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Predictors of Women's Physical Health Problems After Childbirth Journal of Psychosomatic Obstetrics & Gynecology, June 2005; 26(2): 115–125 Predictors of women’s physical health problems after childbirth DONNA ANSARA1,2, MARSHA M. COHEN1,2, RUTH GALLOP3, ROSE KUNG4,& BERIT SCHEI1,5 1Centre for Research in Women’s Health, University of Toronto and Sunnybrook and Women’s Health Sciences Centre, Toronto, Canada, 2Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada, 3Faculty of Nursing, University of Toronto, Toronto, Canada, 4Department of Obstetrics and Gynecology, Sunnybrook and Women’s Health Sciences Centre, University of Toronto, Toronto, Canada, and 5Department of Community Medicine and General Practice, the Norwegian University of Science and Technology, Trondheim, Norway (Received 21 August 2003; accepted 29 June 2004) Abstract The objectives of this study were to document the extent and the correlates of common physical health symptoms in women two months after childbirth. Of special interest was determining whether violence and depression histories increase the risk for experiencing these symptoms. Participants were recruited in six Toronto-area hospitals and were interviewed by telephone 8–10 weeks later. Two hundred of the 332 (60.2%) women who were approached completed the study. Most women (96%) reported at least one physical health symptom 2 months postnatally (Mean = 3.4, SD = 2.0). Stepwise logistic regression was conducted for each outcome. Antenatal depression was a significant predictor of excessive fatigue and bad headaches. Sick leave during pregnancy predicted postpartum backaches. Adult emotional abuse and household income were associated with bowel problems. Episiotomy, maternal complications, and planned pregnancy predicted perineal pain. Finally, being Canadian born and having an assisted vaginal delivery increased the risk for hemorrhoids while cesarean section decreased the risk. A high prevalence of physical symptoms was found in women after childbirth. History of depression and violence were implicated in the occurrence of some of these symptoms. Other important predictors included demographic, maternal, and delivery-related factors. Keywords: Postpartum period, abused women, postpartum depression, pregnancy complications tioners, obstetricians, and gynecologists) to identify Introduction women-centred maternal health outcomes for re- Most existing studies on women’s physical health search. These outcomes represent indicators of health during the postpartum period have focussed on that are considered to be important to mothers. During maternal mortality or major morbidity as the main the sessions, mothers were asked to discuss how outcome variables [1]. Consequently, maternal pregnancy and childbirth had affected their health. morbidity has narrowly been conceptualized as Clinicians were asked to discuss what they considered including rare, severe, and potentially life-threaten- were important maternal health outcomes. Both ing obstetric complications that arise during mother and clinician groups expressed dissatisfaction pregnancy, delivery, and the postpartum period. with the paucity of available information concerning Less is known however, about the extent and the women’s postpartum health. Women reported feeling correlates of less serious (and possibly more pre- unprepared for the health consequences of childbirth valent) physical health symptoms that are meaningful and clinicians felt that the lack of information hindered to women following childbirth. The small emerging their ability to adequately counsel women. body of literature suggests that these less severe With respect to the risk factors for a difficult health problems are highly prevalent among post- postpartum recovery, many studies have focused on partum women [2 – 7]. obstetric or medical factors. There is a paucity of The relevance and timeliness of research focusing on studies that have considered the relevance of these more common maternal health symptoms was women’s psychosocial histories to their postnatal underscored in a study by Kline and colleagues [8]. well-being. Two specific factors that have not been They convened a series of focus groups of new mothers examined are women’s histories of violence and and obstetrician clinicians (midwives, family practi- depression. Correspondence: Dr Marsha Cohen, The Centre for Research in Women’s Health, 7th Floor, 790 Bay Street, Toronto, Canada, M4G 1N8. Tel: 416 351 3800 ext 2704. Fax: 416 351 3746. E-mail: [email protected] ISSN 0167-482X print/ISSN 1743-8942 online # 2005 Taylor & Francis Group Ltd DOI: 10.1080/01443610400023064 116 D. Ansara et al. other risk factors for these symptoms including Violence and physical health sociodemographic characteristics, maternal and de- A