A Feasibility Study to Assess Sleep and Subsequent Breast Milk Volume Among Mothers With Hospitalized Preterm Infants

BACKGROUND

Sleep is essential for optimal health, and disturbed postpartum sleep is associated with compromised infant attachment. The postpartum experience of mothers with preterm infants is unlike the biological norm, as they are separated from their infants and often express breast milk.

PURPOSE

The purpose of this study was to examine the feasibility of conducting a clinical research study among women with hospitalized preterm infants. We also explored for associations between maternal sleep patterns and sleep-related psychological states and subsequent breast milk volume.

METHODS

Participants were recruited from Magee-Womens Hospital, located in Pittsburgh, Pennsylvania New mothers completed daily sleep and pumping logs and scales to measure stress, trauma, depression, fatigue, and sleep quality.

RESULTS

A total of 78 women were screened, 18 women consented, and a total of 8 participants completed the study. Screening from the postpartum unit increased recruitment. The participants experience worsening sleep quality over time, moderate stress, and fatigue. Stress, postnatal depression, and fatigue are negatively associated with milk volume.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Postpartum recruitment with frequent follow-ups improved recruitment and retention. We present a preliminary association between maternal stress, fatigue, and depression, and subsequent breast milk volume. Sleep-related psychological states may negatively influence milk volume.

Correlates of Canadian mothers' anger during the postpartum period: a cross-sectional survey

BACKGROUND

Although some women experience anger as a mood problem after childbirth, postpartum anger has been neglected by researchers. Mothers' and infants' poor sleep quality during the postpartum period has been associated with mothers' depressive symptoms; however, links between mothers' sleep quality and postpartum anger are unclear. This study aimed to determine proportions of women with intense anger, depressive symptoms, and comorbid intense anger and depressive symptoms, and to examine mothers' and infants' sleep quality as correlates of postpartum anger.

METHODS

This cross-sectional survey study was advertised as an examination of mothers' and babies' sleep. Women, with healthy infants between 6 and 12 months of age, were recruited using community venues. The survey contained validated measures of sleep quality for mothers and infants, and fatigue, social support, anger, depressive symptoms, and cognitions about infant sleep.

RESULTS

278 women participated in the study. Thirty-one percent of women (n = 85) reported intense anger (≥ 90th percentile on State Anger Scale) while 26% (n = 73) of mothers indicated probable depression (>12 on Edinburgh Postnatal Depression Scale). Over half of the participants rated their sleep as poor (n = 144, 51.8%). Using robust regression analysis, income (β = -0.11, p < 0.05), parity (β = 0.2, p < 0.01), depressive symptoms (β = 0.22, p < 0.01), and mothers' sleep quality (β = 0.10, p < 0.05), and anger about infant sleep (β = 0.25, p < 0.01) were significant predictors of mothers' anger.

CONCLUSIONS

Mothers' sleep quality and anger about infant sleep are associated with their state anger. Clinicians can educate families about sleep pattern changes during the perinatal time frame and assess women's mood and perceptions of their and their infants' sleep quality in the first postpartum year. They can also offer evidence-based strategies for improving parent-infant sleep. Such health promotion initiatives could reduce mothers' anger and support healthy sleep.

The relationship of maternal anxiety, positive and negative affect schedule, and fatigue with neonatal psychological health upon childbirth

BACKGROUND

Exposure of mothers to negative moods and stress before childbirth leads to negative consequences for the infants. Given the importance of psychological health, this study aimed to examine the effect of these factors on the infants' psychological health.

METHOD

This cross-sectional study was conducted in Shiraz hospitals on 110 pregnant women selected with multistage random sampling. Research tools included The McGill Pain Questionnaire (MPQ) to measure fatigue with three criteria; The Positive and Negative Emotion Schedule (PANAS); and The Spielberger State-Trait Anxiety Inventory (STAI) were used to measure maternal mood and anxiety level. Also, neonatal psychological health was assessed by a checklist. Neonatal psychological health's correlation with maternal anxiety, fatigue, and mental state was assessed. Data were analyzed by SPSS-19 software using Pearson correlation coefficient and statistical regression at the significance level of 0.05.

RESULT

Although there was no significant relationship between maternal anxiety score and neonatal psychological health after birth (p = 0.231; r=-0.343), the relationship was significant immediately after birth with positive (P < 0.001; r = 0.343) and negative affect scores (P < 0.001; r=-0.357).

CONCLUSIONS

There was a statistically significant relationship between the neonatal psychological health and maternal fatigue (p ≤ 0.001; r = -0.357) and PANAS (p ≤ 0.001) of the mother; however, it had no significant relationship with maternal anxiety (p = 0.231; r=- 0.343). Therefore, nurses and midwives can reduce maternal anxiety and improve neonatal mental health by supporting mothers.

Comparison of the Psychometric Properties of Three Fatigue Scales in Persian-Speaking Patients with Multiple Sclerosis

Background

Fatigue is the most disabling symptom in patients with multiple sclerosis (MS). Although there is no standard tool to evaluate fatigue in clinical settings, the Fatigue Impact Scale (FIS), Fatigue Severity Scale (FSS), and Multidimensional Assessment of Fatigue (MAF) scale are popular instruments for this purpose. The aim of this study was to compare the psychometric properties of the Persian versions of these scales.

Methods

One hundred thirty adult patients with MS and 60 controls participated in this study. They completed the scales on two occasions 3 days apart. Reproducibility and internal consistency were evaluated as intraclass correlation coefficients (ICCs) and Cronbach α. Convergent validity was assessed by evaluating the association of the fatigue scales with age, sex, Expanded Disability Status Scale (EDSS) score, disease duration, and sleep quality. Dimensionality was evaluated using confirmatory factor analysis. Acceptability and known-group validity were investigated. The effect size of each scale was computed.

Results

The ICC of all instruments was 0.99. Internal consistency was 0.97 for the MAF scale, 0.93 for FSS, and 0.83 for FIS. The instruments showed moderate-to-good correlations with Pittsburgh Sleep Quality Index, EDSS score, and disease duration. Acceptability was acceptable. The FIS had three dimensions, and the FSS and MAF scale were unidimensional. All scales were able to discriminate patients with MS from controls.

