be confronted immediately after childbirth.

Developmental change is often ushered in by a stressful event
abruptly challenging homeostasis. Leifer (1977) noting 13“; work
cfi‘ Deutch, Benedek, Bibring, Sander“ and Caplan, proposes that
pregnancy is a period of developmental crisis in which
psychological disequilibrium provides a maturational stimulus for
new and more adaptive solutions to previous conflicts. Birth
itself is a stressful event; it involves the management of
dramatic change and within the formulation, loss. Earlier
experiences with loss and change will probably influence the
woman's coping style and adaptive capacity. Consequently, this
model suggests that a history of life change events might be
pertinent to a woman's postpartum course.

If we accord loss a central place in childbirth, then the
commonly reported symptoms in the early postpartum seem more
understandable. The symptoms are related to a sense of loss and
a grief process. The symptoms may be more exaggerated in the
early postpartum because the woman is certainly more physically
vulnerable. we propose that she is also more psychologically
stressed, not only by becoming a mother, but due to her previous
experience with life stress and change, and because of issues

related to the management of the birth and her care in the

22

hospital.

It is interesting to note that there are reports of
depressive symptoms in new fathers (Ginath, 1974; wainwritht,
1966; UJaletsky, 1981) and in adoptive mothers (Einzig, 1980).
These and other studies have identified social and psychological
factors as major contributors to the stress of becoming a new
parent. The new parent is immediately aware of a role change
(and related losses) demanding a mastery of infant care skills
and the redefinitaion of family relationships and obligations.
These depressive symptoms may also signify a phase in the process
of grieving.

The loss and grief framework suggests other variables which
might affect the expression of grief in the postpartum. A
woman's sense of control or mastery over the birth experience
seems one such important variable. A discussion of this variable

follows.
Mastery 9__f_ Childbirth Experience

My clinical experience suggests that the more control a
person has regarding changes in their lives, the less helpless,
angry, and depressed they will feel. white (1959) alluded to
this when he discussed perceived competence as an important
determinant of self-esteem. He described competence in terms of
feeling of efficacy, and expectation that one can successfully
behave in such a way so as to affect outcomes. Competent human
beings exerience the power of initiative and a sense of being the
causal agent in their own lives. Losses experienced as a result
of change are less intense when one can anticipate and remain
involved in the change process.

There is support for this view in the childbirth literature.
Humenick (1981) reports that women who take childbirth classes,
for instance, report less postpartum depression and increases in

self-esteem, changes she regards as indicating better mental

23

health and capacity to cope.

Notman and Nadelson (1978) challenge the current health care
system's resistence to women having more control over their care.
They see physicians as dominant and their established role as one
of being helpful, authoritative and protective. They suggest
that women, in response, tend to be compliant, accommodating and
less well informed. Their passivity is heightened by the social
requirements of the "sick role".

This traditional doctor-patient relationship is being
challenged. Notman and Nadelson suggest that the patient may be
better served if she is able to participate in her own medical
care and if the physician can relinquish some aspects authority
and power.

There has been considerable interest in studying'ratings of
satisfaction with the childbirth experience. Researchers have
found no correlation between reported pain during childbirth and
satisfaction with the experience. Entwistle and Blehar (1979)
found that the amount of medicatiom was inversely related to
positive rating of the birth experience. Participation in the
birthing process seemed more important to women than the level of
pain.

In a retrospective study willmuth (1975) reviewed childbirth
evaluations of 134 women reported that a major factor associated
with a positive birth rating was the woman's perception of
control during birth. She notes that control was defined by the
woman as continuing to be able to influence the decisions made
and to maintain a working alliance with the health care team.

Although measures of parent satisfaction are common in
attempts to understand the realtionship of birth experience to
other postpartum variables, Shearer (1983) cautions that there
are no standardized or validated scales. Findings are unstable
in that a woman rating a forceps delivery which she was told had
saved her child's life, would not tend to be critical of the

procedure, whereas another might. Similarly, as time goes on,

f‘)

«n

24

parents tend to develop a sense of loyalty to the birth
experience. Shearer explains this phenomenon as the need to "put
their lives back together with the new baby" (p.77). Dyanne
Affonso's (1977) paper on "missing pieces" speaks to the tendency
for parents to try to understand and remember the birth and to
set events in order.

How do these observations relate to the guief framework? In
such a framework, the wish to review traumas and the events
around the change or loss is a part of the work that needs to
take place before and adaptation to the change or loss can take
place. In the case of childbirth, it is likely that the need to
review and revise the birth event may be and expression of the
same kind of process. I suggest that having an opportunity of
simply tell the birth story enables a woman to have a sense of
control over the trauma of delivery. The telling of the birth
story lessens the sense of loss.

This study is not concerned with type of birth or with
satisfaction ratings. More central is the woman's evaluation of
her sense of control over the event or series of events leading
up to and including the birth of her child.

Although "sense of control" may be a component of
satisifaction it is also a variable which has independent
influence on the inmediate postpartum reaction. I twpothesize a
relationship between the mother's sense of control over decisions
made in the birthing environment and events in the birthing
process itself, with postpartum blues. I propose that the woman
who feels in control of decisions around these events will be
less apt to feel low self-esteem, depression, helplessness, and
other symptoms associated udifw the blues. Theoretically, ea sense
of control should lessen the sense of loss and change and hence

the grief reaction within the first four days postpartum will be

less intense.

 

25

Life Change

 

If managing loss is a component of the childbirth experience,
how might previous experience in managing life stresses involving
loss affect how well a woman copes with the stress of childbirth?

A death, divorce, marriage, abrupt change in location,
illness, or imprisonment are among the situations defined as
important life changes which are stressful (Homes and Rahe,
1967). There is now an extensive body of literature relating
objective measures of life change to physical illnesses, wyler,
Masuda and Holmes, (1971). If we assume that the stress
associated with life change is, at least in part, the need to
confront losses and grieve, then we might assume that life
changes close to the time of childbirth might add to the sense of
loss normally experienced in childbirth.

Three studies utilizing the life change measures and
pregnancy area of particular interest in this regard; Nuckolls,
Cassel and Kaplan (1972), and Gorsuch and Key (1974), found a
positive relationship between life change and physical
obstetrical difficulties. They investigated the relationship
between life stress and pregenancy and birth complications. No
significant relationships were found when all subjects were
considered. However, when mothers were divided into those
displaying high and low levels of psychosocial assets (available
support systems) significant. relationships emerged. Those Iwith
high levels of such assets and high life change did not show
increased complications while those with low levels of such
assets did have increased frequency of such complications.

Gorsuch and Key (1974) also studied the relationship of
obstetrical abnormalities, life change, and time-specific
anxiety. Life events udthin 23 two year period were recorded by
each woman during her pregnancy. Following the delivery, an
update cfi‘ such events was made. Findings indicated 23 higher

Inagnitude of life change events was related to problem

26

pregnancies ONLY during the six month immediately prior to
delivery. Analysis dividing the stressful events by trimesters
of pregnancy indicated the second and third trimesters were most
highly related to abnormal pregnancies.

The Jones (1978) study, on the other hand, produced an
unexpected inverse relationship. The study assessed the utility
of objective measures of life change, anxiety, and personality as
predictors of labor complications. A moderate and reliable
degree of predictive accuracy was f0und when life change history
measures were taken for the two year period prior to delivery.
It; was, however, negatively associated ufiITI the occurrence of
complications. The lower the scores on the schedule, the greater
the likelihood of complications.

Jones suggests some mediating variables which may have
altered the expected positive relationship. Individual
differences in the perception of stressful events and the
presence of varying levels of psychosocial supports are two such
variables already identified in other studies (Nuckolls, et al.,
1972); Yamamoto and Kinney, 1976). Individual differences in the
level of preparedness of the individual for coping with stress is
also suggested as a likely possiblity.

This last variable is of special interest in that the setting
of the study placed special hardship on the mothers many of whom
were young and separated from home and from important others for
the first time. Jones hypothesized that those mothers who had
experienced higher levels of life change in the past and had
opportunity to make adaptation to change were less affected
psychologically in the setting than mothers with lower levels of
life change.

The loss and grief framework seems relevant in Lmderstanding
these results. Prior experience with life change and the need to
adapt to it might make the life change associated with childbirth
of less magnitude. The death of a parent may have already made

the birthing mother confront the necessity to be more adult. Also,

27

the stresses of the hospital situation may not add as
significantly to the sense of loss. Early experience with
stressful change might help such a person develop a more
effective coping repertory.

Paykel, Fletcher and Rassaby, (1980) investigated the
relationship of life events and social support with mild
postpartum neurotic depression. Measurements of depression were
made at around six weeks postpartum. A life events history was
taken to correspond with the beginning of pregnancy. The report
that "postpartum blues were only associated with neurotic
depression in the absence of undesireable life events" (p.339)
supporting a conclusion of the importance of hormonal variable.
The postpartum blues measure was based on retrospective
self-reporting.

There have been no attempts to relate life change
specifically to postpartum blues. The literature seems to
support an exploration in this area and therefore several

hypotheses related to life change were proposed for this study.

HYPOTHESES

I have supported the idea that postpartum blues may be better
understood if viewed in the context of a theoretical framework of
loss and grief. This framework permits the testing of some
psychosocial variables in the birth situation which might affect
a grief response, (postpartum blues).

Since previous experience with loss and change (life events)
affect the impact of present experience with loss and change,
Revised Life Events Questionnaire. (RLEO) scores and measures of

postpartum blues are used to test the following hypotheses:

l. WOMEN WHO SCORE HIGHER ON THE RLEO PRIOR TO ONE YEAR BEFORE
DELIVERY WILL HAVE POSTPARTUM BLUES OF LESS INTENSITY THAN WOMEN
WHO SCORE HIGHER ON THE RLEO WITHIN THE YEAR OF CHILDBIRTH.

28

2. WOMEN WHO SCORE HIGH ON THE RLEO PRIOR TO ONE YEAR BEFORE
DELIVERY BM). WITHIN THE LAST YEAR OF CHILDBIRTH, WILL HAVE LESS
INTENSE POSTPARTUM BLUES THAN WOMEN WHO SCORE LOW ON THE RLEQ
PRIOR TO ONE YEAR BEFORE CHILDBIRTH AND WITHIN THE LAST YEAR OF
CHILDBIRTH.

Since perceived and actual control and mastery over a loss
experience would theoretically result in a less intense grief
response, we have identified some issues of perceived and actual
control over the birthing experience to test whether this would
affect intensity of the postpartum blues. Such issues as
perceived and actual freedom to have access to the infant,
perceived freedom to have/have not anaesthesia, to stay longer or
leave the hospital sooner, are identified on the Control Over
Birth (COB). We are using this instrument and measures of

postpartum blues to test the following hypotheses:

3. WOMEN WHO PERCEIVE THAT THEY HAVE MORE CONTROL OVER DECISIONS
RELATED TO ASPECTS OF THE BIRTHING EXPERIENCE WILL HAVE LESS
INTENSE POSTPARTUM BLUES THAN WOMEN WHO PERCEIVE THAT THEY HAVE
LESS CONTROL.

4. WOMEN WHO ACTUALLY HAD MORE CONTROL OVER DECISIONS RELATED TO
ASPECTS OF THE BIRTHING EXPERIENCE WILL HAVE LESS INTENSE
POSTPARTUM BLUES THAT WOMEN WHO HAVE NOT HAD ACTUAL CONTROL.

5. WOMEN WHO PERCEIVE THAT THEY WERE AWAKE AND AWARE DURING
THEIR BIRTHING EXPERIENCE AND HAD WISHED THIS KIND OF BIRTH
EXPERIENCE WILL HAVE LESS INTENSE POSTPARTUM BLUES THAN WOMEN
WHOSE PERCEPTIONS WERE NOT CONGRUENT WITH THEIR WISHES.

6. WOMEN WHO PERCEIVE THAT THEY HAD FREEDOM TO DECIDE HOW SOON
TO SEE THEIR INFANT AFTER BIRTH WILL HAVE LESS INTENSE POSTPARTUM
BLUES THAN WOMEN WHO DID NOT PERCEIVE THAT FREEDOM.

29

7. WOMEN WHO PERCEIVE THAT THEY HAD FREEDOM TO DECIDE HOW MUCH
CONTACT TO HAVE WITH THEIR INFANTS AFTER BIRTH WILL HAVE LESS
INTENSE POSTPARTUM BLUES THAT WOMEN WHO DID NOT PERCEIVE THAT
FREEDOM.

Since an opportunity to review the circumstance of a loss is

important in then grieving process, we hypothesize:

B. WOMEN WHO ARE GIVEN OPPORTUNITY TO TELL A DETAILED STORY OF
THEIR BIRTHING EXPERIENCE IN THEIR OWN WAY SOON AFTER BIRTH WILL
HAVE LESS INTENSE POSTPARTUM BLUES THAN WOMEN WHO DO NOT HAVE
THIS OPPORTUNITY.

Since availability of support persons who are familiar and
significant to the person who has experienced loss helps to

modify the intensity of the grief process, we hypothesize:

9. WOMEN WHO WISHED SUPPORT PERSONS WITH THEM DURING THE LABOR,
DELIVERY, AND IMMEDIATE POSTPARTUM AND PERCEIVED THAT THEY HAD
THE OPPORTUNITY TO HAVE HAD THEM PRESENT, WILL HAVE LESS INTENSE
POSTPARTUM BLUES THAN WOMEN WHOSE PERCEPTION AND WISHES WERE NOT
CONGRUENT.

