The Effect of Birth Experience on Postpartum Depression
Sponsored by Missouri Western State University Sponsored by a grant from the National Science Foundation DUE-97-51113
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The proper APA Style reference for this manuscript is:
BLAND, M.A. (1998). The Effect of Birth Experience on Postpartum Depression. National Undergraduate Research Clearinghouse, 1. Available online at http://www.webclearinghouse.net/volume/. Retrieved August 19, 2017 .

The Effect of Birth Experience on Postpartum Depression
MICHELLE A. BLAND
MISSOURI WESTERN STATE UNIVERSITY DEPARTMENT OF PSYCHOLOGY

Sponsored by: Brian Cronk (cronk@missouriwestern.edu)
ABSTRACT
Recent research indicates that postpartum depression affects from 8-26% of new mothers. It is considered to be a serious problem, as its consequences have been demonstrated to be detrimental to the child. The purpose of this study is to see if birth experience, control over the birth process, and place of birth (operating room, labor/delivery room, or home) are related to postpartum depression. The participants consist of three groups: women who have had vaginal hospital deliveries, women who have had caesarean hospital deliveries, and women who have had planned home deliveries. The following self-report scales have been used: the Edinburgh Postnatal Depression Scale (EPDS), and a 25-item scale combining question for both birth experience satisfaction and perceived level of control. The completion of these surveys has been accomplished as follows: Women in the home delivery group have received the surveys from their midwife, and returned them in a self addressed stamped envelope to the researcher. Women who have had hospital deliveries have completed them in the waiting room of their doctor`s office while at their postpartum check-up. The incidence and severity of postpartum depression has been found to be related to the place and type of delivery, the perceived level of control over the birth experience, and the satisfaction level. The home birth group was found to have the lowest rates of depression, have felt the most control over their birth experience, and were the most satisfied. While the caesarean patients were found to have had the least control over their birth experience, data regarding their satisfaction and depression levels were inconclusive. Lack of technological and human intervention in the home birth groups may have given the women more freedom to move about, thus increasing comfort levels, as well as the number of choices that could be made. The increased intervention involved in a caesarean birth may have played a role in the lack of control that the caesarean group experienced.