Conclusions

The Persian version of the MAF scale seems to be the most suitable instrument to evaluate fatigue in patients with MS based on its time efficiency, effect size, and detailed data about various aspects of fatigue.

A Priori and a Posteriori Dietary Patterns among Pregnant Women in Johannesburg, South Africa: The NuPED Study

Dietary pattern analyses allow assessment of the diet as a whole. Limited studies include both a priori and a posteriori dietary pattern analyses. This study aimed to explore the diet of pregnant women in urban South Africa through both a priori and a posteriori dietary pattern analyses and associated maternal and household factors. Dietary data were collected during early pregnancy using a quantified food frequency questionnaire from 250 pregnant women enrolled in the Nutrition During Pregnancy and Early Development (NuPED) cohort. A priori dietary patterns were determined using the Diet Quality Index-International (DQI-I), and a posteriori nutrient patterns using exploratory factor analysis. Based on the DQI-I, the study population followed a borderline low-quality diet. Three a posteriori nutrient patterns were identified: Pattern 1 “plant protein, iron, thiamine, and folic acid”; pattern 2 “animal protein, copper, vitamin A, and vitamin B₁₂”; pattern 3 “fatty acids and sodium”. Pattern 1 was associated with higher dietary quality (p < 0.001), lower maternal educational level (p = 0.03) and socioeconomic status (p < 0.001). Pattern 3 was significantly associated with lower dietary quality. The low dietary quality among pregnant women residing in urban South Africa should be addressed to ensure optimal maternal and offspring health outcomes.

Effects of Postpartum Fatigue and Depressive Cognitions on Life Satisfaction and Quality of Life in Arab Postpartum Women: The Intervening Role of Resourcefulness

The purpose of this study is to explore the relationships among postpartum fatigue (PPF), depressive cognitions, resourcefulness, quality of life, and life satisfaction in Arab postpartum mothers. A conceptual framework is used in this study based on the middle range theory of resourcefulness, which Zauszniewski developed in 2006. The study is a cross-sectional descriptive design with 123 postpartum women who had given birth within the past six months. used WhatsApp and Facebook for recruitment. developed the self-administered online survey in Qualtrics and collected data from 6 January 2017, to 6 February 2017. Correlation analysis is used to address the research aim and used the P value of 0.05 to determine the significance of the results. There were significant correlations among depressive cognitions and resourcefulness, life satisfaction, and quality of life; there were also significant correlations between PPF and life satisfaction, as well as among resourcefulness, quality of life, and life satisfaction. The results of this study emphasized the importance of assessing depressive symptoms and PPF in mothers early in the postpartum period. The results may contribute to designing future intervention studies aimed toward decreasing the risk of mothers with PPF developing more serious depressive symptoms.

Multiple Micronutrients, Lutein, and Docosahexaenoic Acid Supplementation during Lactation: A Randomized Controlled Trial

Breastfed infants require an adequate supply of critical nutrients for growth, tissue functions, and health. Recommended intakes for several nutrients are considerably higher in lactating than non-lactating women but are not always met with habitual diets. We report a randomized, double-blind clinical trial in 70 healthy lactating women in Germany evaluating the effects of supplementation with multiple micronutrients, lutein, and docosahexaenoic acid (DHA) compared to placebo on maternal nutrient status and milk composition. The primary endpoint was the effect on the change of human milk DHA content (as a proportion of total milk fatty acids) during 12 weeks of supplementation. Maternal blood and milk biomarkers were measured as secondary endpoints. Supplementation increased maternal milk DHA by 30% compared to a decline in the placebo group. Supplementation also increased maternal blood DHA (17%), eicosapentaenoic acid (4%), 25-OH-vitamin D (24%), vitamin B12 (12%), lutein (4%), and beta carotene (49%), while homocysteine decreased. No significant difference in the number of adverse events was observed between supplementation and placebo groups. In conclusion, multi-micronutrient supplementation was safe and increased maternal blood and milk concentrations of selected nutrients in healthy women.

A brief sleep focused psychoeducation program for sleep-related outcomes in new mothers: a randomized controlled trial

Study Objectives

Poor sleep is commonly problematic during pregnancy and postpartum and is associated with depression. This trial investigated the efficacy of prenatal brief, group sleep psychoeducation in improving postpartum maternal sleep, and depression.

Methods

A total of 215 healthy expectant first-time mothers were cluster randomized (1:1) to receive either a 2 × 1.5 h psychoeducation intervention and a set of booklets, or a set of booklets only. Participants completed questionnaires during pregnancy (pre-intervention), and 6 weeks and 4 months postpartum. A post hoc subset of questionnaires was collected at 10 months postpartum. The primary hypothesis was the intervention group would have improved postpartum sleep quality, and reduced levels of insomnia symptoms, fatigue, and daytime sleepiness compared to the control group. Secondary outcomes included depression, anxiety, and stress.

Results

Linear mixed model analyses failed to confirm a group by time interaction on primary or secondary outcomes across all time points. There was no effect of the intervention on outcomes at 6 weeks, or 10 months postpartum. A significant time by group interaction was found at 4 months, favoring the intervention for sleep quality (p = 0.03) and insomnia symptoms (p = 0.03), but not fatigue or daytime sleepiness.

Conclusions

Prenatal sleep psychoeducation did not produce a sustained effect on maternal sleep throughout the postpartum period. There was little evidence of benefits on depressive symptoms.

Clinical Trial Registration

ACTRN12611000859987

Trajectory and Predictors of Fatigue Among Chinese Immigrant and Chinese Canadian-Born Women in the Postpartum Period

OBJECTIVE

To describe the proportion of women with improving or worsening symptoms of fatigue at 1, 3, 6, and 12 months after birth; to model the trajectory of fatigue across the first year after birth and identify baseline predictors (e.g., immigrant status) and time-varying predictors; and to describe the degree to which fatigue interferes with activities of daily living across the first year after birth among a cohort of Chinese immigrant and Chinese Canadian-born women.

DESIGN

Prospective cohort study.

SETTING

Toronto, Ontario, Canada.

PARTICIPANTS

Chinese women who were recent immigrants (n = 244), nonrecent immigrants (n = 247), or Canadian born (n = 100).