10. WOMEN WHO WISHED SUPPORT PERSONS WITH THEM DURING THE LABOR,
DELIVERY, AND IMMEDIATE POSTPARTUM AND ACTUALLY HAD THEM
AVAILABLE, WILL HAVE LESS POSTPARTUM BLUES THAN THOSE WHOSE
WISHED AND ACTUAL EXPERIENCE WERE NOT CONGRUENT.

CHAPER II

METHOD

Overview

In this exploratory study, a population of normal low—risk
women who have delivered healthy babies in a hospital setting
were assessed on a variety of psychological and social self
rating scales to test their relationship with a measure of
postpartum blues. During a two and one half month time period
data was gathered for four consective days on each subject,
beginning within the first 24 hours after admission. Information
collected by nurses making routine postpartum adjustment
telephone calls then to twelve days following discharge was also
made available to me.

A smaller group drawn from the original sample was
interviewed to allow an opportunity for the woman to review her
birthing experience (the birth story); to identify critical
aspects (both good and bad) of her birthing and hospital
experience; to check on the validity and reliability of the
self-rating scores; and to get a better picture of the natural
history of the early postpartum experience. These inverviews
enabled me to clarify quantitative findings and to develop

additional insights and hypotheses.

Setting

The study required an obstetrical service which offered a
full range of birthing alternatives to women who are considered
low risk for birthing complications. The setting utilized is a
small general hospital in an urban community within a larger
urban area. Historically, the hospital has had special interest

in its obstetrical service. It served and continues to serve as

30

31

a facility for pregnant adolescents in need of residential care
prior to delivery. Since the number of girls requiring such care
has diminished, one floor of the residence has) been remodeleci
into the Home-Like Birth Center. This unit is physically
connected to the hospital by means of a specially constructed
corridor. The birthing unit numbers an average cfi’ 27 admissions
per month (1983). Birthing suites are available to birthing
mothers, their husbands, and any additional family members
selected by the couple. The birth attendants include a nurse
midwife, other nurses and, at times a consulting obstetrician.

The basic naternity unit offers other alternative plans. It
has available labor rooms, labor/birthing rooms, and a delivery
room equipped for a range of medical interventions including
cesarean section. This unit has 29 beds and averages 134
deliveries per month (1983). Rooms are two and four bed and a
family room is available for family/infant visits. In an effort
to maximize continuity and family focused care, the assigned
nurse follows both the mother and baby as a pair. Admissions
originating at the Home-Like Birth Center are transferred to the
basic maternity unit if an intervention such as fetal monitoring,

forceps delivery, or cesarean section is indicated.

Sample

The systematic sample includes 70 women admitted to the
maternity service or Home-Like Birth Center for childbirth who
met study criteria. A limit was set such that no more than three
new admission daily become part of the study. This allowed
sufficient time to follow each case over the required four day
period.

Originally, subjects were to be selected by beginning with
the first admission during the previous 24 hours on day one and
accepting eligible subjects three and five. On day two, I was to

begin with the second admission and accept eligible subjects four

32

and six. During the approximate ten week period of the study,
admissions were unusually low. On some days there were no
admissions or only two. Procedure was therefore modified.
Although I continued to alternate beginning with the first or
second admisshmi, I would accept consecutive admissions if there
were too few to utilize the original plan.

The sampling procedure prevented the possibility of ever
including any birth that was the seventh or more on a given day.
However, during the study period, more than six deliveries
occurred only once or twice. On the other hand, the low floor
census averaging two to five new patients daily, might have
influenced the care and attention given each subject. This
presented an unexpected variable in the setting.

Criteria for inclusion in the study were: the subject give
written informed consent to become a subject in the study; that
the subject read and write English; that the birth was of a live
infant without congeintal anomaly or special medical problem, and
that the infant was of 37 or more weeks gestation.

Babies of less than 37 weeks gestation are considered
premature and were consequently excluded. They are usually of
low birth weight and because of the immaturity of organ systems,
there area often medical complications which put the infant at
risk for survival. Mothers of pmemature infants have additional
stresses which would introduce new variables to influence the
findings. Similarly, the birth of an infant with a congenital
anomaly or special medical problem would stimulate responses of
shock and grief which are beyond what we are defining as
postpartum blues. Mothers of such infants are also excluded.

I collected descriptive data on all women who participated in
the study and on those who chose not to participate to see how
they differed from the participants. A group of ten women was

selected from the total sample for interviewing.

Procedure

33

A short document was prepared for the hospital research
committee (see Appendix A) and presented to the hospital
administrator for her suggestions prior to forwarding it to the
committee for review. The committee's formal approval of the
study gave me access to the hospital staff and patients. However,
obstetricians and midwives admitting the majority of patients
were contacted individually so that I could introduce myself and
the study personally.

In order to recruit women for the study, I made a
presentation to the obstetrical health care team regarding the
general area of the study and the requirements for participation.
The chief nurse of each maternity floor and her alternate were
interviewed with regard to getting advice about when, where, and
how to best make initial contact with newly admitted women.

Brief descriptions of the study, permission forms (Appendix
B), demographic data questionnaires (Appendix C), and instrument
packets were prepared for each maternity unit. On the regular
maternity service, it was agreed that I was to introduce the
study and invite prospective subjects to participate. The chief
nurse in the Home-Like Birth Center chose to make the initial
contact herself. Since most women remained on the unit for only
12 to 24 hours following delivery with access to a range of
invited family and friends, the nurse felt the need to be the
liason regarding all other requests.

During my first visit with the prospective subject, the
project was described, signed permission obtained, questions were
answered and the data packet for the first day explained. I
advised the woman that I would be returning to collect the data
schedules daily. In some instances, I remained at the bedside
and did the initial mood form with the woman. Women who needed
to remain flat after cesarean section welcomed the assistance.

Ten of the seventy subjects were selected for a

semi-structured inverviews. In order to space them more evenly

34

over the data collection period, I arranged to choose one woman
at random from new admissions every third day until the required
ten interviewees were identified. Each subject designated for an
interview was alerted to the need for this additional time with
me and an appointment was made withing 24 hours of the birth
(whenever possible). In the event that a woman left the hospital
to return home before four days, she was asked to complete all
the schedules except for the postpartum blues measures (which
were designed to be collected daily) before leaving the
hsopital. A packet containing the blues measures for each
remaining day was given to her in a return stamped addressed
envelope. I made a reminder call to the home and invited the
woman to give me the data on the phone.

These calls took only five minutes and were required in only
four' cases. Most women completed the fourth day for": before
leaving the hospital. Others mailed them immediately. Women
recruited from the Home-Like Birth Center had routine visits made
to them by the mdiwife on the fourth day postpartum. Their
completed packets were given to the midwife at that time.

As a token of appreciation for participating in the project,
a bib or pair of booties was presented to each woman on her third
day postpartum. Home-like Birth Center participants were given

the gift along with the instrument packet on the day of delivery.
INSTRUMENTS

Postpartum Blues

Difficulties in measuring postpartum blues arise out of lack
of agreement about definition; about timing of the measurement;
and about self report scales versus observed behavior.

For purposes of this study, I define blues as a mild
transient depression occurring within the first four days

postpartum. To establish the presence of blues, I utilized a

35

measure of depressive affect, the Depression Adjective Check
Lists, (Lubin, 1965), and 23 measure cfl’ the particular subset of
symptoms identified in the literature as very early
characteristics cfi’ the postpartwn blues syndrome. These include
crying, irritability, anxiety, and difficulty concentrating
(Stein, 1983).

To avoid the limitations implicit in collecting retrospective
data, I wanted a measure of blues that could be collected each
day during the first four postpartum days. I assumed that some
women who were (or would become) neurotically depressed might be
difficult to differentiate with any blues. measure during these
early days. If there was overlap, namely that women with
postpartlm1 blues symptoms later developed symptoms of neurotic:
depression, I assumed that the same factors influencing the
development of the blues in the early postpartum also affected
the neurotically depressed. It was therefore acceptable to see
them as having "blues" during the early postpartum and to include
them in the sample.

Psychotic symptomatology is more easily differentiated. I
assumed that the etiology was different from that of postpartum
blues or from neurotic depression. If mothers presented these
symptoms within the postpartum blues four-day time frame, they
would have been deleted from the study. No such women in the
study were identified. This was as anticipated since the
expected incidence of psychosis is one or two per thousand
birthing women.

To measure postpartum blues I chose a combination of
self-report instruments used in two recent studies. Bradley
(1983a) utilized the Depression Adjective Check Lists, DACL
(Lubin, 1965) which were originally developed as part of an
"investigation of mood changes during pregnancy and the
postpartum period" (Lubin, 1965, p.7). The DACL has the
advantage of being brief, (it takes an average of 2.5 minutes to

administer) and has seven alternate forms for the purpose of

36

repeated measurement with only brief intervals between testings.
(see Appendix 0)

Reliability for the DACL was established at between .82 and
.93 among the lists through split—half reliability tests.
Intercorrelates between the forms used in this study (A.B.C.O) is
.87. Validity of the checklists was tested by using normal
persons and non-depressed and depressed patients of both sexes.
The instrument was successful at discriminating between the two
groupings at a 0.0005 level of significance adding to confidence
in the overall validity of the instrument.

In addition to the DACL, a four question revised
questionnaire related to blues and devised by Cutrona (1983) was
used. Cutrona's data was collected three weeks postpartum and
included an additional inquiry related to attibutional style.
This study is designed to collect the data prospectively with
interest in exploring events related to postpartum blues
symptoms, hence the necessity for changes. Fcu‘ example,
Cutrona's question, "Have you cried more easily or more
frequently since the baby was born?" (followed by a series of
choices as to who or what might be responsible), was changed to
"Did you feel like crying at any time today?" "Do you have any
idea about what made you want to cry?"

Similar changes were made for the questions regarding
irritability, anxiety, and difficulty with concentration. These
particular symptoms were chosed from lists of postpartum blues
symptoms because they were identified has having a particularly
high frequency during the first few postpartum days (Stein,
1982).

ll weakness in this brief questionnaire was that it might
prove suggestive, inviting the respondent. to "feel blue." For
this reason, three more questions were added focusing on positive
affect: had the' woman felt confident; had she felt, happy and
"like' her old self"; had she felt rested and relaxed? These

positive states are common in the early postpartum. Women

37

experiencing this sense of well being may or may not also
experience the blues.

This instrument was not designed to be a scale hence no
split-half reliability test was required. There was expectation
that women could feel both positive and negative affect
simultaneously: that one could feel entirely positive (or
negative; or experience as few as one symptom of either kind.

The last question added to the questionnaire was aimed at
getting some sense of the woman's familiarity with her baby and
her own estimate of her competence in caring for the baby. This
was scored on a continuum of one to five. The questionnaire is
reproduced in Appendix 0.

The DACL was scored according to the instructions in the
manual accompanying the instrument (Lubin, 1981). The
questionnaire was scored by counting each claimed symptom of the

blues.

Control Over Birth

 

Control over birth is defined as a sense of continuing to be
free to accept or influence the decisions made regarding the
series of events leading up to and including the birth, delivery,
and postpartum days in the hospital. It is a sense of
maintaining a working alliance with the health care team. This
concept differs from measures of satisfaction in that it does not
deal with likes and dislikes. Also, locus of control or
attributional style is not a central issue because I am concerned
here with whether the mother's cognitive style whatever it is, is
sufficiently responded to by the system such that she feels that
her need to control or have someone take control is met.

The Control Over Birth questionnaire (called Birth Experience
on the instrument form) was adapted from a subset of questions
created to measure this variable by Bradley (1983a). Here too

one question was revised and other items added to more adequately

38

meet the requirements of the present study.

The original subset cfi’ seven questions appear almost exactly
as in the original study. Only one item was changed because it
appeared redundant as written. These items were maintained to
preserve the possibility of eventually comparing findings from
both studies and to test the reliability of new items created for
the instrument. The original subset had an alpha reliability
coefficient of .83. The revised subset designed for this study
had a reliabilty coefficient of .76.

Ideas for additional items came from Fullerton (1982) who
developed a scale measuring attitude toward control of the
"situation specific content of childbirth experience" (p.20).

Locus of control is aa possible influential variable although
not central to control of birth as we define it. Locus of
control is a construct developed by Rotter (1966). It involves a
generalized expectancy that individuals have with regard to the
extent that they have, or do not have, the power to control what
happens to them. Persons with external locus of control defer to
chance or the power of others while persons with internal locus
of control look to power within themselves. This difference in
orientation is bound to make a difference in the need to
personally feel control over birth. The questionnaire as
constructed, however, is designed to accomodate the response of
both types. The issue is, did the woman feel that her needs with
regard to control were responded to appropriately. As a check on
the adequacy of the design, however, I included two items which
ask specifically about locus of control (see items 15 and 16
Appendix E). This enabled me to make some judgement about
whether those with internal or external locus of control
responded in significantly different ways to the questionnairea
items.

The Control Over Birth questionnaire (Appendix E) was
collected on day two. Each question was scored within a five

point scale beginning at +2 indicating strong control, to O,

39

indicating neutrality, 1x) -2 indicating strong lack cfi‘ control.
Ten points were added to each score so that negative scores would
tn; avoided. A question was also asked regarding whether “Owe
decision to have a cesarean section was made before

hospitalization or after labor was begun.