INTRODUCTION
According to Warner, Appleby, Whitton, & Faragher (1996), postpartum depression affects 10% of new mothers, with the range being from eight to 15%. These data cover only the women with non-psychotic depression levels. An additional one to two women per 1,000 experience postpartum psychosis (Stanton & Gallant, 1995; Noncas & Cohen, 1998). Stanton and Gallant (1995) found the rates of postpartum depression to be higher, with a prevalence of 26% of women having at least mild depression. While some believe postpartum depression to be a biological problem (such as a thyroid dysfunction, as proposed by Harris (1993)), and others contend that it is psychological (as proposed by Appleby, Gregoire, Platz, Prince, & Kumar, 1994), most agree that the effects of postpartum depression are detrimental, and that it should be prevented if possible (Walther, 1997). O`Hara and Swain (1996, p. 37) have stated that postpartum depression "is a serious mental health problem for women" and that "it`s consequences have serious implications for the welfare of the family and the development of the child." Many aspects of postpartum depression have been studied (biochemical affects, socioeconomic effects, etc.), but little has been done to study the relationship between actual birth experience and the incidence and degree of postpartum depression. There has, however, been one study indicating that postpartum depression is more prevalent among women who have had cesarean births than women who have had normal vaginal deliveries (Edwards, Porter, & Stein, 1994). These researchers have found that the increased rates of postpartum depression among caesarean subjects compared to those who underwent a normal delivery were significant. The researchers also found that among the caesarean subjects, those who had general anesthesia (a significant intervention) displayed higher depression rates than those who were given an epidural (the milder intervention). A non-significant finding revealed that the depressive illness of caesarean patients started sooner after birth than the control group. In addition, Areias, Kumar, Barros, & Figueiredo, (1996) have found correlations between postnatal depression and negative life events, which may suggest that if cesarean births and some hospital births are traumatic, they may be more likely to trigger postpartum depression than more positive birth experiences. Shields, Reid, Cheyne, Holmes, et. al. (1997), have documented that women who were cared for by midwives in their postnatal period were more likely to report satisfaction with their care, and were less likely to be depressed than women who were given traditional care. The researchers found that there were deficiencies in the psychosocial aspects of traditional medical care for women in the postnatal period, such as a lack of support. Women who were cared for by midwives were reported to have lower levels of depression than the traditional group, although both groups of women had good psychological outcomes. It was also found that group receiving midwife care gave higher ratings to their care (indicating a greater satisfaction with their care than the traditional group). Results also indicated that those cared for by midwives reported receiving more support and better advice on infant feeding than those women cared for by traditionally, and felt more prepared for parenthood. If the level of care may be one determinant in the prevalence and levels of postpartum depression, then the findings of Lane, Keville, Morris, Kinsella, Turner, and Barry (1997) that women who are public patients have higher clinical correlates of postpartum mood disturbance may be relevant.Further, Cohan, Pimm, and Jude (1998), note that informed patients who feel in control of their situation have quicker recoveries and are less prone to depression than patients who do not have that knowledge or control. Patients who were found to have an external locus of control (felt that others determined their fate for them), were more apt to be depressed, while patients who were found to have a high internal locus of control (felt that they were in charge of their own fate), were less prone to depression. Further, as the authors point out, control is abdicated under general anesthesia. The authors point out that the depression experienced by patients after surgery is very similar to the grief that survivors feel when a loved one dies. This depression is said to be "reactive," or, as a result of the surgery. In addition, an amazing one-third of all surgery patients suffer "serious debilitating depression," (p.215). However, the authors explain that a patient can find a "comfortable level of control" if s/he is prepared psychologically for the surgery. This preparation includes good education, which offers reassurance and lower stress levels though understanding. None the less, there is little consensus on the risk factors for postpartum depression (Warner, Appleby, Whitton, & Faragher, 1996).This study aims to learn more about the effects of a woman`s birth experience on levels of postpartum depression. The purpose of this research project is to see if birth experience, control of the birth process, and place of birth (operating room, delivery room, or home) are related to postpartum depression. Multiple hypothesis will be examined. They hypothesis are: 1.) the more control a woman has (or feels she has) over her birth experience, the less apt she is to suffer from postpartum depression, 2.) the more satisfied a woman is with her birth experience, the less likely she is to suffer from postpartum depression, 3.) the less invasive the birth experience, the more the woman will feel in control, and the more satisfied she is likely to be. Thus, it was predicted that the lowest incidence and severity of postpartum depression would occur in the home birth sample, and the caesarean group would have the highest incidence and severity of depression.


METHOD

PARTICIPANTS
Three main groups of women have participated in this study. There were two different types of hospital groups from two different health care facilities, and one group of women who have had home deliveries. The two health care providers were Women`s Health of Saint Joseph, in northwest Missouri, and Kaiser Permanente of Kansas City. Data were collected from two different Kaiser offices, each in a different location in Kansas City (one office was located in Kansas City, Kansas, and the other office was located in Kansas City, Missouri). From the two main providers, data were collected from 53 women who had vaginal hospital deliveries, and 14 women who had caesarean deliveries (67 total hospital patients). From this sample, 47 vaginal hospital delivery patients who were from four to eight weeks postpartum and 13 caesarean patients who were four to eight weeks postpartum were used in one analysis, and 26 vaginal hospital patients and seven caesarean patients who were six weeks postpartum were used in another analysis. These women have diverse backgrounds, but were are all living in the Kansas City area or in north west Missouri, or around Saint Joseph or the surrounding areas at the time of the study. The third group consisted of 42 women who have had home deliveries. From this sample, 33 women who were from four to eight weeks postpartum were used in one analysis, and 12 participants who were six weeks postpartum were used in another analysis. These deliveries were all planned, and were with a midwife, or, by chance, occurred before the arrival of the midwife. These participants vary in their location, with some residing in Alaska, California, Texas, Arizona, New York, Florida, and various other states from around the country. All of the participants vary in age, employment and marital status, and socioeconomic status. Racial and ethnic backgrounds also vary. All participants were treated in accordance with the "Ethical Principles of Psychologists and Code of Conduct" (American Psychological Association, 1992).