METHODS

Women completed surveys at 1, 3, 6, and 12 months after birth. We measured fatigue with the use of the Multidimensional Assessment of Fatigue scale. Fatigue predictor variables were classified as baseline (e.g., immigrant status) or time varying (e.g., depression). We used latent growth curve modeling to examine fatigue trajectories and identify predictors over time.

RESULTS

Fatigue followed a nonlinear pattern: it improved from 1 to 6 months after birth and then worsened from 6 to 12 months after birth. Depression, anxiety, infant sleep characteristics, and breastfeeding problems, but not immigrant status, significantly increased risk for fatigue. Several daily activities were significantly influenced by fatigue, particularly early in the postpartum period as well as later, which showed a U-shaped relationship between fatigue and activities of daily living.

CONCLUSION

Fatigue is common and persistent across the postpartum period. Modifiable risk factors related to mental health, infant sleep, and breastfeeding difficulties suggest that preventive strategies for maternal fatigue warrant further investigation.

Psychosocial factors correlate with fatigue among pregnant women in Jordan

PURPOSE

The study aimed to assess the correlation between fatigue and psychological factors, namely stress, social support, self-esteem, and depression among pregnant women in Jordan.

DESIGN AND METHODS

A cross-sectional design was suggested. Cluster stratified random sampling technique was adopted. Fatigue assessment scale, Rosenberg Self-Esteem Scale, Perceived Stress Scale, Multidimensional Social Support Scale, and Beck's Depression Inventory were used.

FINDINGS

A total of 580 pregnant women were included. Overall, 67.4% of the participants experienced fatigue, about 74.0% had moderate to high stress, 56.0% had moderate social support, around 89.0% had normal self-esteem, and 43.1% experienced moderate to extreme depression. Stress, self-esteem, and depression were correlated with fatigue.

PRACTICE IMPLICATIONS

This study can help develop proper psychosocial care and sustain mental health among women during pregnancy.

Prevalence and Predictors of Postpartum Maternal and Infant Bed-Sharing Among Chinese-Canadian Women

Objective/Background: Our primary objective was to describe and identify predictors of any and predominant bed-sharing at 4 and 12 weeks postpartum among Chinese-Canadian mothers. Participants: We conducted a longitudinal study of 570 Chinese immigrant and Canadian-born women in Toronto, Ontario. Methods: Any bed-sharing, defined as sharing a bed or mattress for any part of the night on any night in the previous week, and predominant bed-sharing, defined as sharing a bed or mattress for most of the night, on more than half the nights of the previous week, were evaluated at 4 and 12 weeks postpartum. Predictors of bed-sharing, evaluated in multivariable logistic regression models, were background (age, parity, education, household size, delivery mode, social support), cultural (immigrant status, acculturative stress, acculturation, postpartum ritual uptake), and postpartum variables (mental health, breastfeeding problems, fatigue, sleep knowledge, plans for bed-sharing, perceptions of infant sleep problems, cognitions about infant sleep). Results: One in five women (20.7%) reported bed-sharing as the predominant sleep location for their infant at 4 weeks postpartum, with nearly half (45.6%) reporting any bed-sharing at this time. The prevalence of any bed-sharing remained relatively stable at 12 weeks postpartum (46.5%), while predominant bed-sharing increased to 30.1%. The most consistent predictors of any and predominant bed-sharing at 4 and 12 weeks postpartum were lower education level, greater acculturative stress, and predelivery plans to bed-share. Conclusions: These findings have implications for the development of clinical recommendations given to expectant and new parents to promote infant sleep practices that are consistent with American Academy of Pediatrics recommendations.

A Systematic Review of Studies Using the Multidimensional Assessment of Fatigue Scale

PURPOSE

To review how the Multidimensional Assessment of Fatigue (MAF) has been used and evaluate its psychometric properties.

METHODS

We conducted a database search using "multidimensional assessment of fatigue" or "MAF" as key terms from 1993 to 2015, and located 102 studies.

RESULTS

Eighty-three were empirical studies and 19 were reviews/evaluations. Research was conducted in 17 countries; 32 diseases were represented. Nine language versions of the MAF were used. The mean of the Global Fatigue Index ranged from 10.9 to 49.4. The MAF was reported to be easy-to-use, had strong reliability and validity, and was used in populations who spoke languages other than English.

CONCLUSION

The MAF is an acceptable assessment tool to measure fatigue and intervention effectiveness in various languages, diseases, and settings across the world.

Fatigue in Pregnancy: The validity and reliability of the Farsi Multidimensional Assessment of Fatigue scale

Objectives

Fatigue is a common discomfort experienced during pregnancy and may contribute to severe labour pain and postpartum depression. This study aimed to translate the Multidimensional Assessment of Fatigue (MAF) scale into Farsi and validate it in a sample of pregnant Irani women.

Methods

This cross-sectional questionnaire study was conducted between January and June 2016 at eight healthcare centres in Sabzevar, Iran. The English version of the MAF scale was translated into Farsi and assessed for content validity. Participants completed the Farsi MAF scale and the Farsi World Health Organization-5 Well-being index (WHO-5). Construct validity was assessed through exploratory factor analysis (EFA). Cronbach's alpha coefficient and the intraclass correlation coefficient (ICC) were used to determine the internal consistency and stability of the Farsi MAF scale.

Results

A total of 582 women met the inclusion criteria, of which 541 completed the MAF scale (response rate: 93%). The EFA of the 15 items confirmed the previously proposed one-factor structure with a Cronbach's alpha coefficient of 0.957 for the Farsi MAF scale. Stability was confirmed by the ICC value (0.702) for the Global Fatigue Index (GFI) and the mean GFI was 20.33 ± 12.71. Concurrent validity was confirmed by a moderate negative correlation (r = -0.35; P <0.001) between the scores of the Farsi MAF scale and the Farsi WHO-5. Women who received a high level of support from their husbands, who were satisfied with the quality of their marital relationship and with a well-being score of >50 reported a lower level of fatigue than the other groups (P ≤0.012).

Conclusion

The Farsi MAF scale is a reliable and valid questionnaire to investigate fatigue in pregnant Irani women. Interventions to promote marital satisfaction and women's well-being are recommended.

Psychometric Properties of the Persian Version of the "Multidimensional Assessment of Fatigue Scale"

Background:

Fatigue is a common symptom in office workers. The purpose of this study was to assess the psychometric properties of the Persian version of the Multidimensional Assessment of Fatigue (P-MAF) scale and its association with productivity among Iranian office workers.