Life Change History

 

For purposes of this study, I required a quantitative measure
of life change events over a person's lifethma in order to test
the notion that the more experience a person had with life
change, the less the sense of loss at the time of childbirth; the
less the sense of loss, the less the need to express grief
(postpartum blues). Also, a measure of more recent life change
events would help explore the relationship of stresses
immediately preceding and during pregnancy and postpartum blues.

An instrument based on the Holmes-Rahe (1967) Schedule of
Recent Experience (SRE) was desirable because of the considerable
experience with the use of such questionnaires in health and
medical research. The original scale includes a variety of life
events drawn from the areas of family constellation, marriage,
residence, education, occupation, health, relationships, and
religion. Some events may be seen as desirable (graduation) and
some as upsetting (illness). Holmes assumed that change was more
important than the positive or negative way a person viewed that
change.

The original SRE instrument contained 43 items. A subject's
life stress score was simply the number of events he or she
reported over a recent time interval (usually six months to two
years). Since it was recognized that some SRE items required
considerable more adjustment than others (for example, a death
versus a change of location), a subsequent instrument called
Social Readjustment Rating Scale (SRRS) (Holmes and Rahe, 1967)

was developed. Here life events were weighted according to the

4O

amount. of readjustment of "getting used to" each required. A
cumulative weighted score was assumed to reflect the amount of
change that took place in a person's life. The instrument has
proved stable across subculture groups :01 the United States and
cross-culturally (Miller, Bentz, Aponte & Brogan, 1974). Samples
from different populations tend to give similar weights to life
events despite the fact that the original sample was middle-class
urban Americans.

The scale was designed assuming that adaptation to life
events was stressful and that such stress might play a role in
the etiology of various somatic and psychiatric disorders
(Dohrenwend and Dohrenwend, 1974). Examination of the
considerable research in this area confirms the existence of a
significant relationship between the experience of stress as
defined by life events scales and a rmxfi: of adverse somatic and
psychological conditions. Despite these findings, serious
questions remain about methodology.

One of the problems with the original scale was that items
were too general for use with specific populations such as adult
female respondents of childbearing age. With this in mind,
Norbeck (1984) revised the scales testing new items relevant to
this specific population. Her Life~ Events Questionnaire (LEO)
was a modification of existing instruments. In particular, the
format and instructions come from the work of Sarason, Johnson,
and Siegel (1978). New items related to such issues as
separations and reconciliations, parenting, job finding, housing,
and being a victim of a violent sexual act.

Not only do given life events have different impact but they
also have individual impact depending on whether an event was
desirable or not for that individual. A miscarriage, for
instance could represent an enormous loss, or a tremendous
relief, or both, depending on how the woman felt about the
pregnancy. Norbeck suggests solving this problem by utilizing

self-weighted (both positive and negative) scores. This also

41

permitted her to include new items without needing to establish
empirically derived weights.

This study utilized Norbeck's newly developed scale (LEO)
with some revisions. The LEO test-retest reliability is reported
by Norbeck for negative, postive, and total scores. For the
entire LEO, each score had a high degree of test-retest

reliability (.78 to .83). A more complete discussion is found in
Norbeck, 1984, p.66.

Validity of the instrument was tested by relating LEO scores
with psychological symptoms neasured tn/ three instruments.
Evidence of validity was strongest for the negative events scores
for the entire questionnaire. The range using varied instruments
was between .30 and .39. Pearson correlation coefficients
between the LEO negative events score and measures of
Depression-Dejection was .34 or at the .01 level of significance
using a two-tailed test. (Norbeck, 1984, p.67).

Revisions of the LED fku' this study included shortening the
scale from 79 to 71 items. Some of the items did not apply to
this group; for example, started menopause, retirement frmn work.
Some were too general for my needs; for example, major changes in
eating habits or sleeping habits. Still others were designed for
male response should the scale be used for both males and
females; for example, wife or gfirlfriends pregnancy. In addition
to deleting these items, I also changed the questionnaire format
slightly so that the respondent could indicate those events which
occurred in her lifetime and those which occurred within the last
year. The instrument as it is used in this study is called the
Revised |_ife Events Questionnaire (RLEO) and is reproduced in
Appendix F.

Scoring for RLEO involved adding the weighted scores.
Positive and negative scores were totaled separately and together
for each time period; totals were made of positive and negative
scores across both time periods; and a. grand total score was

established for the entire schedule.

42

Time Period

 

The choice of time periods covered in the RLEO include
"within one year: and "over your lifetime". The first choice
reflects previous research which indicates that stress during the
last 'two trimesters of pregnancy increased the possibility of
obstetrical complications (Gorsuch and Key, 1974). The one year
time period is also of particular interest also because we
suspect clinically that conception ancl pregnancy often follows.
loss.

The second time period "during your lifetime" is included
because one of the hypotheses is that high life stress histories
will relate to less postpartum blues. Again, the assumption is
that a woman with this history will not experience the same
degree of loss around the birth of a child. Hurst (1979)
supports the use of longer time period in that he reported that
the test-retest reliability of the original life event
questionnaire is higher when there is a longer time period being
considered. Also, Perkins (1982) comments that although three to
six months is generally recommended as an optimal time interval
to look for a relationship between a life event and a symptom,
any cut-off point seems arbitrary short of a person's entire life

time since we know so little about the temporal effect of such

events.
INTERVIEW

Ten women were interviewed utilizing a semi—structured
interview schedule. (Appendix G). The schedule was designed to
allow an opportunity for the woman to review her birthing
experience (the birth story): to identify critical aspects (both
good and bad) of her birthing and hospital experience; to check
on the reliability and validity of the other instruments by

reviewing her responses to the questionnaires; and to allow other

43

issues to emerge which I had not considered.

The Birth Story

The beginning of the interview invites the woman to tell her
birth story without interruption. Jordan (1983) suggested the
potential usefulness of a story as representation of a cultural
event and as such, a way of learning more directly about issues
important to the participants.

Of interest also is the potential therapeutic value of
tellirm; a story related to trauma. and loss. Schneider (1983)
sees this as a key factor in facilitating grief. The environment
must be permissive of the disclosure of a range of emotions and
the telling and retelling of the story of the loss. Sullivan and
Beernman (1981) discuss the pervasive need for women to
reconstruct their birth experience, and in their sample, 80%
mentioned that they had wanted to discuss the delivery soon after
birth. I had the opportunity to observe this need in my limited
sample. The question of whether "telling the story" has amwy

connection to postpartum blues remains untested.

Critical Issues

Asking the subject to consider critical issues in her
experience, both good and bad, is another way to allow new ideas
to emerge about. what is important to the participant. I was
interested also in seeing if any critical issues related to
control over birth. The rest of the interview was related to a
review of the questionnaires and the woman's responses to the
instruments.

The interview was planned to take place over two visits. The
first was to include the birthing experience and occur within 24
hours of the delivery; the second was to take place just before

discharge so that the woman had the opportunity to complete the

44

questionnaires. In the even that the subject was discharged
within a 24 hour period, I planned to telephone or arrange a home

visit. The latter did not prove necessary.

PILOT STUDY

A pilot study was arranged at a community University-run
hospital under the supervision of a consulting psychiatrist who
was a member of the obstetrical department and service. She
arranged for me to meet several of the attending obstetricians,
resident physicians, and nursing staff so that I could introduce
myself and the study. I received permission to select and follow
five newly birthed mothers.

Type cfi’ delivery included ‘bmj cesarean sections and three
vaginal births. All the women were receptive to participating in

the study and all were able to complete the required instruments.
Revisions

Revisions made as a result of running the pilot included:
1. Names of the instruments were changed to neutralize their
intent. Hence, the "Control Over Birth" questionnaire was
renamed "Birth Experience" questionnaire. The "Blues"
questionnaire title was revised to "How Did Your Day Go Today."
2. The pilot study alerted me to the need to take time to gain
entry to the study setting. I allowed at least one week to be in
the setting without collecting data to enable me to talk
informally with staff and to accustom them to my presence on the
obstetrical floors.
3. The value of wearing a name-tag became apparent in view of the
number of staff members (and shift changes of personnel) in
contact with new mothers.
4. The need 1x) give special attention to rooms where there were

two or more mothers. If both were in the sample, some

4S

precautions had to be taken so that they would not share
responses before completing the qeustionnaires. If one was not
in the sample, an explanation needed to be given so that she
would not feel left out.

5. Question #15 in the Efirth Experience questionnaire related to
whether or not a perineal shave and enema were procedures
discussed with the birthing mother. I learned that at the
University Hospital, these procedures were no longer done. I did

not delete the time, however, because they were done on occasion
at the setting for the study.

CHAPER I II

ANALYSIS OF RESULTS

Introduction

 

This chapter reports the results of this investigation. It
is divided into four sections. The first provides an overview of
the data collected and analyzed. The second is a description of
the sample. The third section consists (fi’ a restatement of the
research hypotheses along with the results of statistical
analyses. It also includes other quantitative findings which
were not ewmicipated. The fourth section summarizes qualitative
data derived from the blues questionnaire and interviews.

The collected data were analyzed to determine a) if a woman's
history of stressful life events (RLEO) is related to postpartum.
blues, b) if a woman's sense of control over her birth experience
(C08) is related to postpartum blues and c) to learn more about
her experience with mood changes over the first four days
following delivery.

Postpartum blues is measured by four forms of the Depression
Adjective Check Lists (DACL, forms A,B,C,D) and by a
questionnaire regarding symptoms cfi’ the blues experienced by the
mother. These measures were made for the first four days
postpartum.

T-tests were utilized to determine if there are differences
in blues experienced by mothers related to their experience with
a sense) of control over birth. T-tests. were also utilized ‘to
determine if differences in intensity of the blues experienced
were related to scores on stressful life-event histories within
one year of delivery and/or prior to one year.

T-tests were also used to test whether there are significant
differences in blues experienced by women who were asleep or
awake during delivery; who felt they had "much" versus "little"

contact with their newborn infant; who felt they had (versus had

46

47

not) freedom to decide how soon to see their infant after birth;
who felt they had (versus not) their desired support persons with
them during the birthing experience.

T-tests were again utilized to compare this sample of women
to those of the larger population user! by Lubin to establish
norms for the Depression Adjective Check Lists (DACL). An alpha
of .05 was set for rejection of all null hypotheses.

Demographic information obtained ‘from the questionnaire and
medical chart as well 6E5 from hospital statistical summaries is
used to describe the sample. Additional information collected
firm] questionnaires, the' medical chart, and hospital follow-up

discharge notes is also described and summarized.
Description 9: Sample

A total of 86 women was selected from total admissions for
the study. Of these, 4 women were ineligible. One woman's
father died during the second day postpartum; one woman's baby
was sent to another hospital for further evaluation; and two were
under 18 years of age and therefore could not legally give
permission to participate.

Eleven women refused to participate in the study leaving a
total of 71 subjects in the final sample. The age ranged from 19
to 38 years of age. The mean age is 27 years. For 29 women
(40.8%) this was the birth of their first child; for 22 (31%) a
second child; for 10 (14.1%) a third child and for the remaining
10 (14.1%) their fourth or more child. Of the 71 subjects, 11
(15.5%) were single, 56 (78.9%) were married, and 4 (5.65) were
living with the father of the baby.

48

Table I summarizes age and marital status.

TABLE I
AGE AND MARITAL STATUS

AGE SINGLE MARRIED LIVING WITH
Fr % Fr % Fr %

UNDER 21 1 2.8 2 2.8 1 1.4
21-24 5 7.8 18 25.4 3 4.2
28-29 2 2.8 18 22.5 8 8.8
38-33 1 1.4 11 15.5 8 8.8
34 PLUS 1 1.4 9 12.7 8 8.8
CULUMN 18 57 4 71
TOTAL 15.5 78.9 5.8 188%

The racial distribution of time sample is 48 (67.7%) white,
22 (31%) black, and 1(1.4%) others. Median income for the group
was between #20,000 and $30,000 per year.
Table II Sumarized educational level.

TABLE II

EDUCATIONAL LEVEL OF WOMEN

LEVEL OF EDUCATION FREQ RELATIVE EREQ%
GRADE 10 T0 12 30 42.3
JR. COLLEGE 17 23.9
COLLEGE 20 25.2
GRADUATE 4 5.5

TOTAL 71 100.0

 

49

Table III describes occupations of mothers.

TABLE III
OCCUPATION OF WOMEN

OCCUPATION CATEGORY FREO RELATIVE FREO%
PROF EXEC 1 1.4
BUS MANAGER 9 12.7
SEMI—PROF 22 31.0
CLER AND SALES TECH 17 23.9
SKILLED MANUAL 3 4.2
SEMI-SKILLED 4 5.5
UNSKILLED 2 2.8
HOUSEWIFE/MOTHER 9 12.7
UNEMPLOYEO 2 2.8
MISSING 2 2.8
TOTAL 71 100.0

The sample population had considerable familiarity with the
community in that 50% of the women had lived in the area for
longer than 16 years. If women who had been in the community for
six years or longer are included, the number rises to 75%.
Potential support was also high. Mothers of 67% of the women
lived nearby. The fathers of 44% were in the community and 56%
of the women indicated that their inlaws lived in the area.

The study sample was compared with the total persons
discharged from the hospital maternity services over the same
period. The mean age of the larger sample was slightly younger,
26.4 years of age as compared with 27 for the study group. This
is understandable since all women under 18 were excluded from the
study. In the study sample, 63.4% of women were delivered
vaginally and 36.6% were delivered by cesarean section. The

larger sample indicated that vaginal deliveries accounted for 73%

 

50
of the sample and cesarean sections for 27%. This difference
might have been less if women 18 and under had been represented

in the study.