MATERIALS
This project is looking at control, satisfaction, and depression in women in three groups: a home birth group, a "normal" in hospital delivery group, and group of women who have had caesarean sections. The goal was to measure levels of control, satisfaction, and depression in each of the three groups of women. In order to measure these constructs, two surveys were used. The first was a 10 item depression scale, called the Edinburgh Postpartum Depression Scale. This scale has been validated numerous times, and has been found to be reliable. It can be found in the British Journal of Psychiatry, published in 1987, in Volume 150 on page 786. The other was a 25 item scale combining questions for both birth experience satisfaction and perceived level of control. This scale has been demonstrated to have face validity, but has not been validated or tested for reliability. The maximum number of points that participants could score on the depression scale was 66. Examples of questions that measured control are questions that regard the participants freedom to move about during labor, be in any desired position during delivery, drink liquids or eat during labor, and participation in labor/delivery choices. Other questions pertaining to control referred to how soon the mother was given access to her baby after delivery, her ability to make informed decisions throughout her birth experience, whether or not she had time to make informed decisions, the level of coherence and control over her body that she had (indicated by the type of pain relief used), and access to family members/loved ones given to the participant. A total number of 46 points could be scored for satisfaction. Questions that measured satisfaction were related to physical comfort during labor and delivery, thirst and hunger felt during labor/delivery, the woman`s perception of how she was treated by the medical staff or her midwife and attendant, and her perception on how her needs were met after delivery. Other questions measuring satisfaction asked if and how the participant tore, how she felt about it, and how many pelvic exams she was given.

PROCEDURE
The method of data collection was as follows: Both scales were enclosed in an envelope along with an informed consent form and a brief set of instructions. The women who gave birth in the hospital were handed this packet by the receptionist at their six week postpartum check-up, and asked to fill it out. The receptionist briefly informed them that it was an optional survey for research purposes, and that it did not have to do with their private institution. Further information was included inside the packet explaining that nobody but the researcher would see the information, including their doctor. They were not asked to put their names, or any other form of identification on the surveys (in fact, they were instructed not do so). When finished, they sealed the envelope and returned it to the receptionist, or the nurse, if they completed it while waiting in the examination room. One copy of the informed consent form was sealed in the envelope for the researcher to file, and the other was kept by them. For this purpose, carbon paper or a duplicate copy of the consent form for the participant to sign and keep was used to provide two copies of the informed consent form. These data were collected over a period of four to five weeks from two health care institutions: Women`s Health of Saint Joseph, and Kaiser Permanente of Kansas City. Upon returning the sealed envelope to the receptionist or the nurse, the patient was handed a debriefing sheet which briefly explained in more detail the purpose of the study, and when the results would be available. Further, the paper explained how to contact the researcher for further information about the study or results. The involvement of human subjects ended when they received this debriefing paper, or, if and when they chose to contact the researcher.For the women who gave birth at home, the same packets were used, except that their midwives either handed the packets to them at their delivery (SASE to the researcher) and requested that they fill it out at six weeks postpartum and then mail it to the researcher, or, the SASE packet was put into another envelope (postage paid by the researcher) to be mailed to their clients around five weeks, which was also filled out at or around six weeks postpartum and mailed to the researcher. (The midwives were instructed that women from four to eight weeks postpartum were eligible to participate, but to strive to see that their clients participated at six weeks postpartum.) Their identity was not to be on the envelopes, and the researcher requested that they use their midwives address as the return address. Upon receiving their surveys, or learning that their surveys had been mailed to the researcher, their midwives were granted permission to debrief them and give them the address and e-mail address of the researcher (as the other two groups were given).The total number of participants obtained from both participating health care institutions and the participating midwives was 110. Of these 110 participants, one had to be dropped because she gave birth at a birthing center, and three were dropped because they did not state how many weeks postpartum they were. Of the remaining participants, six women in the home delivery group, three women in the vaginal hospital group, and one women in the caesarean delivery group were not included in one analysis because they were less than four weeks postpartum or greater than eight weeks postpartum, and were not well distributed. (For example, there were four home birth women at one week postpartum, but no hospital or caesarean participants in that category. Likewise, there was one hospital participant who was two weeks postpartum, but no home or caesarean participants to compare her to.) Additionally, in the second analysis, which included only women who were six weeks postpartum, 30 home delivery participants, 24 vaginal hospital participants, and seven caesarean participants were excluded. This group was used as a comparison to the broader sample of four to eight weeks which covers a month of the postpartum period and does not take into account differences in depression levels at various stages in the postpartum period.