Methods:

In order to validate the MAF scale, using “forward-backward” translation, cognitive debriefing, and cultural adaptation procedure, the English version of the MAF was translated into Farsi. A total of 129 Iranian office workers with at least 1-year job experience were included in the study. The Persian version of the Health and Work Questionnaire was used for assessment of the productivity in the participants.

Results:

Internal consistency for all subscales of the P-MAF scale was acceptable (α ≥ 0.854). The correlation of convergent validity and the correlation of discriminant validity for all subscales ranged from 0.466 to 0.948 and 0.121 to 0.5, respectively. Internal consistency of each subscale of P-MAF for sex, marital status, job tenure, and daily working hours was high (0.810–0.952). Factor analysis of the P-MAF scale revealed that its items were related to severity, distress, timing of fatigue, interference with activity at home, and interference with activity away from home. The results showed significant correlations between the score of fatigue and some subscales of P-MAF, including concentration/focus (r = 0.649, P < 0.001) and impatience/irritability (r = 0.334, P = 0.001).

Conclusions:

The P-MAF had appropriate structural characteristics, was a valid and reliable instrument, and could be used for measuring fatigue among Iranian office workers.

The cytokine profile of women with severe anxiety and depression during pregnancy

BACKGROUND

Controversial findings regarding the association between pro-inflammatory cytokines and depression have been reported in pregnant subjects. Scarce data about anxiety and its relationships with cytokines are available in pregnant women. To understand the association between anxiety and cytokines during pregnancy, we conducted the present study in women with or without depression.

METHODS

Women exhibiting severe depression (SD) and severe anxiety (SA) during the 3rd trimester of pregnancy (n = 139) and control subjects exhibiting neither depression nor anxiety (n = 40) were assessed through the Hamilton Depression Rating Scale (HDRS) and the Hamilton Anxiety Rating Scale (HARS). Serum cytokines were measured by a multiplex bead-based assay. Correlation tests were used to analyze the data and comparisons between groups were performed. A general linear model of analysis of variance was constructed using the group as a dependent variable, interleukin concentrations as independent variables, and HDRS/HARS scores and gestational weeks as covariables.

RESULTS

The highest levels of Th1- (IL-6, TNF-α, IL-2, IFN-γ), Th17- (IL-17A, IL-22), and Th2- (IL-9, IL-10, and IL-13) related cytokines were observed in women with SD + SA. The SA group showed higher concentrations of Th1- (IL-6, TNF-α, IL-2, IFN-γ) and Th2- (IL-4, and IL-10) related cytokines than the controls. Positive correlations were found between HDRS and IL-2, IL-6, and TNF-α in the SA group (p < 0.03), and between HDRS and Th1- (IL-2, IL-6, TNF-α), Th2- (IL-9, IL-10, IL-13) and Th17- (IL-17A) cytokines (p < 0.05) in the SD + SA group. After controlling the correlation analysis by gestational weeks, the correlations that remained significant were: HDRS and IL-2, IL-6, IL-9, and IL-17A in the SD + SA group (p < 0.03). HARS scores correlated with IL-17A in the SA group and with IL-17A, IL-17F, and IL-2 in the SD + SA group (p < 0.02). The linear model of analysis of variance showed that HDRS and HARS scores influenced cytokine concentrations; only IL-6 and TNF-α could be explained by the group.

CONCLUSIONS

We found that the cytokine profiles differ when comparing pregnant subjects exhibiting SA with comorbid SD against those showing only SA without depression.

Postpartum fatigue and depression: A systematic review and meta-analysis

BACKGROUND

New parents are vulnerable to fatigue and depressive symptoms. Many studies have reported significant positive correlations between the two in postpartum parents, but the size of correlations varies considerably between studies. The relationship between postpartum fatigue and depression is yet to be systematically synthesized and meta-analyzed.

METHODS

A PROSPERO registered systematic review and meta-analysis (CRD42017065240) was conducted on the correlation between fatigue and depression within the first two years postpartum in parents. Moderation analysis was used to examine the influence of demographic and measurement factors on the effect sizes.

RESULTS

Thirty-five eligible papers were identified (34 on mothers, 1 on fathers). The meta-analytic summary effect size for simultaneously measured fatigue and depressive symptoms among women in the postpartum period was r = 0.52, 95% CI [0.45, 0.59], p < .001. There was a high degree of heterogeneity in the strength of the correlation between studies. This heterogeneity was not accounted for by demographic (e.g., infant age, maternal age, population type) or methodology (e.g., measurement) related moderators.

LIMITATIONS

Studies not reporting or providing correlation between fatigue and depression were not included. Unable to assess some moderators due to limited sample size.

CONCLUSIONS

There is a strong correlation between fatigue and depressive symptoms among women in the first two years after child-birth, but a high degree of heterogeneity in correlation strength exists between studies. Careful assessment of both fatigue and depression when either symptom is reported could facilitate accurate differential diagnosis and prioritizing treatment in postpartum women. Further implications for assessment, treatment, and future research are discussed.

Prevalence and predictors of exclusive breastfeeding among immigrant and Canadian-born Chinese women

Breastfeeding is the optimal method for infant feeding, yet migrant women may be at risk for suboptimal exclusivity rates. In a cohort of immigrant and Canadian-born Chinese women, our objectives were to (a) describe patterns and prevalence of exclusive breastfeeding at 1, 3, and 6 months postpartum; (b) identify risk and protective factors associated with exclusivity; and (c) examine potentially differential importance of these factors across this 6-month period. This was a prospective study of 565 immigrants and Canadian-born Chinese women (Toronto, Canada). Exclusive breastfeeding was measured at 1, 3, and 6 months postpartum. Predictors comprised fixed (demographics, history of depression, immigrant status, prenatal breastfeeding classes, in-hospital formula supplementation, baseline social support, and baseline acculturative stress) and time-dependent (depression, anxiety, fatigue, and breastfeeding problems) variables. Descriptive statistics, logistic regression, and generalized linear mixed models, respectively, were undertaken to address the objectives. Patterns of breastfeeding practices included exclusive breastfeeding in all time points (26.8%) or none (32.9%) and moving from exclusive to nonexclusive (20.3%) or nonexclusive to exclusive breastfeeding (15.2%). Women less likely to breastfeed exclusively at 1, 3, or 6 months were those whose infants received in-hospital formula supplementation. Exclusivity attrition was higher between 3 and 6 months than 1-3 months. Immigrant status and in-hospital formula supplementation had a significant impact on exclusivity earlier in the postpartum period while breastfeeding problems were associated with decreased exclusivity across time. Proactive preventive efforts are need to maintain breastfeeding exclusivity especially between 3 and 6 months if women are to meet international breastfeeding recommendations.