Table IV compares both samples.
TABLE IV

COMPARISON OF TOTAL DISCHARGED AND STUDY SAMPLE

 

 

TOTAL DISCHARGED STUDY SAMPLE
N=243 N=71

Mean age 26.4 27.03

BEE.

White 70% 67.6%

Black 29% 31.0%

Others 1% 1.4%

TYPE QE_DELIVERY
Vaginal 73% 63.4%
C/Section 27% 36.6%

The 11 persons who refused to participate in the study had a
mean age of 24.5. There were 2 black mothers and 9 white mothers
in the group. Eight of the 11 were married. 72% had vaginal
deliveries and 27.2% had cesarean sections. Place of birth
included 8 from the maternity floor, 2 from Home-Like Birth
Center and 1 was a transfer from this unit. Reasons given
included; my husband would rather I did not participate (2); I
don't have enough time to complete the instruments (4); would
prefer not to participate (5).

Except for the younger mean age, this group does not seem to
differ in any special way from the research sample. The two
refusals invoking husband disapproval came early in the study. I

subsequently was more careful to involve husbands in the decision

 

S1

process by explaining the study and asking for permission in his
presence. Once this plan was adopted. no other refusals occurred

for this reason.

Results gf_Hypothesis Tests

 

Ten hypotheses were developed to test empirically the
relationship between identified psychosocial variables
(independent variables) and postpartum blues (dependent
variable). Only one of these original hypotheses yielded
findings significant at the alpha (p=.05) level set. However,
other evidence of relationships between variables tested and
postparthT blues did emerge. These will be discussed in the

context of reviewing the original hypotheses.

H-1

WOMEN WHO SCORE HIGHER ON THE RLEO PRIOR TO ONE YEAR BEFORE
DELIVERY WILL HAVE POSTPARTUM BLUES OF LESS INTENSITY THAN WOMEN
WHO SCORE HIGHER ON THE RLEO WITHIN THE YEAR OF CHILDBIRTH.

H-2

WOMEN WHO SCORE HIGH ON THE RLEO PRIOR TO ONE YEAR BEFORE
DELIVERY AND WITHIN THE LAST YEAR OF CHILDBIRTH, WILL HAVE
POSTPARTUM BLUES OF LESS INTENSITY THAN WOMEN WHO SCORE LOW ON
THE RLEO PRIOR TO ONE YEAR BEFORE CHILDBIRTH AND UHTHIN THE LAST
YEAR OF CHILDBIRTH.

T-tests run to test for differences in postpartum blues
scores between the groups described in H-1 and H-2 did not yield

results significant at the .05 level.

52

H-3

WOMEN WHO PERCEIVE THAT THEY HAVE MORE CONTROL OVER DECISIONS
RELATED TO ASPECTS OF THE BIRTHING EXPERIENCE WILL HAVE LESS
INTENSE POSTPARTUM BLUES THAT WOMEN WHO PERCEIVE THAT THEY HAVE
LESS CONTROL.

Utilizing Pearson product-moment correlation, no significant
relationship between perceived control over decisions regarding
birthing (COB scores) and postpartum blues was found. Similarly
significant findings were not obtained using a t—test to see if
there were differences between extremely-high and extremely-low

blues scoring groups and C08 scores.

H-4

WOMEN WHO ACTUALLY HAD MORE CONTROL OVER DECISIONS RELATED TO
ASPECTS OF THE BIRTHING EXPERIENCE WILL HAVE LESS INTENSE
POSTPARTUM BLUES THAN WOMEN WHO HAVE NOT HAD ACTUAL CONTROL.

This hypothesis was not testable since there was no objective
way to compare a woman's perception of her control and her actual
control over decisions related to her birthing experience. For
example, an attempt was made to compare the "actual" and
"perceived" duration of and difficulty with labor. The hospital
chart generally indicated the time of labor onset once the woman
arrived at the hospital. Some women arrived at the hospital
almost fully dilated; others entered when the waters broke but
when labor was barely begun; some were induced and experienced an
intense active labor; others had a longer but less intense
experience. The information in the chart does not clarify these
issues and different obstetricians do not report information in

the same way.

53

H-S

WOMEN WHO PERCEIVE THAT THEY WERE AWAKE AND AWARE DURING THEIR
BIRTHING EXPERIENCE AND WISHED THIS KIND OF BIRTH EXPERIENCE,
WILL HAVE LESS INTENSE POSTPARTUM BLUES THAN WOMEN WHOSE
PERCEPTIONS WERE NOT CONGRUENT WITH THEIR WISHES.

This hypothesis was not testable because the sample groups
were too small. There was only one case where the woman was
awake and aware and did not wish to be. Of the five women who
reported being "half asleep", three wished that they had been
more awake; of the only three who were asleep during the
delivery, only one did not wish it to be that way. Clearly the
great majority of women in this sample were awake and this was

congruent with their wishes.

H-6

WOMEN WHO PERCEIVE THAT THEY HAD FREEDOM TO DECIDE HOW SOON TO
SEE THEIR INFANT AFTER BIRTH WILL HAVE LESS POSPTARTUM BLUES THAN
WOMEN WHO DID NOT PERCEIVE THIS FREEDOM.

The number of women who reported that they had the
opportunity to see their baby soon after birth as they wished
were in the great majority. Sixty-one of 85.9% saw the baby
within minutes of its birth; 9, or 12.7% saw the infant within a
few hours and one person could not remember. Sixty-three or
88.7% felt that they saw the child as soon as they wished.

A total of eight persons had experiences which were not
congruent with their wishes. Two persons saw their baby within
the first hour and one wished she could have seen the child
earlier; 7 saw the baby within a few hours and of these 6 wished
they could have seen the child earlier; one person could not
remember.

T—tests comparing the means on postpartum blues of those who

saw their babies as soon as they wished and those who did not,

 

54

did not differ significantly at the .05 standard set.

H-7

WOMEN WHO PERCEIVE THAT THEY HAD FREEDOM TO DECIDE HOW MUCH
CONTACT TO HAVE WITH THEIR INFANTS AFTER BIRTH WILL HAVE LESS
INTENSE POSPTARTUM BLUES THAN WOMEN WHO DID NOT PERCEIVE THAT
FREEDOM.

A t-test comparing the means on postpartum blues for womem
who felt they had freedom to decided about infant contact (N=66)
and those who felt they did not (N=5) yielded a t value of -3.23
with p=.05.

Unexpectedly, the five women who felt that they had less
freedom to decide about contact with their infant had a lower
postpartum blues mean score than those who felt they had more
freedom. Three of these women had infants that needed to be
placed under lights because of high bilirubin levels. Although
this is not a serious problem with infants, it did deny the
mother access to the baby in her own room. A third woman was
not able to manage her baby for about eight hours following a
cesarean section. The last was a mother who learned that her
baby was restless during the night following circumcision. She
indicated that she would have preferred that she had been wakened

to care for him.

H-B

WOMEN WHO ARE GIVEN OPPORTUNITY TO TELL A DETAILED STORY OF THEIR
BIRTHING EXPERIENCE IN THEIR OWN WAY SOON AFTER BIRTH WILL HAVE
LESS INTENSE POSTPARTUM BLUES THAN WOMEN WHO DID NOT HAVE THIS
OPPORTUNITY .

A t-test comparing the means of postpartum blues scores of
women who told me their birthing stories and all others in the

sample did not yield significant differences.

55

Only ten women formally told me their story as a part of the
study plan. I soon learned, however, that women were telling
birthing stories to visitors, to each other, and to friends
calling on the telephone. Subjects who were not in the selected
interview sample would often tell me at least some part of their
story although I did not invite them to do so. Telling the story
did seem to be a need for women and so it was a variable that

could not be controlled.

H-9

WOMEN WHO WISHED SUPPORT PERSONS WITH THEM DURING THE LABOR, AND
DELIVERY, AND IMMEDIATE POSTPARTUM AND PERCEIVED THAT THEY HAD
THE OPPORTUNITY TO HAVE THEM PRESENT, WILL HAVE LESS INTENSE
POSTPARTUM BLUES THAN WOMEN WHOSE PERCEPTION AND WISHES WERE NOT
CONGRUENT.

This hypothesis is not testable because only three persons in
the entire sample felt that they did not have the support persons
they wished to have there.

H-1O

WOMEN WHO WISHED SUPPORT PERSONS WITH THEM DURING THE LABOR,
DELIVERY, AND IMMEDIATE POSTPARTUM AND ACTUALLY HAD THEM
AVAILABLE WILL HAVE LESS POSTPARTUM BLUES THAN THOSE WHOSE WISHES
AND ACTUAL EXPERIENCE WERE NOT CONGRUENT.

This hypothesis is not testable. Again, 68 or 95.8% of the
women felt that support was adequate; that all the persons they
wanted with them were there when they wanted them.

It is possible that the birth plans around support were made
carefully and well. It is also possible that postpartum women
tend to say that they wanted the persons who actually attended
them during birthing. It may be a way of coming to terms with

the reality of what happened. To prevent this kind of bias, it

56

would have been better to have collected data regarding choice of

support persons during the last months of pregnancy.

Comparison 93: DACL Norms and Sample DACL Means

 

There were indications that the incidence of postpartum blues
in this sample was less than the 50%-60% or Rmre than might be
expected from my review of the literature. To verify this in a
general way, the group with high postpartum scores was plotted
over the four days postpartum. Every subject who had at least
one postpartwn blues score that was one standard deviation above
the mean established as a. DACL norm (Lubin, 1981,p.7) with 2
blues symptoms was included in this group. Forty—three women or
60.6% did not have any such scores. Twenty-eight or 39.4% did
have blues by this definition. Of these, 19 had only one such
score; 6 had 2 scores; and 3 had such scores for 3 days. These
unexpectedly low findings prompted the investigation of whether
the depressive mood in the sample of birthign women was within
the range of what ndgh be empected among populations of "normal"
women.

Measures for depressed mood in the study utilized four forms
of the depression adjective check lists, (DACL), designed by
Lubin. One of four different forms was given each day over a
period of four days. Mean scores and standard deviations on each
fornn were compareci with the Means and standard deviations for
female non-psychiatric patient samples utilized by Lubin to
establish nonms for the instrument (Lubin, 1981,p.7). Persons in
his sample seem to be comparable to those in my sample. A
specific description of the Lubin sample is not available. The
Lubin subjects numbered 591. The number of subjects in this

study is 71.

 

57

Table V compares the DACL Means of both groups.

TABLE V
COMPARING SAMPLE DACL MEANS AND LUBIN MEANS

THIS STUOY LUBIN

FORM A (Day 1)

MEAN 8.19 7.78

5.0. 4.95 5.39
FORM 8 (Day 2)

MEAN 5.93 7.32

3.0. 4.15 5.48
FORM C (Day 3)

MEAN 7.4O 7.87

5.8. 4.3O 5.33
FORM O (Day 4)

MEAN 5.71 7.82

5.0. 3.32 4.95

The following hypothesis was then tested;

THE LEVEL OF DEPRESSIVE MOOD IN THE SAMPLE POSPARTUM
POPULATION WILL BE GREATER THAN DEPRESSIVE MOOD IN A NORMAL
POPULATION.

58

Table VI show results of t-tests comparing the sample DACL "bans
and the DACL Means established for normal populations (Lubin).
TABLE IV
T-TEST RESULTS FOR SAMPLE DACL MEANS AND LUBIN MEANS

DACL FORM t p
Form A (Day 1) 0.816 -
Form B (Day 2) -2.70 *
Form C (Day 3) —O.92 -
Form D (Day 4) -2.82 *
*p=.05

The t values for Day 1 and Day 3 are not significant. We may
therefore assume that there is no difference between this
postpartum sample and a population of normal women regarding
level of depressive mood on these two days.

On Day 2 and Day 4, however, there are differences at the .05
level of significance. These are in a negative direction
indicting that the postpartum groups are significantly less
depressed than the norm Lubin established.

This is understandable for Day 4. It is homegoing day for
the majority of women and affect must be colored by this
expectation. Day 2 is more of a puzzle. It may be that it is a
more comfortable day for the mother. She has the opportunity to
see her infant and significant others in a more leisurely way.

The above findings challenge Tina notion that the first four
days postpartum are likely to marked by unusually depressed
affect.

Follow-up Data

Ten days after discharge from the hospital each woman was

telephoned by one of the head nurses to learn how the postpartum

59

home adjustment was going. In the context of asking about the
health of both mother and baby (nutrition, sleep) and the
adjustment of spouse and siblings, the subject was asked about
her emotional state. Data is complete for 58 subjects in the
sample. (10 subjects could rmfl: be reached after three telephone
attempts and three were from the HLBC and were routinely
contacted on the 4th rather than the 10th day).

Of the 58 responding, 48 or 79.3% reported feeling
emotionally stable and happy. Eleven or 19% reported having some
ups and downs mostly related to fatigue. Only 1 (1.7%) reported
feeling depressed and blue for the past three days.

This indicates that in the group that responded, complaints
of blues and depression were present in about 21% of cases after
10 days at home. The majority of women dicl not report such

episodes.
Additional Findings

Three additional analyses were carried out to answer the
following questions:

1. Is locus of control related to control over birth scores or
measures of postpartum blues?

T-tests cfixj not indicate significant differences related tn)
internal or external locus of control.