RESULTS

WOMEN FOUR TO EIGHT WEEKS POSTPARTUM
For the women four to eight weeks postpartum, the data were analyzed by using four one-way ANOVA tests, five correlational tests, and two general linear regressions. In addition, the frequency of varying levels of depression among the three groups was analyzed. The ANOVA tests measured: a.) postpartum depression as it relates to the birth experience (home, vaginal hospital, cesarean hospital), b.) the patients perceived level of control in each category of birth experience, c.) the patients level of satisfaction with their birth experience in each category of birth experience, and d.) the patients level of satisfaction with their birth experience (minus two questions) in each category of birth experience. (This final test was done in order to correct for a potentially unfair assignment of 11points to the caesarean subjects. The two removed questions dealt with the presence/absence of a vaginal/cervical tear, and feelings regarding them.) The five correlational tests measured: a.) the strength of the relationship between postpartum depression and the perceived level of control over birth experience, b.) the strength of the relationship between postpartum depression and the patients satisfaction level with her birth experience, c.) the strength of the relationship between postpartum depression and the patients satisfaction once the two aforementioned questions are removed, d.) the strength of the relationship between the satisfaction the women had with their birth experience and her perceived level of control, and, e.) the strength of the relationship between the satisfaction the women had with their birth experience and her perceived level of control once the satisfaction score was adjusted to remove the two previously mentioned questions. For women who were four to eight weeks postpartum, a one-way ANOVA was computed comparing postpartum depression levels of participants who gave birth in one of three groups. A significant difference was found between the groups (F(2,90) = 4.07, p = .02). Tukey`s HSD was used to determine the nature of the differences between delivery types. This analysis revealed that participants who gave birth at home were less depressed (M = 4.91, sd = 3.70) than participants who had a vaginal hospital delivery (M = 7.66, sd = 4.33). Participants who had caesarean deliveries (M = 6.85, sd = 5.29) were not significantly different from either of the two groups. A second one-way ANOVA was calculated for women four to eight weeks postpartum, comparing control scores of participants who gave birth in one of three groups. A significant difference was found between the groups (F(2,86) = 295.82, p < .001). Tukey`s HSD was used to determine the nature of the differences between the delivery types. This analysis revealed that participants who gave birth at home (M = 65.55, sd = 1.15) perceived to have a higher level of control than participants who gave birth vaginally in a hospital (M = 46.10, sd = 5.54) and participants who had a caesarean delivery (M = 35.92, sd = 4.17). Participants who delivered vaginally in a hospital received significantly higher control scores than participants who had a caesarean delivery. Within the same time period postpartum, a third one-way ANOVA was calculated comparing the overall satisfaction levels of participants who had one of three types of deliveries. A significant difference was found between the delivery types (F(2,82) = 11.22, p < .001). Tukey`s HSD was used to determine the nature of the differences between the delivery types. This analysis revealed that participants who delivered their babies at home were more satisfied (M = 39.09, sd = 2.98) than participants who delivered vaginally in a hospital (M = 34.57, sd = 4.88). Participants who experienced a caesarean delivery (M = 35.67, sd = 3.67) were not significantly different from either of the other two groups. A final one-way ANOVA was calculated for women four to eight weeks postpartum comparing satisfaction scores that were calculated without the points from two questions pertaining to tearing (which, in most cases, is not an experience that caesarean patients would encounter) of subjects who delivered in one of three fashions. A significant difference was found between the three delivery types (F(2,83) = 14.15, p < .001). Tukey`s HSD was used to determine the nature of the differences between the delivery types. This analysis revealed that participants who gave birth at home scored higher for satisfaction (M = 29.00, sd = 2.70) than both the vaginal hospital group (M = 24.73, sd = 3.99), and the caesarean group (M = 25.78, sd = 3.59). Participants in the vaginal hospital delivery group were not significantly different from participants in the caesarean delivery group. A Pearson correlation was calculated examining the relationship between a participant`s level of depression between four and eight weeks postpartum and amount of control she