Nutrition during pregnancy and early development (NuPED) in urban South Africa: a study protocol for a prospective cohort

BACKGROUND

Adequate nutrition during pregnancy is important to ensure optimal birth outcomes, maternal health and offspring development. However, little is known about the dietary intake and nutritional status of pregnant women residing in urban South Africa. Therefore, the Nutrition during Pregnancy and Early Development (NuPED) cohort study was initiated to assess early nutrition-related exposures predictive of early childhood development in urban South Africa.

METHODS

The aims of this prospective cohort study are: 1) to assess dietary intake and nutritional status of urban pregnant women in Johannesburg, South Africa, and 2) to determine associations with birth outcomes, measures of maternal health, as well as measures of offspring health and development. Pregnant women (< 18 weeks' gestation) (n = 250) are being recruited from primary healthcare clinics in Johannesburg and are followed-up at a provincial hospital. Participants' dietary intake and nutrient status (focus on micronutrients and fatty acids) are assessed at < 18, 22 and 36 weeks' gestation. Additional assessments during pregnancy include anthropometric and blood pressure measurements, obstetric ultrasound screens, and assessments of food security, maternal fatigue, prenatal depression, allergy, immune function, morbidity and gestational diabetes. At birth, maternal and neonatal health is assessed and an umbilical cord blood sample collected. Maternal and offspring health is followed-up at 6 weeks, as well as at 6, ≈7.5 and 12 months after birth. Follow-up assessments of mothers include anthropometric measures, diet history, nutrient status, blood pressure, breast milk composition, and measures of postnatal depression and fatigue. Follow-up assessments of the offspring include feeding practices, nutrient status, measures of growth, psychomotor, socio-emotional and immune development, morbidity, allergy, as well as analysis of the gut microbiome and the epigenome.

DISCUSSION

Ensuring adequate nutrition during pregnancy is one of the key actions endorsed by the South African Government to promote optimal early childhood development in an effort to eradicate poverty. The results from this study may serve as a basis for the development of context-specific nutritional interventions which can improve birth outcomes and long-term quality of life of the mother and her offspring.

Evaluation of the Reliability and Validity of the Persian Version of the Fatigue Assessment Scale in Iranian Sarcoidosis Patients

INTRODUCTION

Fatigue is one of the common symptoms of sarcoidosis, which occurs in about 50-70% of patients.

AIM

Considering that there are no valid Iranian questionnaires for evaluating fatigue in sarcoidosis, in the present study, for the first time, we translated Fatigue Questionnaire into Persean and evaluated its validity and reliability among Iranian patients with sarcoidosis.

MATERIAL AND METHODS

In methodological research, English version of Fatigue assessment scale (FAS) 10 items questionnaire which is designed to assess physical or mental fatigue in chronic disease patients, was translated into Persian and back-translated into English. Its validity and reliability were studied on the one hundred and thirteen confirmed sarcoidosis patients are referring to respiratory referral hospital of Iran. Reliability analysis was performed by estimation of Cronbach`s alpha test.

RESULTS

According to the cut-off point of 22.84 (74%) of the studied patients were suffering from fatigue. The internal consistency calculation revealed that the alpha value of the physical fatigue and mental fatigue was 0.945 and 0.896, respectively.

CONCLUSION

We concluded that the existence of questions number 4 and 10 in the questionnaire reduces the continuity of the questions, and therefore we suggest applying the FAS questionnaire without the two questions 4 and 10. This study showed that FAS questionnaire was very practical and can routinely be applied to assess the fatigue scale in sarcoidosis patients.

Unique trajectories of anxiety among Chinese-Canadian women across the first postpartum year: A longitudinal cohort study

BACKGROUND

Our objectives were to identify subtypes of Chinese-Canadian women with unique trajectories of anxiety symptomatology over the first postpartum year, investigate covariates associated with group membership, and determine if mental healthcare utilization varies by group membership.

METHODS

This was a longitudinal cohort study of 570 Chinese immigrant and Canadian-born women in Toronto, Canada with live births in 2010-2014. Covariates were age, immigrant status, income, fatigue, social support, acculturative stress, and depression. Mental healthcare utilization included visits at 4-24 weeks postpartum. Anxiety symptomatology was measured using the State-Trait Anxiety Inventory-State. Growth mixture modeling was used to identify latent classes corresponding to trajectories of anxiety symptomology at 4-52 weeks.

RESULTS

Three groups were identified: "consistently non-anxious" (74%, stable low levels of anxiety), "consistently anxious" (19.5%, clinically meaningful anxiety at baseline and across time), and "anxious-improving" (6.5%, high anxiety at baseline followed by decline). Compared to consistently non-anxious women, consistently anxious women were more likely to report baseline fatigue, depression, and acculturative stress; anxious-improving women were more likely to report baseline fatigue, depression, and history of depression before pregnancy. At 12-24 weeks, 13.8% of anxious-improving women sought mental healthcare compared to 8.6% of consistently-anxious women and 4.7% of non-anxious women (p = .06).

LIMITATIONS

Our sample comprised Chinese immigrant and Canadian-born women; results should be replicated in other groups.

CONCLUSIONS

We identified three subtypes of postpartum anxiety trajectories. These groups of women may respond differently to interventions due to exposure to various combinations of risk factors.

Determinants of comorbid depression and anxiety postnatally: A longitudinal cohort study of Chinese-Canadian women

BACKGROUND

Women with comorbid depression and anxiety in the postpartum period experience more complex and severe symptoms than women with depression or anxiety alone; however, little is known about what influences these symptoms, especially among women from specific ethnic backgrounds. The objective of this study was to identify determinants of comorbid depression and anxiety symptomatology by 24 weeks postpartum in a cohort of Chinese-Canadian women.