2. Does type of delivery affect postpartum blues scores?

A t-test did not indicate significant differences between
cesarean sections and all other types of delivery and measures of
postpartum blues.

3. Are primiparas more prone to postpartum blues?
A t-test did not indicate significant differences for

primiparas as compared to multiparas on measures of postpartum

blues.

 

6O

QUALITATIVE DATA

Blues Questionnaire

In addition to scoring a DACL form daily, each respondent
was also asked to complete an attached questionnaire regarding
symptoms of postpartum blues. This questionnaire was called HOW
DID YOUR DAY GO TODAY (Appendix 0). Four questions were designed
to explore the woman's understanding of why she might feel like
crying; why she might have cried; why she might have felt
irritable, anxious, or why she might have had a hard time
concentrating.

Similarly, questions were asked about positive states,
namely, feeling confident; happy and like one's old self; rested
and relaxed.

Most women made brief comments about what made them feel the
way they indicated they were feeling. A content analysis of
these statements is beyond the scope of the present study.
However, some illustrations of the kinds of events or situations
that stimulatemj a feeling response are presented. Common ones
relating to positive affect are reported below.

On the day of childbirth, many women reported feeling excited
and happy that the baby was born or finally born, that the child
was healthy; that it was the sex it was. Feelings of
self-confidence were related to support from spouse; feeling able
to care for baby; having someone (baby) "depend on me". During
the second and third day, several women linked feeling confident
with being up and around; feeling less pain; feeling stronger and
able to nurse baby better. A great number of women linked
feelings cfi’ confidence with having the opportunity to take a
shower. On the third and fourth day, happiness, excitement, and
self-confidence were linked to the expectation of going home.
Several women who had gone home on day 2 or 3 indicated that

being at home was connected with feeling happy and "like my old

 

61

self."

Responses to what made the woman feel like crying or what
made her cry, feel irritable, anxious, or unable to concentrate
were very varied. Many "one of a kind" statements occurred.
Illustrations of the more common responses, however, may be
grouped under such themes as recollections of the birth; present
physical discomfort; concern over older children; loneliness;
ability to care for infant; comments of nurses; and lack of
sleep. Some examples are given with the postpartum day on which

they were reported indicated in parenthesis.

RECOLLECTIONS OE BIRTH:

 

(1) the spinal numbed we LKJ‘UJ my chest and II had fears about
being able to breath... felt tied down in delivery... it all
came back and made me feel like crying.

(1) felt angry that the epidural they gave me was not
enough manage the pain and thinking about it made me cry

(1) cried when I samu the baby, felt so relieved that the birth
was over

(1) keep thinking about the birth and what might have happened
(crying)

(1) am crying from relief: now that the birth is over, I don't

have to worry about it anymore
PRESENT PHYSICAL DISCOMFORT:

(1) hurting too much to nurse the baby (felt like crying)... too
uncomfortable to hold him...no family here, they all live away

(1) my butt hurts and my nose is stopped up.. I think it is from
drugs (feel like crying)

(2) worried that my bowels haven't moved and that something bad
will happen (anxious)

(2) have head and abdominal pain and I worry that I'll never get

 

62

to go home (anxious and crying)
(2) the pain medications make me groggy (concentration)
(3) crying because they had trouble with the IV and the kept

fussing over it.. I think I have a bad infection
CONCERN OVER OLDER CHILDREN:

(1) worried about the two kids at home; I cried when I talked to
them on the phone

(1) all of a sudden I'm the mother of two kids and it makes me
anxious; I know the older one is having a hard time with all of
this

(2) I have never been away from my little girl and she cried when
she had to leave me today and I cried too

(2) this is the first time my son is living away for home and I'm
worried about him

(3) I worry how the older children will adapt to the baby and I
thought about that all day today

(3) my husband has to go back to work today and I know the baby

(two-year old) will be scared

LONELINESS:

(1) I thought how I missed my husband and little girl at home
(crying)

(2) this is the first time I've ever slept in a room alone; I
cried when my roommate left

(2) I wanted my husband to keep me company because I'm lonely and

I got angry when he left

ABILITY IQ_CARE FOR INFANT:

 

(1) scared to hold the baby; afraid it would choke (anxious)

(1) (anxious) worried that 11 ckrflt; have enough things for the

63

baby

(2) anxious because the baby sleeps too much; doesn't feed well

(2) baby wouldn't quiet down and I didn't know what to do (felt
like crying)

(3) my breast was engorged and the baby wouldn't grasp and they
left me all alone with her until noon (felt like crying; had not

confidence)

NURSING RESPONSE:

 

(1) nurse told me that I was holding the baby wrong and I felt
dumb (cried)

(2) I didn't want to feed the baby at 6AM because I felt too
unwell and I think the nurse was angry and thought I was a
bad mother (crying and irritable)

(3) I felt irritated because the nurses weren't giving me any
attention and the baby kept crying and I wanted help to quiet
him

(3) I told the nurse that I didn't want to breast feed and I know

she was angry (anxious and irritable)

LACK 95 SLEEP:

 

(2) just couldn't sleep last night or today; feel exhausted
(irritable)
(3) they left me with the baby all night and I couldn't get any
sleep (crying)
(2) I just feel so tired that it scares me (anxious and
irritable)

Illustrations of the still other kinds of responses are as
follows:
(2) the father didn't come to the birth and he's not here now and

this pregnancy was unplanned and I just feel disappointed

(crying)

 

64

(2) the baby was circumcized and the nurse said he was up all
night and I felt sad and angry that they didn't bring hhn to me
(irritable) and I feel upset that it was done at all (crying)

(3) (crying) when my parents came and held the baby it just felt
so overwhelming like a miracle but it was sad too

(1)(crying) just so many unexpected things keep happening that I
worry if I'll ever get through it all (unplanned C section)

Of interest is that pll_ respondents gave explanations for
some of the blues symptoms they experienced although they did not
necessarily comment on each instance. Only two women noted on
the questionnaire that they didn't know what might be responsible
for their negative feelings.

In my conversations with women, it was common to hear "I
don't know why I'm feelin blue" as an initial response. However,
when I pursued the inquiry, asking if they and any hunches about

why, they always reconsidered and gave an explanation.
Interviews

Ten interviews were completed. Each interview began by
making a recording of the birthing story. Each woman was told to
begin wherever she liked and to indicate to me when she was
finished with her story; that I would not interrupt. In two
instances, the husband was present at the interview and
participated in telling the story. All participants knew that
the information would be kept confidential; the data would be
kept under code numbers; and that they would receive a copy of
the recording on the following day.

All of the women or couples interviewed reported that they
enjoyed 'the opportunity of telling the story. Eight of them
spontaneously said that the process made them feel better.

Following the story, each woman was asked to tell the three

best and worst times for them during the birthing experience.

The remaining questions related to their experience in completing

 

65

the study instruments. I was open to .also hearing about any
other comment they wished to make about birthing and their
observations about any variations in mood since the delivery.

Most of the interviews took place at the bedside with the
infant present. In five cases, the father was also present. The
low maternity-unit census permitted privacy in that most women
roomed alone. At the HLBC, one interview took place at the
bedside and the other in a sitting room.

The scope of this study did not permit analysis of the
birthing stories. The focus for purposes of this research
was to give the new mother an opportunity to review the birth in
the presence of another person. Illustrations of the interview
summaries appear in Appendix H.

A review of themes identified when women discussed best and
worst times of their birthing experience, revealed some
commonalities. Positive themes were associated with beginning
labor and getting to the hospital or birthing center; seeing the
baby born and being able to confirm for oneself that the baby was
OK: that the baby was the desired sex; that support was present,
particularly the fathers.

Negative commonalities are connected with severe pain,
especially just prior to delivery; post-delivery pain and
discomfort; and disppointment about the type of delivery or the
way the delivery went. Even after having one or more childbirth
experiences, the amount of pain and discomfort experienced seemed
unexpected. Unexpected amount of pain; unexpected changes in the
delivery plan; unexpected response a given mother had to the
pain, and changed circumstance all were related to "worst times."
Post-delivery pain often made women angry. They were being asked
to be joyous and to look after the baby and yet felt that they
were too uncomfortable to do either.

Postpartum blues symptoms in this small sub-sample, when they

occurred, lasted for only one day. In each instance, symptoms

were associated with physical discomfort.

 

66

Reactions to the research instruments indicated confusion
with the RLEQ. Women had difficulty recollecting positive and
negative events over their lifetime. They explained that what
was once important to them did not seem so any longer. One said
"having a baby makes everything else seem like nothing by
comparison."

Reactions. to the C08 instrument were that although choices
were available, it was not always possible to have the choice you
most wanted. Namely, there really wasn't much choice about have
a cesarean section. "It had to be done." Similarly, there were

compelling reason to agree to have a fetal monitor or to remain

in the hospital for a required number of days.

 

 

CHAPTER IV
SUMMARY AND DISCUSSION

This study proposed 1x) identify psychosocial factors related
tr) postpartum blues. Review of the literature indicated that
postpartunl blues is, in this culture, an indentifiable entity
characterized lay sporadic crying related to depressed ‘feelings
during the first three to five days following childbirth. Because
of the high incidence of this syndrome (50% to 85% in this
culture), it has been considered by many as a normal reaction to
childbirth.

Suggested explanations for the blues have included its
relationship Tuith "milk fever", (Savage, 1875); the trauma of
birth such as long labors, medication, disappointment in the
labor experience, (Affonso, 1977); mother-infant separation .and
the absence of significant support persons (Klaus and Kennel,
1982). Research efforts have reflected biological, psychosocial,
and crosscultural perspectives.

This study proposed that postpartum blues is a type of grief
response to the experience of loss related to physical, social,
and psychological changes engendered by the childbirth. Although
often unacknowledged and less intense, this experience parallels
a grief process. The birthing environment and system were
considered important variables in affecting the intensity of
grief. Also of importance was a woman's sense of control over
the birth and her previous experience with life changes. To test
the utility of this framework for understanding blues, I
hypothesized that postpartum blues would vary with measures of
control over birth and reports of life change history, (life
events). No previous attempts had been made to relate these
specific variables to postpartum blues.

A sample of 71 women who delivered babies in a setting which

permitted a broad range of birthing plans and interventions was

67

68

studied. All deliveries were considered low risk. All infants
were delivered near or at term and were considered to be normal.
Women in the study were asked to fill out checklists and
questionnaires and ten of the sample were interviewed. Although
none of the study's primary hypotheses tested yielded significant
findings, some important unexpected findings did emerge.

Most important was the discovery that the incidence of
postpartum blues in this sample (as measured by daily combined
scores of depressed mood and postpartum blues symptoms), was much
lower than expected. Over a four-day period, less than 40% of
women experienced blues and of these, only 12.6% experienced them
for more than one day.

A comparison of scores on the Depressed Adjective Check Lists
(DACL) of this sample and the norms established for the
instrument indicated that this group of women did not differ from
the normal population on days one and three of the four-day
measurement period. On days two and four, depressed mood was
significantly lggg than what might be expected in a normal
population. Follow-up data collected for 58 subjects 10 days
post-hospitalization indicated that 19% experienced minor mood
variations attributed by the women to fatigue. Only one person
had more pervasive and enduring depressive symptoms.

Variables expected to relate 1x) the intensity of blues were
unexpectedly homogeneous. Most women in the sample were awake
and wanted to be; saw their infant soon after delivery and wanted
to; had as much contact with their infants as they wished; and
had wished-for support persons available to them. I was unable
to adequately test for differences in intensity of blues because
the subsample of mothers who were negative regarding these
factors was too small.

In addition, other characteristics of the sample population
may have also affected the blues scores. Three quarters of the
women had lived in the community for more than six years and had

available family support in the immediate area. Most had

69

reasonable financial resources and were essentially healthy
persons with no chronic diseases.

Ten of the 71 women were given the opportunity to tell their
birth story within 24 hours of delivery with the assumption that
this experience might modify the intensity of the blues. Again,
this variable, when tested, was not significant. The setting,
however, seemed to permit and even invite most women to tell
their stories. Each woman had a private telephone; each woman
had permission to have at least two support persons with her
constantly and other family and friends were permitted access for
two hours daily. Also, since the floor census was low, many of
the women may have had more than usual access to the staff. The
implication is that "telling the story" as a variable could not
be controlled.

Responses to the blues symptoms questionnaire and interview
material indicated that women were able to relate depressed mood
or blues symptoms to particular events or circumstances in their
present situation. This was contrary to Yalom's conclusions
(1968) that women were puzzled by their symptoms and could not
explain them. In the present research, women attributed their
blues symptoms to recollections of the birth; to postpartum
physical discomfort; to concern over older children left at home;
to loneliness; to concerns about ability to care for the infant;
to nursing comments experienced as being critical; and to lack of
sleep.

In my view, the above set of factors relate to grief.
Childbirth is experienced as trauma and is connected with
physical and emotional loss. When invited to describe their
birth experience, the ten women welcomed the opportunity. They
appeared to find significant emotional relief in detailing the
events, suggesting that the telling of the birth story
significantly aided coping with the disruptive and frightening
aspects of the experience. Having physical discomfort at a time

when one expects to enjoy a new status and to invest energy in

7D

the new baby is experienced as disappOinting. Worry about older
children and a sense of loneliness is a function of feeling the
loss of important others in their lives as well as the loss of
the home environment.