had over the birth process. A moderate negative correlation was found (r(88) = -.367, p < .01) indicating a significant linear relationship between the two variables. Less control over the birth process tends to indicate higher depression levels. A Pearson correlation was calculated examining the relationship between a participant`s level of depression between four and eight weeks postpartum and amount of satisfaction with the birth experience. A moderate negative correlation was found (r(84) = -.343, p < .01) indicating a significant linear relationship between the two variables. Subjects who are less satisfied with their birth experience tend to experience higher levels of depression. Also for women between four and eight weeks postpartum, a Pearson correlation was calculated examining the relationship between the satisfaction score without the points for the questions pertaining to tearing (done in an attempt to rule out bias for caesarean patients) and level of depression. A moderate negative correlation was found (r(85) = -.343, p < .01) indicating a significant linear relationship between the two variables. Subjects who are less satisfied with their birth experience tend to experience higher levels of depression. A Pearson correlation was calculated examining the relationship between a participant`s level of satisfaction and level of control. A moderate positive correlation was found (r(81) = .550, p <.01) indicating a significant linear relationship between the two variables. Participants who experience more control over their labor and delivery tend to be more satisfied with their birth experience. A similar correlation was found (r(82) = .550, p < .01) between the adjusted satisfaction scores and perceived level of control. Multiple linear regression was calculated predicting participants` depression level from their overall satisfaction and level of control. A significant (F(2, 79) = 10.997, p < .001) regression equation was found with an R2 of .218. Participants` predicted depression level is equal to 21.195 + -.109(control) + -.243(satisfaction) when satisfaction and control are measured using the Birth Experience scale and depression is measured using the Edinburgh Postnatal Depression Scale. Participants decreased .109 points of control and .243 points of satisfaction for each point of depression that they increased. Both satisfaction and control were significant predictors. In this model, control and satisfaction accounted for 21.8% of the variance in postpartum depression. Multiple linear regression was calculated predicting participants` level of depression from satisfaction level without regarding feelings toward tearing and level of control over the birth experience. A significant (F(2,80) = 10.041, p < .001) regression equation was found with and R2 of .201. Participants` predicted depression level is equal to 18.898 + -.116(control) + -.231(compensated satisfaction) when satisfaction and control are measured using the Birth Experience scale and depression is measured using the Edinburgh Postnatal Depression Scale. Participants decreased .116 points of control and .231 points of compensated satisfaction for each point of depression that they increased. While control was a significant predictor of depression, the changed satisfaction score was not. In this model, control and the changed satisfaction score accounted for 20.1% of the variance in postpartum depression. The frequency of postpartum depression was calculated for each group (vaginal hospital delivery, caesarean delivery, and home delivery) from four to eight weeks postpartum. Twenty eight out of 33 women who gave birth at home (84.85%) had EPDS scores that did not indicate a depressive illness of any degree. Twenty nine out of 47 participants who had a vaginal hospital delivery (61.70%) had EPDS scores that did not indicate a depressive illness of any degree. Eight out of 13 caesarean subjects (61.54%) had EPDS scores that did not indicate a depressive illness of any degree. Three out of 33 women who delivered at home (9.09%) had EPDS scores that met the 9/10 cut-off for a postpartum depressive illness of varying severity. Twelve out of 47 women who delivered vaginally in a hospital (25.53%) had EPDS scores that met the 9/10 cut-off for a postpartum depressive illness of varying severity. Two out of 13 women who had a caesarean delivery (15.18%) had EPDS scores that met the 9/10 cut-off for a postpartum depressive illness of varying severity. Two out of 33 participants who had a home birth (6.06%) had an EPDS that met the 12/13 cut-off for a postpartum depressive illness of varying severity. Six out of 47 participants who gave birth vaginally in a hospital (12.77%) had an EPDS that met the 12/13 cut-off for a postpartum depressive illness of varying severity. Finally, three out of 13 caesarean participants (23.08%) had an EPDS that met the 12/13 cut-off for a postpartum depressive illness of varying severity.