METHODS

A longitudinal cohort study was completed where 549 Chinese immigrant and Canadian-born women in Toronto were followed to 24 weeks postpartum. Questionnaires included risk factors measured at 4 weeks. Logistic regression was used to develop a model of comorbidity (Edinburgh Postnatal Depression Scale score > 9; State-Trait Anxiety Inventory score > 40) up to and including 24 weeks.

RESULTS

Previous history of postpartum (AOR 2.42, 95% CI 1.42-4.14) and non-postpartum (AOR 4.20, 95% CI 2.21-7.98) depression, maternal age < 26 years (AOR 1.83, 95% CI 1.04-3.22), perception of support (AOR 0.97, 95% CI 0.94-1.00), acculturative stress (AOR 1.03, 95% CI 1.01-1.04), maternal fatigue (AOR 1.12, 95% CI 1.07-1.17), and perceived infant sleep problems (AOR 2.06, 95% CI 1.27-3.43) were significantly associated with comorbid depression and anxiety in the first 24 weeks postpartum.

LIMITATIONS

Our sample consisted of Chinese-Canadian women; this study should be replicated in other ethnic groups to see if and how risk factors of postpartum comorbidity differ.

CONCLUSION

The factors identified herein offer insight into groups of Chinese-Canadian women who might benefit most from early identification and treatment and suggest targets for prevention.

The Spanish version of the Fatigue Assessment Scale: reliability and validity assessment in postpartum women

Background

Fatigue is the most widely reported symptom by women during pregnancy, labour, the postpartum period, and early parenting. The objective was to translate the Fatigue Assessment Scale (FAS) into Spanish and assess its psychometric properties.

Methods

Instrumental Design. The FAS was translated into Spanish (FAS-e) using forward and back translation. A convenience sample was constituted with 870 postpartum women recruited at discharge from 17 public hospitals in Eastern Spain. Data was obtained from clinical records and self-administered questionnaires at discharge. Internal consistency, factor structure, comparisons between known groups and correlations with other variables were assessed.

Results

Cronbach’s alpha coefficient was .80. Findings on the dimensionality of the FAS-e scale indicated that it was sufficiently unidimensional. FAS-e scores were higher among women who had undergone caesarean births (p < .05), had a higher level of postpartum pain (p < .01), experienced difficulties during breastfeeding (p < .01) and had lower levels of self-efficacy for breastfeeding (p < .01).

Conclusions

An equivalent Spanish version of the FAS was obtained with good reliability and validity properties. FAS-e is an appropriate tool to measure postpartum fatigue.

Cross-sectional and longitudinal validation of a 13-item fatigue scale among Japanese postpartum mothers

This study examined the psychometric properties of a 13-item fatigue scale for postpartum mothers. Japanese mothers (n = 2026) from a cohort study completed questionnaires (e.g. fatigue scale, Japanese version of the Edinburgh Postnatal Depression Scale, demographics) during their hospital stay after childbirth (baseline) and at 1, 2, 4 and 6 months postpartum. Initial factor analysis of baseline data revealed that the fatigue scale had three factors or subscales (physical, emotional and cognitive). Within-group analysis across each measurement time revealed the same three-factor structure with acceptable fit. Between-group analysis also showed longitudinal factorial invariance across time. The fatigue subscales had acceptable divergent and convergent validities with the depression scale. The subscale scores differed significantly based on participant background. The Japanese Fatigue Scale is a concise and informative tool for assessing aspects of fatigue in clinical settings and in the community.

Relationships between parental sleep quality, fatigue, cognitions about infant sleep, and parental depression pre and post-intervention for infant behavioral sleep problems

Background

Maternal and paternal depression has been associated with infants’ behavioral sleep problems. Behavioral sleep interventions, which alter parental cognitions about infant sleep, have improved infant sleep problems. This study reports relationships between parental depression, fatigue, sleep quality, and cognitions about infant sleep pre and post-intervention for a behavioral sleep problem.

Methods

This secondary analysis of data from Canadian parents (n = 455), with healthy infants aged 6-to-8-months exposed to a behavioral sleep intervention, examined baseline data and follow-up data from 18 or 24 weeks post intervention (group teaching or printed material) exposure. Parents reported on sleep quality, fatigue, depression, and cognitions about infant sleep. Data were analyzed using Pearson’s r and stepwise regression analysis.

Results

Parents’ fatigue, sleep quality, sleep cognitions, and depression scores were correlated at baseline and follow-up. At baseline, sleep quality (b = .52, 95% CI .19–.85), fatigue (b = .48, 95% CI .33–.63), doubt about managing infant sleep (b = .44, 95% CI .19–.69), and anger about infant sleep (b = .69, 95% CI .44–.94) were associated with mothers’ depression. At baseline, fathers’ depression related to sleep quality (b = .42, 95% CI .01–.83), fatigue (b = .47, 95% CI .32–.63), and doubt about managing infant sleep (b = .50, 95% CI .24–.76). At follow-up, mothers’ depression was associated with sleep quality (b = .76, 95% CI .41–1.12), fatigue (b = .25, 95% CI .14–.37), doubt about managing infant sleep (b = .44, 95% CI .16–.73), sleep anger (b = .31, 95% CI .02–.59), and setting sleep limits (b = −.22, 95% CI -.41-[−.03]). At follow-up, fathers’ depression related to sleep quality (b = .84, 95% CI .46–1.22), fatigue (b = .31, 95% CI .17–.45), sleep doubt (b = .34, 95% CI .05–.62), and setting sleep limits (b = .25, 95% CI .01–.49).

Conclusions

Mothers’ and fathers’ cognitions about infant sleep demonstrate complex relationships with their depression scores. While mothers’ setting sleep limit scores are associated with decreased depression scores, fathers’ setting limits scores are associated with increased depression scores. Parental doubts about managing infant sleep and difficulties with setting sleep limits require attention in interventions.

Validity and reliability of the multidimensional assessment of fatigue scale in Iranian patients with relapsing-remitting subtype of multiple sclerosis

PURPOSE

The purpose of this study is to investigate the validity and reliability of the Persian version of the Multidimensional Assessment of Fatigue Scale (MAFS) in an Iranian population with multiple sclerosis.