Concerns about the ability to care for the infant, response
to nursing comments and lack of sleep may also be related to a
grief response. They reflect worry about the need to learn the
mothering role (and coping with the losses implicit in that
change). Worries are compounded by feeling physically
uncomfortable and/or tired. Some mothers comment on how they
worry that they will never have enough rest again. New mothers
in this situation are often vulnerable to what they interpret as
critical comments cfi’ nurses. Sadness, anxiety, and anger become
common and understandable affective responses.

During interviews, women commenting on the negative aspects
of their birthing experience identified severe> pain during the
post—delivery as a central factor. No amount of Cmeparation was
effective in helping them cope with this. Unexpected character
of the pain, unexpected changes in their delivery plan and
unexpected sex of the baby were also connected with negative:
aspects of their birthing experience. These events seem to
reflect times of less control. By contrast, positive aspects of
the birthing experience were relatecl to high control and less
sense of loss. Such concrete events as finally going into labor
and getthmg to the hospital are examples. Others include seeing
the baby born, seeing that the baby was of the desired sex, and
having wished-for support available.

Although the original hypotheses were not supported, these
findings encourage continued exploration of the relationship of

loss and grief to postpartum blues.

71
Incidence pf; Postpartum Blues

In this study the incidence of postpartum blues was less than
expected. If the birthing setting exerts an effect on the
incidence of postpartum blues we may conclude that the syndrome
is potentially modifiable. An important consequence of such a
conclusion is that research into the proportional contribution of
biological, psychological and social factors will continue to be
studied and that the current bias toward biological causation
will be modulated.

It is important to realize that this study was conceptualized
during a period of reevaluation of the birthing system in this
culture. Increased awareness of the medicalization and
technicalization of birth and its possible consequence to the
emotional response of birthing women has become more common.
Hospitals and obstetrical practice began to reflect the demand
for change. This study set about testing ideas about an old model
in an already developing new model of care.

This time gap created a serious problem for the researcher.
It was anticipated, for example, that choice for the birthing
woman would be limited and that if it was limited in certain
critical areas, this would affect postpartum blues. Instead,
most women felt they had choice regarding type of birth, presence
of support, access to the infant, etc. The hospital setting of
the study had already created a more flexible system such that
birthing plans could be more individualized to meet the needs of
the woman and her family.

Jordan, (1983), suggests that such flexibility in the system
is more likely to reflect the current changing social context for
women and their new perceptions of themselves and their power to
affect their lives. She implies that this may be more beneficial
in improving birth experience and outcome than fixing on one
specific model of care. Indeed, such flexibility may also be

affecting the incidence of postpartum blues.

72

Limitations pf the Study

A limitation of this study is its reliance upon the self
report method for gathering information about the subject's
experiences, history, and present state. Subjective biases are
introduced .suggesting cautious interpretation of the scores can
the adjective check lists and questionnaires.

For example, asking subjects to respond to these instruments
soon after delivery did seem to interfere with the capacity for
some to recall events for the RLEQ. Women reported that they
were so fixed on the childbirth experience, they found it hard to
recall or appropriately weigh the effect of other events in their
lives. Also, feeling unwell seemecl to inspire recollection of
more negative events. Feeling happy and relieved inspired a more
positive set. Similarly satisfaction or cfisappointment with the
baby's father's attentiveness colored RLEO reporting of their
history as a couple and the changes in their relationship.

Another, more general limitation of the RLEQ instrument is
that it involves retrospective self-reporting and as such is open
to memory error. This is a particular problem when the
respondent is asked to recall a lifetime of events. Recollection
may also depend upon the trauma associated with the event and/or
timing of the inquiry. For example, an illness which felt
traumatic one month ago is forgotten six month later. Also, the
order of the items may influence associations in ways that alter
what is remembered and what is forgotten. These remain
limitations for this instrument as well as for most life event
schedules.

For future studies I Idould suggest that the RLEO be given
within the last trimester of pregnancy and that the time frame of
"events in your complete lifetime" be modified to "within the
.last ten years". Early childhood experience could be more

(effectively gathered by a straightforward inquiry regarding

t
AH

1A

to

:u

8.".

1 F11

in

73

personal history. Deaths, divorce of parents, major relocation
and the like could be learned in this way. An objective check of
the subject's recollection of events would strengthen the
findings. A spouse or significant friend or relative might be
recruited to provide such a check.

In this regard, there were no objective observations of
actual behaviors related to the blues symptoms made in this
study. The study depended upon the subject's perception of all
these factors. Such observations would have helped to validate
measures of the blues.

Responses. to the Control Over Birth questionnaire Tmay have
also been biased by the respondent's loyalty to the birth and by
her gratitude that the pregnancy had a "good outcome".

The Control Over Birth questionnaire may need further
modification if it is to be used in further studies. The
instrument must reflect not only the feeling that there was
choice, but on whether the subject felt that she was given true
options. For example, some women complained that choosing to
have a cesarean section was the only possible choice in view of
what they were told were complicating circumstances. They were
concerned that other options remained unexplored. Such
situations led to reporting high control over birth despite the

feeling that there was little control.

Suggestions for Further Research

Measuring the incidence of postpartum blues in a setting
which is based on an earlier model of obstetrical care would help
to verify that the setting and system within that setting might
affect postpartum blues.

The continued exploration of the relationship between grief
and postpartum blues seems to be a promising area of research.
There is sufficient clinical evidence to encourage more studies

in this area. Comparisons of the behaviors of postpartum women

74

zmnj persons undergoing other major life change is one
possibility. Carefully tracking and providing women with an
opportunity to tell and retell their birth story as an aid to
grieving and measuring its effect on blues is still another
possible project.

Discussions with seasonecl nursing staff on the obstetrical
service supported the notion that more mature women had less
postparthT blues than women who were less experienced in the
world. Nurses felt that there were fewer women havirm) blues
nowadays and saw this as related to the birthing women being more
mature. Perhaps continued refinement of the RLEO would help
demonstrate this clinical impression.

Nurses also felt that I was giving too little attention to
the issue of drugs. They explained that women were given
codeine, demerol, restoril, and dalmane to help them cope with
discomfort. These drugs often make women feel more disabled,
interfering with their capacity to concentrate. Many women never
had drugs of this kind before and became frightened and depressed
in response to them. Certainly it would be important to include
drugs as still another variable affecting blues.

Most important is to continue the exploration of blues
symptoms as having meaning. We may be calling a set of
understandable, normal, coping behaviors the postpartum blues. By
so doing, we imply that these behaviors and feelings are a form
of illness. This assumption can seriously prevent new
understanding .and has often done a disservice to women. For
example, women who complained about being tied down during
delivery were once thought 1x) be neurotically disturbed. It is

now seen as an understandable and appropriate reaction

75
Implications for Social Work

In their recent comprehensive review article on improving
pregnancy outcome Royer and Barth (1984) suggest the need for
interventive strategies for social workers to use at the policy,
program and case levels to effect this change.

They note that thus far the profession's focus has been
almost exclusively on the study and treatment of complicated
pregnancies. and premature) births. This severely limits social
work's potential role in promoting maternal and infant health in
more normal populations. It could be argued that the more
normative population of pregnant and postpartum women should be a
central concern to social work in order for the profession to be
effective in preventive efforts.

Social workers have a range of interventive opportunities
available in a comprehensive system of maternal and infant health
care (Watkins, 1979). Such opportunities begin with the nmther's
preconceptual health, the infant's intrauterine development, and
includes the mother's and infant's postnatal course.

It has been previously demonstrated that isolated women with
high life-change scores during pregnancy have increased
complications around birthing (Nucholls, Cassel, and Kaplan,
1972). Women who have the continuous company of a lay person
during labor and delivery tended to have shorter labors, fewer
instances of cesarean sections, forceps deliveries and
stillbirths (Sosa et al., 198O). Such studies point to the
importance of assessing psychosocial variables and their impact
on the birthing woman.

A major focus of this study has been to discover the effects
of the birthing environment on the new mother's postnatal
adaptation. By suggesting that the postpartum blues experience
varies in response to social and psychological issues, the
possibility is reopened for designing birthing environments and

systems of care which will diminish the incidence, intensity and

76

duration of the blues. Through research, the social work
profession can participate in facilitating institutional
responsivity to the changes birthing women require.

My discussions with nurses on the obstetrical floor
reinforced for me the need for adding a social work perspective.
Although care was compassionate and thoughtful, there was
insufficient attention paid to the particular social and
psychological needs of the individual patient. Caretakers need
to be alerted to the double messages given their patients. On
the one hand, postpartum women are told that they are ill enough
to need IV's and medication. On the other hand, they are told
they are well enough to show intense interest in their infant.
They also are urged to care for the infant no matter how badly
they feel physically or psychologically. Similarly, the nurse
who reports: "Mrs. X is irritable; I told her it was probably the
blues; She was relieved to know that this was the trouble;" may
be helped to respond to such patients with greater capacity to
understand what factors are behind the blues in that particular
woman.

Clinically, it would be important to remain alert to the
losses involved in normal childbirth and to develop programs to
keep both women and caretakers mindful of this issue. Educational
groups such as the ones developed by Dooley and associates (1983)
are excellent models.

Perinatal programs developed by social workers must maintain
a comprehensive approach. Support programs as outlined by Gray
(1982) for parents at risk for child abuse might ideally be made
available to all mothers. Such programs include opportunity for
prenatal education, prenatal family and peer support, presence of
helper during hospitalization, early contact between parents and
infant, easy access of infant (rooming-in), ongoing contact
postnatally (including supportive telephoning, home visits,
availability of support groups), concrete economic and health

care services, and professional referral. In addition, I would

77

assure parents choice of birthing environment most congruent with
their needs. Provision of such choice lends professional
confirmation to the knowledge that childbirth is a significant
change event for the mother, father, and significant others.
Childbirth in this. highly technological and socially isolating

culture deserves this kind of planning and attention.

APPENDICES

APPENDIX A

SUMMARY OF RESEARCH FOR HOSPITAL COMMITTEE

THE RELATIONSHIP OF LIFE CHANGE HISTORY AND CONTROL OVER

BIRTH TO POSTPARTUM BLUES

APPENDIX A
SUMMARY OE_RESEARCH STUDY FOR HOSPITAL COMMITTEE
THE RELATIONSHIP OF LIFE CHANGE HISTORY AND CONTROL OVER
BIRTH TO POSTPARTUM BLUES

This study explores the relationship between some
psychosocial variables (life change history and control over
birth) and the common mild transient depression occurring within
three to five days of delivery. The incidence of postpartum blues
remains high. The estimate is about 60% in normal populations.
Although biological factors probably contribute to the timing and
intensity of the "blues", the literature and clinical experience
indicate that other variables might also be influential.

The study requires a sample of 70 postpartum women. Type of
delivery is not an issue as long as mother and full term newborn
have no unusual complications. The study will be explained to
each prospective subject and a Signed letter of consent will be
obtained before her participation begins.

Each woman who agrees to participate will be asked to fill
out a total of two brief questionnaires on each of the first four
postpartum days. The Depression Adjective Check List designed by
Lubin (1969) to measure mild depression in postpartum populations
will be collected daily. In addition, each woman will be asked
to complete a Schedule of Life Changes patterned after the
instrument designed by Holmes and Rahe (1967), and a short
questionnaire regarding her role in the birthing experience
patterned after one developed tn! Bradley (1983). Dr. Bradley, a
research associate at the School of Nursing at the University of
British Columbia has corresponded with me about the possibility
of comparing findings.

A random sample of 10 women will be selected from the
original group of 70 for interviewing. These women will be asked

about their birth experience and will also be asked to elaborate

7B

79

on their responses to the questionnaire.

Booth Memorial Hospital was ChOSETI as the proposed setting
for the study on the recommendation of Marshall Klaus, M.D. who
advised me of its excellent reputation and special interest in
birthing research. He also suggested that the philosophy and
caring ways of the naternity service would probably result in a
lower blues incidence in the population served by the hospital.

This research project has been reviewed by my doctoral
committee at Michigan State University which includes senior
faculty in the fields of social work, clinical psychology, and
anthropology.

They agree that this study will have no negative effects and
might indeed tn; a positive and interesting experience for the
participants.

I am prepared to do all the interviewing and data collection
personally and to complete these aspects of the project in a 30
day period. Confidentiality will be maintained and great care
will be taken to minimize interruption of the usual floor
routine.

My qualifications to do this project are enhanced by my being
an experienced practicing social worker with long term interest
in new mothers and their infants.
about
Lubin, B.L. Adjective check list for measurement of depression.

Archives 9: General Psychiatry, 1965, 12, 57-70.

 

Bradley, C. The antecedents and consequences of maternal adaptation in
the postpartum period.University pf; British Columbia and the Vancouver
Health Department.March, 1983.

 

 

APPENDIX B
CHILDBIRTH RESEARCH STUDY

Informed Consent Form

APPENDIX B
CHILDBIRTH RESEARCH STUDY

Informed Consent Form

 

We are trying to learn more about childbirth so that we may
increase our understanding and sensitivity to the needs of women
at this important time. This study asks participants to respond
to some questionnaires about their present birth experience and
life history.

Participation is voluntary. The permission statement which

follows provides more detail:

I understand:

1. that this is a research project, the nature of which has
been explained to me.

2. that my voluntary participation involves completing a
series of brief questionnaires during the first four days after
delivery and perhaps an intervieul with the researcher, Marsha
Worby.

3. that I am free to discontinue my participation in the
study at any time without penalty.

4. that all information that I give will be treated in the
strictest confidence and that at no time will my name or the name
of my infant be used in the report of the study.

