Hypertension in pregnancy : gaining insight into women's mental health and birth experience 6-12 months postpartum

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๐˜‰๐˜ข๐˜ค๐˜ฌ๐˜จ๐˜ณ๐˜ฐ๐˜ถ๐˜ฏ๐˜ฅ Pregnancy and childbirth, while usually joyful experiences, can be traumatic leading to depression, anxiety and post-traumatic stress disorder (PTSD). Women may be more prone to psychological morbidity following a complicated pregnancy and/or birth. Hypertension in pregnancy (HIP) is the most common medical complication of pregnancy. Women diagnosed with HIP require more intensive monitoring, antenatal admissions, a longer postnatal stay that may include acute care, and some give birth to a preterm baby requiring time in a nursery. There are reports of the short and long term health risks following HIP, particularly cardiovascular health, but there is limited knowledge about the impact on mental health, birth experience, and whether the care received influences womenโ€™s experiences. ๐˜ˆ๐˜ช๐˜ฎ The aim of this study was to investigate the mental health (depression, anxiety and posttraumatic stress disorder) and childbirth experiences at six to 12 months postpartum in women who had HIP and those who had normal blood pressure (normotensive) in pregnancy. ๐˜”๐˜ฆ๐˜ต๐˜ฉ๐˜ฐ๐˜ฅ๐˜ด This was a longitudinal prospective observational study using mixed methods. There were two phases: 1) the mental health of women and their birth experience following a normotensive pregnancy or one complicated by hypertension, using a quantitative design; and, 2) the experience of women who had HIP, using a qualitative approach. At six months postpartum, women completed four screening instruments: the Edinburgh Postnatal Depression (EPDS), General Anxiety Disorder (GAD), Posttraumatic Stress Diagnostic, and Maternal Infant Bonding (MIB) scales. Birth experience data were collected using a seven point Likert Scale and two open ended questions. The qualitative component used individual, face-to-face, semi-structured interviews with a subset of 20 women at 10-12 months postpartum. Descriptive statistics, univariate and multivariate logistic regression and ordinal regression analyses were conducted on the quantitative data, with a thematic analysis undertaken on the interview transcripts. ๐˜™๐˜ฆ๐˜ด๐˜ถ๐˜ญ๐˜ต๐˜ด There were 237 women in the normotensive (NT) group and 84 in the hypertensive (HT) group. Both groups had similar demographic characteristics. Compared to the NT group, the HT group experienced more interventions during labour and birth, with the HT group having higher rates of induction of labour (70% versus 29%, p=<0.001) and caesarean sections (43% versus 18%, p=<0.001) compared to the NT group. Women in the HT group recorded significantly higher mean EPDS score (p=0.03) and more scored above the threshold for possible depression (p=0.03) compared to women in the NT group. There were no differences in anxiety, PTSD or bonding scores between groups. The proportion of women who identified their birth experience as traumatic was greater in the HT group (p=0.006). The strongest predictor of possible depression in the whole cohort was being a first time mother (AOR 5.03; 95% CI 1.19-21.3), and for PTSD it was having a preterm baby (AOR 7.46; 95% CI 0.61-91.17). Women in the NT group were three to five times more likely to respond positively to the birth experience questions. The qualitative study identified the themes: reacting to the diagnosis, challenges of being a mother, processing and accepting the situation, and moving on from the experience. Mediating factors that improved the womenโ€™s experience were: feeling safe and trusting the care providers, continuity of care and carer, and valuing social support from partner, family and friends. ๐˜‹๐˜ช๐˜ด๐˜ค๐˜ถ๐˜ด๐˜ด๐˜ช๐˜ฐ๐˜ฏ Although the results showed more depressive symptoms in the women in the HT group and more reported their birth as a traumatic event, the prevalence of depression and PTSD was less than that previously reported in the literature. In an effort to further improve social, emotional and mental health outcomes for women, four elements of care are suggested. These are based on the quantitative and qualitative findings and current evidence: providing continuity of midwifery care in a collaborative model, facilitating social support for the woman, prevention and early identification of poor mental health, and keeping mother and baby connected. ๐˜Š๐˜ฐ๐˜ฏ๐˜ค๐˜ญ๐˜ถ๐˜ด๐˜ช๐˜ฐ๐˜ฏ Women have profound experiences after the diagnosis of HIP. They face challenges for months after the birth of their baby. It is essential for women to have access to appropriate multidisciplinary collaborative models of care, prompt referral to mental health services, and social support following a pregnancy complicated with hypertension. Furthermore, it is essential that maternity care providers keep the woman and her baby connected despite the physical separation that sometimes occurs.
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