METHOD

A self-reported survey on fatigue including the MAFS, Fatigue Impact Scale and demographic measures was completed by 130 patients with multiple sclerosis and 60 healthy persons sampled with a convenience method. Test-retest reliability and validity were evaluated 3 days apart. Construct validity of the MAFS was assessed with the Fatigue Impact Scale.

RESULTS

The MAFS had high internal consistency (Cronbach's alpha >0.9) and 3-d test-retest reliability (intraclass correlation coefficient = 0.99). Correlation between the Fatigue Impact Scale and MAFS was high (r = 0.99). Correlation between MAFS scores and the Expanded Disability Status Scale was also strong (r = 0.85). Questionnaire items showed acceptable item-scale correlation (0.968-0.993).

CONCLUSIONS

The Persian version of the MAFS appears to be a valid and reliable questionnaire. It is an appropriate short multidimensional instrument to assess fatigue in patients with multiple sclerosis in clinical practice and research. Implications for Rehabilitation The Persian version of Multidimensional Assessment of Fatigue is a valid and reliable instrument for the assessment and monitoring the fatigue in Persian-language patients with multiple sclerosis. It is very easy to administer and a time efficient scale in comparison to other instruments evaluating fatigue in patients with multiple sclerosis.

Associations between Nausea, Vomiting, Fatigue and Health-Related Quality of Life of Women in Early Pregnancy: The Generation R Study

The objective of this study was to evaluate the independent associations between nausea, vomiting, fatigue and health-related quality of life of women in early pregnancy in the Generation R study, which is a prospective mother and child cohort. Analyses were based on 5079 women in early pregnancy in the Rotterdam area, the Netherlands. The information on nausea, vomiting and fatigue in the previous three months was measured in the questionnaire at enrollment, as well as potential confounders (i.e., maternal/gestational age, ethnic background, educational level, parity, marital status, body mass index, tobacco and alcohol use, chronic/infectious conditions, uro-genital conditions/symptoms, sleep quality, headache, anxiety, and depression). Health-related quality of life was assessed by the 12-item Short Form Health Survey and physical and mental component summary scores were calculated. Multivariate regression models were performed to evaluate the independent associations of the presence of nausea, vomiting and fatigue with health-related quality of life, adjusting for potential confounders. 33.6% of women experienced daily presence of nausea, 9.6% for vomiting and 44.4% for fatigue. Comparing with women who never reported nausea, vomiting and fatigue, women with daily presence of at least one of these symptoms had significantly lower scores of physical component summary and mental component summary, after adjusting for potential confounders. Our study shows how common nausea, vomiting and fatigue are among women in early pregnancy and how much each of these symptoms negatively impact on health-related quality of life. We call for awareness of this issue from health care professionals, pregnant women and their families.

The Immune System and the Role of Inflammation in Perinatal Depression

Major depression during pregnancy is a common psychiatric disorder that arises from a complex and multifactorial etiology. Psychosocial stress, sex, hormones, and genetic vulnerability increase the risk for triggering mood disorders. Microglia and toll-like receptor 4 play a crucial role in triggering wide and varied stress-induced responses mediated through activation of the inflammasome; this leads to the secretion of inflammatory cytokines, increased serotonin metabolism, and reduction of neurotransmitter availability along with hypothalamic-pituitary-adrenal axis hyperactivity. Dysregulation of this intricate neuroimmune communication network during pregnancy modifies the maternal milieu, enhancing the emergence of depressive symptoms and negative obstetric and neuropsychiatric outcomes. Although several studies have clearly demonstrated the role of the innate immune system in major depression, it is still unclear how the placenta, the brain, and the monoaminergic and neuroendocrine systems interact during perinatal depression. Thus, in the present review we describe the cellular and molecular interactions between these systems in major depression during pregnancy, proposing that the same stress-related mechanisms involved in the activation of the NLRP3 inflammasome in microglia and peripheral myeloid cells in depressed patients operate in a similar fashion in the neuroimmune placenta during perinatal depression. Thus, activation of Toll-like receptor 2 and 4 signaling and the NLRP3 inflammasome in placental immune cells may promote a shift of the Th1/Th2 bias towards a predominant Th1/Th17 inflammatory response, associated with increased secretion of pro-inflammatory cytokines, among other secreted autocrine and paracrine mediators, which play a crucial role in triggering and/or exacerbating depressive symptoms during pregnancy.

Effect of Pilates exercises on postpartum maternal fatigue

INTRODUCTION

Postpartum fatigue is a pervasive phenomenon and often affects mothers immediately after delivery. The present study aimed to assess the effect Pilates home exercises had on postpartum maternal fatigue.

METHODS

A total of 80 women participated in our clinical trial study. The women were randomly divided into two groups - the intervention group (n = 40) and the control group (n = 40). In the intervention group, the women performed Pilates exercises five times a week (30 min per session) for eight consecutive weeks. The first session was conducted 72 hours after delivery. The control group did not receive any intervention. Each woman's level of fatigue was evaluated at hospital discharge (as a baseline), and at four and eight weeks after delivery, using the standard Multidimensional Fatigue Inventory (MFI-20) questionnaire and repeated measures analysis.

RESULTS

During the eight weeks of follow-up, we found that the intervention group had lower mean MFI-20 scores than the control group with regard to general fatigue (7.80 ± 2.07 vs. 12.72 ± 1.79; p < 0.001), physical fatigue (7.12 ± 1.41 vs. 10.42 ± 2.02; p < 0.001), reduced activity (6.95 ± 1.35 vs. 11.27 ± 1.70; p < 0.001), reduced motivation (6.20 ± 1.01 vs. 9.80 ± 2.04; p < 0.001) and mental fatigue (6.85 ± 1.45 vs. 10.72 ± 1.98; p < 0.001).

CONCLUSION

The present study's findings show that physical exercise can significantly reduce postpartum maternal fatigue in all subscales.

Maternal outcomes at 3 months after planned caesarean section versus planned vaginal birth for twin pregnancies in the Twin Birth Study: a randomised controlled trial

OBJECTIVE

To compare outcomes at 3 months post partum for women randomised to give birth by planned caesarean section (CS) or by planned vaginal birth (VB) in the Twin Birth Study (TBS).

DESIGN

We invited women in the TBS to complete a 3-month follow-up questionnaire.

SETTING

Two thousand and eight hundred and four women from 25 countries.

POPULATION

Two thousand and five hundred and seventy women (92% response rate).