5. that participation in the study does not guarantee any
beneficial results to me (although it may be of eventual benefit
to birthing women).

6. that the proposed research in no way interferes Tuith
standard medical treatment or my rights as a patient.

7. that at my request, I can receive additional explanation
and results of the study after my participation is completed.

8. I give my permission to Marsha Worby to have access to

the medical records of myself and my infant.

BO

81

Date:

Signed Witness

 

This study is conducted by Marsha Worby ACSW under the
supervision of Gerald Bostwick, Ph.D., School of Social Work
Michigan State University. Permission and approval has been
received from the appropriate administrators and research

consultants at Booth Memorial Hospital.

APPENDIX C

DEMOGRAPHIC DATA

APPENDIX C
DEMOGRAPHIC DATA
ID# TEL# DATE:

Age:
Marital Status: Please Check:

 

 

Single Married (how long) Living/with (how long)

Ever divorced (how long ago)

Pregnancy: First___ Second____ Third____ Fourth or more_____
New Baby's Sex: Girl____' Boy
Other Children? Please give sex and age: Age___Sex__
Age___Sex__
Age__ Sex__
Education: Check last completed:
Grade 9 or less ____ Jr. College____
Grade 10-12___ College____ Postgraduate____

Occupation:

Your occupation before (or during) pregnancy
Your husband/partner's occupation
Family income: Check one:

10,000 and under

10,001 - 20,000

20,001 - 30,000

Over 30,000

Did you attend prenatal classes in childbirth education? Yes
N0

How long have you lived in this area?

Do other family members live in this area? Please check:

mother father
sister brother
inlaws others

82

APPENDIX D
MEASURES OE POSTPARTUM BLUES

1. Depression Adjective Checklists
Forms A,B,C.D.

2. (Blues Questionnaire)

HOW DID YOUR DAY 90 TODAY?

PLEASE NOTE:

Copyrighted materials in this document
have not been filmed at the request of
the author. They are available for
consultation, however, in the author's
university library.

These consist of pages:

APPENDIX D: 83-86

 

 

 

 

 

 

Uni '
NvEtTonyfilms
International

300 N. ZEEB 90.. ANN ARBOR, MI 48106 (313) 761-4700

APPENDIX D

CHECK LIST

DACL FORM A
By Bernard Lubin
Name Age Sex
Date Highest grade completed in school

DIRECTIONS: Below you will find words which describe different kinds of moods
and feelings. Check the words which describe How You Feel Now - - Today. Some
of the words may sound alike, but we want you to check all the words tint describe
your feelings. Work rapidly and check all of the words which describe how you
feel today. —'

 

 

 

1.0 Wilted ' 17. 0 Strong
2.0 Safe 18. 0 Tortured
3. [j _Miserable 19. Cl listless
4.1:] Gloomy . 20. [:1 Sunny
5.Cl Dull 21. E1 Destroyed
6.D Guy 22. D Wretched
7.0 Law-spirited 23. 0 Broinen
8.0 Sad 24. 0 Light-hearted
9. 0 Unwanted 25. 0 Criticized
10.0 Fine 26. Cl Grieved
11.0 Broken-hearted 27. El Dreamy
12.0 Down-cut 28. 0 Hopeless
13. 0 Enthmiutic 29. 0 Oppreeeed
14. 0 Failure 30. Cl Joyous
15.0 Afflicted a1. 0 Weary
16.0 Active 32. 0 Droopy

Q...- .. m.-...................................... .................................._.

83

APPENDIX D

CI-IECK LIST

 

DACL FORM D
By Bernard Lubin
Name Age___ Sex
Date Highest grade completed in school

 

DIRE CTIONS: Below you will find words which describe different ldnds‘ of moods
and feelings. Check the words which describe How You Feel Now - - Today. Some
of the words may sound alum, but we want you to check all the words that describe

 

your meg. Work rapidly and check .a_ll_ of the words which describe how you
feeltoday.

1. 0 Depressed ' 17. 0 Fit.

2. D Elated 18. D lonesome

3. 0 Awful 19. 0 Unloved

4.0 lifeless 20. 0 Glad

5. 0 Griefsbicieen 21. 0 Grave

6. 0 Inspired 22. 0 Sunk.

7. 0 Woeful 23. 0 Shot

6.0 Lonely 24. 0 Merry

9. 0 Suffering - 25. 0 Wasted

10.0 Mellow 26. 0 Washstut

11. 0 Drooping 27. 0 Clear

12.0 Rejected 28. 0 Gruesome :

13.0 Fortunate 29. 0 Tired

14.0 Dreary 30. 0 High

13.0 may 31. 0 Worse

16.0 Good 32. 0 Drainsd

One: “I momumsflummm-‘wm monk-”mummy“-

86

APPENDIX 8
(Blues Questionnaire)
HOW DID YOUR DAY 88 TODAY?

DAY# ID#

THIS QUESTIONNAIRE ASKS FOR INFORMATION ABOUT YOUR MOOD TODAY.
SINCE YOUR MOODS WILL VARY EACH DAY YOU ARE IN THE HOSPITAL, WE
ASK THAT YOU FILL ONE OUT FOR EACH DAY FOLLOWING DELIVERY. (FOUR
TIMES). PLEASE DO IT AFTER YOU HAVE HAD YOUR SUPPER.

1.

Did you feel like crying today? Yes No

 

Did you actually cry? Yes No

 

Do you have any idea about what made you want to cry?

(If yes, please answer in a few sentences)

Have you felt self-confident today? Yes No

 

Do you have any idea about what made you feel self-confident?

(If yes, please answer in a few words or sentences)

Have you felt anxious or worried today? Yes No

 

Do you have any idea about what made you feel that way?

(If yes, please answer in a few words or sentences)

Have you felt irritable today? Yes No

 

 

Do you have any idea about what made you feel that way?

(If yes, please answer in a few words or sentences)

Have you found it hard to concentrate today?Yes No

 

B7

BB

6. Have you felt excited, happy, and "pretty much your old self"
today? Yes No

 

 

Any idea of what was making you feel so happy?

(If yes, please answer in a few sentences or words)
7. Have you felt relaxed and well rested today?Yes No

8. PLEASE CHECK ONE OR MORE:

Today I felt as if:
didn't know how to respond to my baby at all___
began to get the idea of how to respond ___
felt I knew how to respond pretty well____

felt I knew how to respond very well

HHHHH

felt I knew how to respond to my baby better

than any of the nurses

THANK YOU

APPENDIX E

(CONTROL OVER BIRTH)

BIRTH EXPERIENCE

 

APPENDIX E
(CONTROL OVER BIRTH)
BIRTH EXPERIENCE
IDi_____ DATE OF DELIVERY
TODAY'S DATE

This questionnaire is designed to learn about some aspects of

 

 

your total birthing experience, particularly labor and delivery.

There are no right or wrong answers. We are interested in your

honest feeling about how things went for you.

1. My labor experience was what I expected it to be.

--* ........... u ___________ u ___________ x ............ a----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

2. My delivery experience was as I expected it to be.

--* ........... u ___________ u ___________ a ............ *----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

3. How would you rate your labor and delivery?

--* ___________ a ___________ u ___________ x ............ *-_--
Very long Very Short
4. How would you rate labor and delivery?
--* ___________ 2 ___________ a ___________ x ____________ *---_
Easy Difficult
5. I felt that I had control over my birthing experience.
_-* ----------- u ----------- x ----------- a ------------ *_---
Strongly Agree Neutral Disagree Strongly
Agree Disagree

89

90

6. My birth experience has made me afraid to go through it again.

--* ----------- a ----------- u ----------- u ------------ u----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

7. I was able to have the baby whenever I wanted to and return

him/her to the nursery whenever I wished.

--* ----------- X ----------- a ----------- a ------------ *----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

8. My husband/partner was free to participate in caring for our

baby whenever he wished.

--* ----------- u ----------- n ----------- a ------------ *-_--
Strongly Agree Neutral Disagree Strongly
Agree Disagree

9. I was able to see my baby as soon after the delivery as I

wanted to.

--* ----------- u ----------- n ----------- u ------------ *----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

10. The amount of pain medicine that I had during labor was just
what I needed.

--* ----------- u ----------- a ----------- n ------------ x----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

11. I was permitted to decide whether or not I wanted a relative
or friend with me during labor and delivery.

--* ----------- a ----------- a ----------- u ------------ *_-_-

Strongly Agree Neutral Disagree Strongly

Agree Disagree

91

12. During labor I was free to do whatever I felt would make me

most comfortable.

--* ----------- x ----------- u ----------- a ------------ *_-__
Strongly Agree Neutral Disagree Strongly
Agree Disagree

13. I was invited to help decide how long I needed to be in the

hospital.

--* ----------- x ----------- a ----------- n ------------ x----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

14. I was free to decide whether I wanted to be asleep or awake

during delivery.

--* ----------- u ----------- x ----------- u ------------ *---_
Strongly Agree Neutral Disagree Strongly
Agree Disagree

15. The decision about whether or not to have a perineal shave

and enema was discussed with me.

--x ----------- a ----------- x ----------- a ------------ x----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

16. I helped make the decision about whether to have a fetal

monitor during labor.

--* ----------- x ----------- u ----------- x ------------ *----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

FOR CESAREAN SECTION MOTHERS

 

A. I felt that I participated in make the decision to have a C

Section before I came to the hospital.
--* ----------- a ----------- a ----------- a ------------ *----

Strongly Agree Neutral Disagree Strongly

Agree Disagree

92

B. I participated in the decision to have a C Section after I was

in labor.

_-* ___________ it ___________ it ___________ it ____________ *_,___
Strongly Agree Neutral Disagree Strongly
Agree Disagree

FOR ALL MOTHERS

 

17. In general I would prefer that decisions with regard to labor

and childbirth to made by professionals.

_-* ----------- u ----------- x ----------- x ------------ u----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

18. In general, I would prefer to understand and participate in

all decisions concerning labor and childbirth.

--* ----------- a ----------- r ----------- u ------------ *----
Strongly Agree Neutral Disagree Strongly
Agree Disagree

19. PLEASE CHECK ONE:

---I was awake during delivery

---I was half asleep during delivery
---I was asleep during delivery

This was how I wanted it: Yes No

 

20. THE FOLLOWING PERSONS WERE 0F SUPPORT TO ME DURING MY
BIRTHING EXPERIENCE.(Please check all that apply)

My husband or partner_____ My woman friendL____
My mother____ Doctor___ Midwife___
My father_____ The nurse

My sister____ My mother in law

My brother Others...(Please List)

 

93

I wanted more support
Support was adequate

I wanted less support

21. Please check one:
I got to see my baby within minutes after delivery___
within an hour after delivery__

within a few hours after delivery__

a day or more after delivery

This was how I wanted it: Yes No

ANY COMMENTS:

APPENDIX F

REVISED LIFE EVENTS QUESTIONNAIRE

LIFE EVENTS

APPENDIX F

REVISED LIFE EVENTS QUESTIONNAIRE
LIFE EVENTS

 

I.O.#_____ DATE:
THIS QUESTIONNAIRE IS A REVIEW OF LIFE EXPERIENCES AND THE DEGREE
OF IMPACT THEY HAVE HAD ON YOUR LIFE. IT TAKES ABOUT 10-15
MINUTES TO COMPLETE.

 

FOR EACH EVENT LISTED BELOW, PLEASE CHECK
A. IF THE EVENT HAS gyga HAPPENED IN YOUR LIFETIME
8. CHECK IT AGAIN IF THE EVENT HAPPENED DURING THIS PAST YEAR.
C. INDICATE IF THE EVENT WAS "G000" OR 3§591_FOR YOU.
(IF THE EVENT HAPPENED MORE THAN ONCE, RATE THE ONE THAT WAS
MOST SIGNFICANT FOR YOU).
0. CHECK THE EFFECT THE EVENT HAD ON YOU USING A SCALE OF
O=no effect
1=little effect

2=some effect

 

3=great effect

THERE ARE NO RIGHT OR WRONG ANSWERS. PLEASE TRY TO REMEMBER THE
EVENTS AS BEST YOU CAN AND ESTIMATE THEIR IMPACT ON YOUR LIFE.

DURING DURING EVENT EFFECT
CHEN: LIFETIME LAST WAS 0N
YEAR ME
YES.NO YES.NO GOOD.BAD 0,1,2,3
Example:
Major trip x . . x . x 2

94

95

A. HEALTH
1. Major personal illness ___3
or injury
2. Major dental work ___,
3. Pregnancy ___,
4. Miscarriage ___.
5. Abortion .

6. Major difficulties
with birth control

pills or devices .

8. WORK.
7. Difficulty finding a .___.
job
8. Beginning work outside ____.
the home
9. Changing to a new type ___J
of work
10.Changing work hours .

or conditions
11.Change in responsi- .

bilities at work

12.Troubles at work with your .

employer or co-workers

13.Major business -___.
readjustment

14.Being fired or laid off ___3____
from work

15.Taking courses by mail or ___,

studying at home to

help you in your work .

96

C.SCHOOL

16.8eginning or ceasing .

 

college, or training program

17.Change of school,college, .

 

or training program

18.Change in career goal or .

 

academic major

19.Problems in school, college__,

 

or training program

D.RESIDENCE

20.0ifficulty finding housing __.

 

21.Changing residence within .

 

the same town or city

22.Moving to a different .

 

town,city,state,country

22A.Moving away from your .

 

parents to a different town,etc.