substantial body of literature has documented the livery factors, and other psychosocial characteristics. pernicious health effects of interpersonal violence. General population surveys suggest that the lifetime Methods prevalence of violence against women and female children to be significant. With respect to violence Ethics approval was first obtained from the Uni- experienced during adulthood, results from Statistics versity of Toronto and the six participating hospitals. Canada’s 1993 Violence Against Women Survey The hospitals were located in the Greater Toronto (VAWS) [9] suggest that approximately one in two Area (GTA) and consisted of three teaching hospitals (51%) women has experienced at least one episode of and three large community hospitals. These hospitals physical or sexual assault since the age of 16, and were selected, in part, because they had a large 10% have been assaulted in the year preceding the number of deliveries and serviced a wide range of survey. In the study, the lifetime prevalence of sexual socioeconomic and ethnic groups. and physical assault was 39% and 34%, respectively. Eligible women were recruited on the postpartum With respect to child abuse, the 1990–1991 Ontario ward the day after delivery. The inclusion criteria Mental Health Supplement (OHSUP) [10] surveyed were: being at least 18 years of age, able to under- close to 10,000 men and women 15 years of age or stand and speak English, having a full-term singleton greater and found that the lifetime prevalence of infant, not giving the baby up for adoption, and child physical abuse was 31.2% in men and 21.1% in providing informed consent. The exclusion criteria women, while the prevalence of child sexual abuse were: being under 18 years of age, unable to speak was 4.3% and 12.8% in men and women, respec- English, giving the baby up for adoption, having a tively. multiple birth, a premature delivery, an infant with a Although the psychological health effects of congenital illness or requiring the use of the neonatal violence have been well studied, researchers have intensive care unit. Women who could not be easily only recently begun to explore the physical sequelae contacted by telephone for the postpartum interview of violence. Beyond the acute physical consequences were also excluded. of physical and sexual violence, interpersonal vio- Two female research assistants, who were hired to lence has been linked to the reporting of more work on this study, identified eligible women with the physical health symptoms, medical problems, poorer assistance of the postpartum ward staff. The research self-rated health, poorer functional ability [11 – 14], assistants approached eligible woman individually and increased use of the health care system [15]. and invited them to take part in a study on women’s health after childbirth. Although women were not specifically told that they would be questioned about Depression and physical health their experiences of depression, violence, or their The relationship between depression and physical postpartum physical health, they were informed that health has also been well established. Individuals the interview might contain some sensitive questions. with a clinical diagnosis of depression or who Those who consented to participate were adminis- experience lower-grade depressive symptoms are tered a brief socioeconomic survey in the hospital. more likely to report various somatic complaints, Women were also asked permission to review their chronic medical problems, and poorer self-rated medical records to obtain information about their health than are non-depressed individuals [16 – 19]. pregnancy and delivery. Finally, women were con- Depressed individuals have also been found to have tacted 8–10 weeks later by telephone to set up a more functional disability [19] and to have more convenient time for the telephone interview to take frequent use of the health care system [20] than non- place in private. Interviews lasted between 25 and 30 depressed individuals. Based on the results of an minutes. Up to eight calls were attempted. The international study of primary care patients that interviews were conducted by four trained female examined the relationship between depression and research assistants. Although the interviewers were somatic symptoms, the authors concluded that not trained to offer counseling to women, a referral ‘somatic symptoms are a core component of the protocol was arranged in the event that women depressive syndrome’ (p. 1333) [17]. wished to seek counseling services. Lacking from the literature are studies that explore the relationship between women’s histories of vio- Instruments lence and depression and their postpartum physical health specifically. Thus, the objectives of this study Postpartum
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