WOMEN SIX WEEKS POSTPARTUM
A second set analysis was done for women who were six weeks postpartum. Results were found to be similar to those found from four to eight weeks postpartum. For example, a one-way ANOVA was calculated comparing the depression levels of participants from one of three different delivery types. A significant difference was found between the labor and delivery types (F(2,42) = 3.79, p <.05). Tukey`s HSD was used to determine the nature of the differences between the groups. This analysis revealed that participants who gave birth at home were less depressed (M= 3.67, sd = 2.19) than participants who gave birth vaginally in a hospital (M = 7.85, sd = 4.94). Participants who had a caesarean delivery (M = 6.00, sd = 4.86) were not significantly different from either of the other two groups. A second one-way ANOVA was calculated for women who were six weeks postpartum comparing levels of control with one of three different types of labor and delivery. A significant difference was found between the groups (F(2,40) = 88.39, p < .001). Tukey`s HSD was used to determine the nature of the differences between delivery types. This analysis revealed that women who gave birth at home had more control (M = 65.58, sd = 1.44) than women who gave birth vaginally in a hospital (M = 47.27, sd = 6.06) and women who had a caesarean delivery (M = 37.21, sd = 3.74). Women who gave birth vaginally in a hospital experienced significantly more control than women who delivered by a caesarean section. A Pearson correlation was calculated examining the relationship between a participant`s level of depression and control. A moderate negative correlation was found (r(42) = -.479, p = .001) indicating a significant linear relationship between the two variables. Participants who were in more control tended to have lower levels of depression. Multiple linear regression was calculated predicting the participants` level of depression from their level of control and satisfaction. A significant (F(2,33) = 10.801) regression equation was found with an R2 of .396. Participants` predicted level of depression is equal to 24.932 + -.243(control) + -.157(satisfaction) when satisfaction and control are measured using the Birth Experience survey. Participants decreased .243 points of control and .157 points of satisfaction for each point of depression that they increased. While control was found to be a significant predictor of depression, satisfaction was not. Thus, a simple linear regression was calculated predicting the participants` depression level from their level of control. A significant (F(1,41) = 209.992, p < .001) regression equation was found with an R2 of .229. Participants` predicted depression level is equal to 16.765 + -.202(control) points when points are measured using the Birth Experience survey. Participants control level decreased .202 points for each increased point of depression. In this model, control accounted for 23% of the variance in postpartum depression for women six weeks postpartum. The frequency of occurrence of postpartum depression was also calculated for women six weeks postpartum. Twelve out of 12 women (100%) who gave birth at home did not meet any of the criteria for postpartum depression on the EPDS. Fifteen out of 26 women who had vaginal deliveries in a hospital (57.69%) did not meet any of the criteria for postpartum depression on the EPDS. Five out of seven women who had a caesarean delivery (71.43%) did not meet any of the criteria for postpartum depression on the EPDS. Eight out of 26 women who delivered vaginally in a hospital (30.77%) met the minimum criteria (9/10) for a depressive illness of varying severity. One out of seven caesarean patients (14.29%) met the minimum criteria (9/10) for a depressive illness of varying severity. Three out of 26 women who had vaginal hospital deliveries (11.54%) met the 12/13 cut-off for postpartum depressive illness of varying severity. One out of seven caesarean patients (14.29%) met the 12/13 cut-off for postpartum depressive illness of varying severity. The following analyses were not discussed because the number of caesarian participants available for these analyses were three: two one-way ANOVA`s comparing both variations of the satisfaction score with the type of delivery, three Pierson correlation`s, two examining the strength of the relationship between both variations of the satisfaction score with levels of depression, and one examining the strength of the relationship between overall satisfaction and control, and one linear regression predicting depression levels from control and modified satisfaction levels.