23.Major change in your living__,

 

conditions(home improve-
ments or a decline in
home or neighborhood)

E.LOVE AND MARRIAGE

24.8egan a new, close, .

 

personal relationship

 

 

25.Became engaged .
26.Girlfriend or boyfriend .
problems

27.Breaking up with a

 

97

boyfriend or girlfrend
28.Getting married (or ____2___

beginning to live

with someone)
29.A change in closeness with

your spouse or partner___,____
30.Unfaithfulness .

31.Trouble with in-laws .

32.5eparation from spouse
or partner due to conflict
33.5eparation from spouse ____.
or partner due to
travel, (etc.)
34.Reconciliation with .
spouse or partner

35.0ivorce .

 

 

36.Change in your spouse or .
partner's work outside
the home (begin work,

change jobs,laid off,etc.)

F.FAMILY AND CLOSE FRIENDS

 

37.0ain of a new family .

member through birth,
adoption, relative move-in
38.Family member leaving .

home due to marriage,

college, or other reasons

 

98

39.Major change in health of __ .

 

family member or close friend
(illness,accident,drugs,etc.)

40.0eath of spouse or

 

 

partner

41.Death of family member .

 

 

or close friend
42.Birth of grandchild .

 

 

43.Change in marital status

 

 

of your parents, (divorce,
separation,remarriage,
death of one)

G. PARENTING

44.Change in (your) child .

 

 

care arrangements

45.Conflict with spouse or .

 

partner about parenting
46.Conflicts with child's

 

 

grandparents(or other
important person)

about parenting
47.Taking on full .

 

 

responsibility for
parenting(as single
parent)

48.Custody battles with .

 

former spouse or partner

H.PERSONAL AND SOCIAL

49.Major personal
achievement

50.Major decision regard—
ing immediate future

51.Change in your religious
beliefs

52.Change in your political
beliefs

53.Loss or damage of

personal property

54.Took a vacation

55.Took a trip other
than vacation
56.Change in family
get-to-gethers
57.Change in your
social activities
(clubs,movies,visits)
58.Made new friends
59.8roke up with a
friend
60.Acquired or lost
a pet

I.FINANCIAL
61.Major change in

finances (increase

or decrease)

1OO

62.Made moderate .
purchase(TV,car,
freezer,etc).

63.Made major purchase .
or mortgage loan
(house,business,etc)

64.Experienced a .
foreclosure on loan

65.Credit rating .
difficulties

J.CRIME AND LEGAL

66.Being robbed .

67.Being a victim of a .
violent act(rape,assault)
68.Being involved in an .

accident
69.Involved in a law
suit
70.Involved in a minor .
violation of the law
(like traffic tickets,
disturbing the peace)
71.Legal troubles like .
being arrested or

held in jail

K.OTHER

Other experience you
have had which have had

an impact on your life

101

LIST AND RATE

 

THANK YOU FOR COMPLETING THIS FORM.
PLEASE PLACE IT IN THE FHJACHED ENVELOPE FOR COLLECTION.

 

i‘Modified and reprinted by permission of Jane S. Norbeck, author
of the Life Events Questionnaire.
** The RLEQ utilized in the study was reduced in print size so it

required only two pages.

APPENDIX G

SEMI-STRUCTURED INTERVIEW SCHEDULE

 

APPENDIX G
SEMI-STRUCTURED INTERVIEW SCHEDULE

INTRODUCTION TO SUBJECT:

Talking with women like yourself about your birthing experience
helps us learn more directly about what birthing is really like
for individual women. This will enable us to meet women's needs

more effectively.

I would like you to tell me your birth story and permit me to
record it so that I can review it later. Please begin wherever
you like. We will have about 20 minutes for the story. I won't

interrupt until you are finished.

AFTER THE STORY IS RECORDED:

Is there anyting you left out? that you would like to add?
Is there any part that deserves special emphasis? that you would

like to say more about?
CRITICAL INCIDENTS:
Please tell me about three moments (times) in your experience

which you feel were the best. What about the experience made

you feel good?
Please tell me about three moments (times) in your experience

which you feel were the worst. What about the experience made
you feel bad?

102

103

LIFE CHANGE EVENTS:

Interviewer will review questionnaire with mother and ask
about the impact of individual life change events. Interviewer
will also ask about whether a particular loss has special meaning
or feels related to the present delivery. How has she coped with

past life changes; how does she feel she is coping now?

CONTROL OVER THE BIRTH EXPERIENCE:

Interviewer will review questionnaire with mother and ask
what the impact of either having/not having a sense of control
over events had for her. Interviewer will ask if critical
incidents previously identified have anyting to do with the issue

of control.

POSTPARTUM AFFECTIVE RESPONSE;

Interviewer will ask about mother's feeling state since
delivery; how had it varied; any ideas about the context in

which the affective change took place.

CLOSURE:

Interviewer will ask mother how it felt to talk together;
if she felt that she was able to tell me about things that she
felt were important that I know; if she had any questions she

would like to ask of me.

APPENDIX H

ILLUSTRATIONS g1 INTERVIEW SUMMARIES

 

APPENDIX H

ILLUSTRATIONS OE INTERVIEW SUMMARIES

 

Interview #1

Mrs. A is 21 years old and has been married for 2 1/2 years. She
had a vaginal delivery (in the delivery room) of a third child,
and first boy. She has a high school education and has not been
employed outside the home since her marriage. She is black and
has lived in this area for only one year. Relatives all live in

another city in this state.

She began her story at the time she began to feel labor pains at
home. She remembered her reluctance to go to the hsopital. She
worried about leaving her 3 and 1 year old. She was also

apprehensive about the pain of delivery.

Her husband and sister-in-law remained with her through labor and
delivery. She ended her story by saying that she gave three or

four big pushes and out he came.

The most positive times were when the baby was born; when "I saw
for myself it was a boy"; the look on my husbands face when he
saw the baby. The most negative time was related to having labor

pains just before she delivered. There was no other.

Mrs. A explained that this delivery was just what she wanted. At
previous deliveries she was cut and had a spinal. She didn't
want that again and had explained that to her doctor. She felt
that the presence of her husband at the delivery allowed her to
concentrate on her work. She didn't have to worry about anything
else. He would look out for that.

104

105

She is bottle feeding her baby. She indicates an internal locus

of control.

A year ago her grandmother died and she recalls being upset for
months afterwards. She wishes her grandmother could have seen
this new baby. RLEQ scores are balanced between negative and
positive events. She reports that thinking back over her whole

life was difficult to do. She was not sure she remembered all

events.

Blues scores were low. When asked, however, she did say that the
time she feels most sad is when she does not have a visitor.
She feels lonely and wishes she could be at home. Remembered
feeling blue after her first child and thought it was because she

felt so lousy, "hurt all over for a long time."

Follow-up call indicated that she was feeling fine. Her husband
was a good support. She was having some trouble with her

one-year old who was more babyish since she came home.

Interview #2

Mrs. B is white, 27 years old and has been married for 2 years.
She had a vaginal delivery in the birthing room. She was
transferred from the HLBC when labor did not progress and fetal
monitoring was suggested. This is; the couple's first child and
it is a girl. The couple has lived in the area for 5 years. It
is their original home, however, and both their parents and
several siblings also live here. Mrs. B has had 3 years of

college and is employed as an occupational therapist.

She began her story two days before the delivery when she was

106

asked to come in to do a stress test. She reflected that this
was a time when she wondered if things were going to go as she
had planned. Delivery in the HLBC did not work out and she felt
upset that she had to be transferred. She described in detail
how everyone encouraged her not to give up. This, she felt,
enabled her to avoid a C section. She cried as she described
seeing the baby and feeling relief that it was over and that the
baby was OK. Her husband and friend attended the birth.

The most positive times were seeing that the baby was there and
that it was normal; when everyone was helping and telling her to
push, it meant a lot; when she got to the birth center and she
knew that "this was it." The worst times were the last few
contractions; pain from the episiotomy; feeling so uncomfortable

the next day.

Mrs. 8 explains that she is religious and that she felt that God
would see her through whatever had to happen. She knows she has
a special relationship with Jesus. When things did not go as she
had anticipated, she felt she lost faith. Her husband was
frightened too but remained helpful to her.

She is breast feeding her baby. She indicates an external locus
of control. RLEQ scores indicate only positive events during the
last year. Other RLEQ scores are around the group average. COB

score was more than one standard deviation below the mean.

Blues score was high on day one. She told me that telling the
birth story helped her feel better. She said she felt bad
because her vagina and abdomen hurt . She also felt upset and

scared when she realized that so many unexpected things had

happened.

107

Follow-up indicated that she was happy; that things were going

well and that her husband and mother were helping.

Interview #3

Mrs. C is a 30 year old woman who had divorced 1 1/2 years ago
and remarried eight months ago. She has.51 5 year old child from
the first marriage. She completed high school and worked as a
waitress until her second marriage. She had a vaginal delivery
of a baby boy in the HLBC. She has lived in this area for over

15 years and her family all lives here as well.

Her story began when she cfiscovered that she was pmegnant. She
and her boyfriend were very happy about this and decided to
marry. She ended her story by telling how exciting it was to see
the baby born and to see the faces of family members who all were
so dear to her. Her mother, husband, father and daughter
attended the birth.

Best times for her included watching her father and daughter talk
about what the birth was going to be like (father was to be the
support person at the birth for his granddaughter); seeing the
baby born; and having her husband with her. Worst times were
related to having labor pains that were worse than she expected,
and when she felt that because of the pain she was irritable with

her husband.

Mrs. C said that she believed that a gentle entry into the world
shapes a person. She herself was adopted at nine months. She
believes that she came into the world well because she is usually
feeling content and loving. Her first daughter had this kind of
birth and she was pleased that her son did too. It felt
important to her to have her daughter there with her father to
see the birth.

108

Mrs . C is breast feeding her baby . She indicates an internal
locus of control. Blues scores are very low. COB score is
average; RLEQ scores are average except that the negative score
for "years ago" is more than one standard deviation above the
mean. Most of the items scored related to her negative

experience in her first marriage.

Interview #4

Ms D. is a 20 year old white unmarried woman who gave birth to
her first child by cesarean section. She has a high school
education and worked as a vending machine attendant until the
week she delivered her baby. She has lived in this area for

twenty years and all of her family still reside here.

She began her story by telling about another pregnancy she had
three years earlier. This pregnancy ended with an abortion at
three months because the fetus wasn't growing and tests indicated
that the baby was anencephalic. The father of that baby left as
soon as he learned she was pregnant. The current pregnancy was
welcome because she has always wanted a baby. She was also
scared that something might be wrong with the baby. Her story

ended with her remembering how great it was to see the baby born.

The best moments for her included being reassured when she was
eight months pregnant that her baby would be fine; beginning
labor; and seeing the baby born. The worst time was hearing that
she would be having a cesarean section. They told her that the
baby could not take the stress of delivery. She worried that

something was wrong with the baby. The other hard time was the

first day after the delivery when she felt so sick.

Ms D is bottle feeding her baby. At the end of 48 hours she had

109

not yet named him saying that it was hard to make a choice. The
father of the child was present during the delivery and visited
daily. Since he was not yet divorced, they were not planning to

live together.

Blues scores were low except for the third day where her score
was made high because she responded to so few items on the DACL.
She indicates that she was told that her blood pressure was high
and that she had had a headache all day long. The COB score was

average and an internal locus of control was noted.

RLEQ scores are all average except for the negative score within
the past year. This is above one standard deviation from the
mean. She indicates that a close friend died in an accident

within the past year.

At follow-up, she stated that she was feeling fine and happy.

Her boyfriend and mother were being very supportive.

Interview #5

Mrs. E is a 35 year old black married woman who delivered her
second son via cesarean section. She was disappointed that the

child was a son. She had wished for a daughter.

She attended junior college and was employed as a machine
operator until the last three months of her pregnancy. She has
lived in this area for 11 years. Both families of origin have

always lived here.

Her story was brief. It began with feeling labor pains at night
and coming in to the hospital. She labored for about 7 hours
before they decided to do a cesarean section. She was annoyed

that the decision got postponed for so long. She felt that it

110

was delayed because her own doctor was not available. Her
husband remained with her through the labor and delivery. She
ended her story with saying that she was put to sleep during the

delivery which is just how she wanted it to be.

Mrs. E. told me that the first time she delivered, she felt too
alone so this time she had told her husband that if he wanted to
name the baby, he had better be there. He thought he would
faint and was pleased to see that he did OK and that it felt
important to see the baby delivered as well as how much "pain and

suffering" his wife endured.

The best part of the birthing experience for Mrs. E. was when
they finally decided to do the section and when they put her out.
She was also glad that her husband decided to stay with her. The
worst times were when she was in hard labor and when she first

came to the hospital and learned that her own doctor wasn't going
to be there.

The baby is to be tmttle fed. COB score was below two standard
deviations from the mean. She indicated an external locus of
control. She said that not having much control over the birth
might have been acceptable except for her disappointment about

the absence of her physician.

RLEQ scores are all average. The within-the-last-year negative
events score, however, indicated considerable marital difficulty

which was verfied in the interview.

Her postpartum blues score was high on day one. She indicated
that the anaesthesia had made her feel sick and irritable. She
was also disappointed when she learned about the sex of the

child. She guessed that she would get over it in a day or two.

111

Follow-up indicated that. Mrs. E. was feeling pretty good. She
felt that her down times were related to feeling tired. Her
mother was spending time with her and would look after the baby

when she returned to work in a few weeks.

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and

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