DISCUSSION
It was hypothesized that a.) the more control a woman has (or feels she has) over her birth experience, the less apt she is to suffer from postpartum depression, b.) the more satisfied a woman is with her birth experience, the less likely she is to suffer from postpartum depression, c.) the less invasive the birth experience, the more the woman will feel in control, and the more satisfied she is likely to be. Thus, it was predicted that the lowest incidence and severity of postpartum depression would occur in the home birth sample, and the caesarean group would have the highest incidence and severity of depression. For the women who gave birth at home and the women who delivered vaginally in a hospital, the findings of this study were consistent with the current literature on an internal locus of control and lower levels of depression. Cohan, Pimm, and Jude (1998) note that informed patients who feel in control of their situation have quicker recoveries and are less prone to depression than patients who exhibit an external locus of control (feel that their fate is determined by others). The results were inconclusive for the caesarean patients. However, these results were consistent with the findings of these researchers that control is abdicated under general anesthesia and in surgery. Thus, the findings that women who had a caesarean (surgical) delivery had the least control over their delivery, and women who had a home birth had the most control (with vaginal hospital patients having a significantly distinct level of control between these two groups) were consistent with the current literature and the predicted outcome for these groups. For the women who gave birth at home and the women who delivered vaginally in a hospital, findings regarding satisfaction levels and type of delivery as well as depression levels and satisfaction were consistent with the current literature on satisfaction and postpartum depression. Shield, Reid, Cheyne, Holmes, et. al. (1997) found that women who were cared for by midwives in their postnatal period were more likely to report satisfaction with their care, and were less likely to be depressed than women who were given traditional care. Thus, the findings that women who were tended to by a midwife were found to be more satisfied with their birth experience than women who delivered vaginally in a hospital and were tended to by a traditional medical team are consistent with the literature. The results were inconclusive for the caesarean patients. The results pertaining to the type of labor and delivery experience and frequency and severity of postpartum depression were consistent with the prediction for women who had a home delivery or a vaginal delivery in a hospital, but were inconclusive for women who had a caesarean delivery. No current literature is known to be available to compare these findings with. As Warner, Appleby, Whitton, & Faragher (1996) have reported, there is little consensus on the risk factors for postpartum depression. The results obtained from this study as they pertain to the general home birthing population should be highly generalizeable, as the home delivery sample consists of women from varying socioeconomic statuses, ethnic backgrounds, and ages, and the sample was obtained nationwide. (Some of these women are residing in New York, Alaska, California, Missouri, Texas, New Mexico, Florida, and other states.) The results obtained from both hospital populations should be generalizeable as well, limited only to minute regional differences in medical practices. Given that the hospital samples were obtained from two different, unaffiliated health care institutions, and that one of the institutions provided women from separate regions of the city (the Kansas or Missouri side), and that these women varied in socioeconomic status, ethnic backgrounds, and ages, these results should be generalizeable. In addition, the variety of doctors, staff, and hospitals involved further helped to diversify the hospital deliveries experienced by both hospital samples, and thus, the generalizeability of the results obtained from these samples. The small number of caesarean participants acts as a limitation in this study. While fourteen subjects is an adequate sample, it was not large enough to allow the researcher to draw many reliable conclusions from. Thus, further research is suggested that includes a larger sample of caesarean participants. Further research that compares the severity and frequency of postpartum depression among the three groups of women at different points postpartum (four, six, and eight weeks, for example), would be interesting and is suggested. A study incorporating samples of women who have given birth in a birthing clinic or center, either attended to by a midwife or a physician, and a sample of women who have delivered in a hospital setting and were attended to by midwives, should be conducted.


REFERENCES
Appleby, L., Gregoire, A., Platz, C., Prince, M., & Kumar, R. (1994). Screening women for high risk of postnatal depression. Journal of Psychomatic Research, 38, 539-545.Areias, M. E. G., Kumar, R., Barros, H., & Figueiredo, E. (1996). Correlates of postnatal depression in mothers and fathers. British Journal of Psychiatry, 169, 36-41. Cohen, C., Pimm, J. B., & Jude, J. R. (1998). Coping with Heart Surgery and Bypassing Depression: A Family`s Guide to the Medical, Emotional, and Practical Issues. Madison: Psychosocial Press/International Universities Press, Inc.Edwards, D. R. L., Porter, S. A. M., & Stein, G. S. (1994). A pilot study of postnatal depression following caesarean section using two retrospective self-rating instruments. Journal of Psychosomatic Research, 38, 111-117.Harris, B. (1993). A hormonal component of postnatal depression. British Journal of Psychiatry, 163, 403-405. Lane, A., Keville, M., Morris, A., Kinsella, A., Turner, M., & Barry, S. (1997). Postnatal depression and elation among mothers and their partners: Prevalence and predictors. British Journal of Psychiatry, 171, 550-555.Nonacs, R., & Cohen, L. S. (1998). Postpartum mood disorders: Diagnosis and treatment guidelines. Journal of Clinical Psychiatry, 59, Suppl. 2, 34-40. O`Hara, M., & Swain, A. (1996). Rates and risk of postpartum depression-a meta-analysis. International Review of Psychiatry, 8, 37-54.Shields, N., Reid, M., Cheyne, H., Holmes, A., et. al. (1997). Impact of midwife-managed care in the postnatal period: An exploration of psychosocial outcomes. Journal of Reproductive and Infant Psychology, 15, 91-108. Stanton, A., & Gallant, S. (1995). The Psychology of Women`s Health. Washington, D.C.: American Psychological Association. Walther, V. N. (1997). Postpartum depression: A review for perinatal social workers. Social Work Health Care, 24, 3-4, 99-111.Warner, R., Appleby, L., Whitton, A., & Faraghen, B. (1996). Demographic and obstetric risk factors for postnatal psychiatric morbidity. British Journal of Psychiatry, 168, 607-611.


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AUTHOR NOTES
I would like to thank Kaiser Permanente of Kansas City for providing access to patients, with special appreciation to Arne Beck, for all of his help and time, to Julie Kurtis, the Clinical Supervisor at the Blue Ridge office, to Judy, the full time receptionist at the Blue Ridge office, for her patience and skill, to Ann Olde, the Clerical Supervisor at the Mission Office, for her kindness, and to the OB/GYN receptionists at the Mission Office, for their help and patience; I would also like to thank Women`s Health of Saint Joseph for providing access to patients, with special appreciation to the nursing staff and to Diane McAfee, for her time, patience, and kindness.; I would like to thank all of the participating midwives for providing access to their clients, for their referrals, and for their support and time. Thank you.

AUTHOR CONTACT AND WEBSITE:
To contact the author, please email Michelle@birthstudies.com or visit www.birthstudies.com.(Alternative email address: birthstudy@earthlink.net)

Submitted 12/3/98 2:32:55 PM
Last Edited 1/30/2009 1:26:36 PM
Converted to New Site 03/09/2009

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