METHODS

Women randomised between 13 December 2003 and 4 April 2011 in the TBS completed a questionnaire and outcomes were compared using an intention-to-treat approach.

MAIN OUTCOME AND MEASURES

Breastfeeding, quality of life, depression, fatigue and urinary incontinence.

RESULTS

We found no clinically important differences between groups in any outcome. In the planned CS versus planned VB groups, breastfeeding at any time after birth was reported by 84.4% versus 86.4% (P = 0.13); the mean physical and mental Short Form (36) Health Survey (SF-36) quality of life scores were 51.8 versus 51.6 (P = 0.65) and 46.7 versus 46.0 (P = 0.09), respectively; the mean Multidimensional Assessment of Fatigue score was 20.3 versus 20.8 (P = 0.14); the frequency of probable depression on the Edinburgh Postnatal Depression Scale was 14.0% versus 14.8% (P = 0.57); the rate of problematic urinary incontinence was 5.5% versus 6.4% (P = 0.31); and the mean Incontinence Impact Questionnaire-7 score was 20.5 versus 20.4 (P = 0.99). Partner relationships, including painful intercourse, were similar between the groups.

CONCLUSION

For women with twin pregnancies randomised to planned CS compared with planned VB, outcomes at 3 months post partum did not differ. The mode of birth was not associated with problematic urinary incontinence or urinary incontinence that affected the quality of life. Contrary to previous studies, breastfeeding at 3 months was not increased with planned VB.

TWEETABLE ABSTRACT

Planned mode of birth for twins doesn't affect maternal depression, wellbeing, incontinence or breastfeeding.

Relationship between Fatigue, Sleep Disturbance, and Gestational Stress among Pregnant Women in the Late Stages

PURPOSE

The objective of this study was to investigate the relationship between fatigue, sleep disturbance, and gestational stress in women during late stage of pregnancy.

METHODS

This study was conducted with 113 healthy pregnant women at gestational age greater than 27 weeks who were registered at community health centers and received prenatal care. A structured questionnaire regarding fatigue, sleep disturbance, and gestational stress was used. The data was analyzed using a t-test, an ANOVA, and Pearson correlation coefficients.

RESULTS

The subjects with unplanned pregnancies and irregular exercise patterns showed a higher level of fatigue than those with planned pregnancies and regular exercise patterns. Pregnant women with caffeine intake manifested higher levels of gestational stress and sleep disturbance than those without. The levels of sleep disturbance and gestational stress increased as the fatigue levels increased. The fatigue levels increased with increased levels of sleep disturbance.

CONCLUSION

Planned pregnancy, regular exercise patterns, and caffeine intake were related with fatigue, sleep disturbance, and gestational stress in women during late stages of pregnancy. Fatigue, sleep disturbance, and gestational stress had close associations to each other. In the future, such results should guide development of nursing intervention programs for women in late stages of pregnancy.

Perinatal stress, fatigue, depressive symptoms, and immune modulation in late pregnancy and one month postpartum

Stress and fatigue are common complaints of pregnant and postpartum women as is depression. These symptoms may be related to immunomodulation. However, few studies have examined these relationships. The aim of this study was to examine the relationships among stress, fatigue, depression, and cytokines as markers of immune modulation in prenatal and postpartum women. Women completed questionnaires and gave blood samples during late pregnancy and again at 4–6 weeks postpartum. Blood was analyzed for cytokines as measures of immune modulation. Stress, fatigue, and depression were experienced at moderately high levels, with higher levels of fatigue and depression in the postpartum but higher stress in the prenatal period. Levels of several cytokines were increased in the postpartum over the prenatal period. Stress and depression were related in the prenatal period and stress, depression, and fatigue were related in the postpartum. While various cytokines were related to each other in both periods, only stress was related to MIP-1β, a cytokine that may be important for childbirth processes. More studies, especially longitudinal and interventional studies, are needed to increase our knowledge about etiology, patterns, symptoms, factors, and management of maternal distress. The search for reliable biomarkers for at-risk mothers remains a priority.

A prospective study of effects of psychological factors and sleep on obstetric interventions, mode of birth, and neonatal outcomes among low-risk British Columbian women

Background

Obstetrical interventions, including caesarean sections, are increasing in Canada. Canadian women’s psychological states, fatigue, and sleep have not been examined prospectively for contributions to obstetric interventions and adverse neonatal outcomes.

Context and purpose of the study: The prospective study was conducted in British Columbia (BC), Canada with 650 low-risk pregnant women. Of those women, 624 were included in this study. Women were recruited through providers’ offices, media, posters, and pregnancy fairs. We examined associations between pregnant women’s fatigue, sleep deprivation, and psychological states (anxiety and childbirth fear) and women’s exposure to obstetrical interventions and adverse neonatal outcomes (preterm, admission to NICU, low APGARS, and low birth weight).

Methods

Data from our cross-sectional survey were linked, using women’s personal health numbers, to birth outcomes from the Perinatal Services BC database. After stratifying for parity, we used Pearson’s Chi-square to examine associations between psychological states, fatigue, sleep deprivation and maternal characteristics. We used hierarchical logistic regression modeling to test 9 hypotheses comparing women with high and low childbirth fear and anxiety on likelihood of having epidural anaesthetic, a caesarean section (stratified for parity), assisted vaginal delivery, and adverse neonatal outcomes and women with and without sleep deprivation and high levels of fatigue on likelihood of giving birth by caesarean section, while controlling for maternal, obstetrical (e.g., infant macrosomia), and psychological variables.

Results

Significantly higher proportions of multiparas, reporting difficult and upsetting labours and births, expectations of childbirth interventions, and health stressors, reported high levels of childbirth fear. Women who reported antenatal relationship, housing, financial, and health stressors and multiparas reporting low family incomes were significantly more likely to report high anxiety levels. The hypothesis that high childbirth fear significantly increased the risk of using epidural anaesthesia was supported.

Conclusions

Controlling for some psychological states and sleep quality while examining other contributors to outcomes decreases the likelihood of linking childbirth fear anxiety, sleep deprivation, and fatigue to increased odds of caesarean section. Ameliorating women’s childbirth fear to reduce their exposure to epidural anaesthesia can occur through developing effective interventions. These include helping multiparous women process previous experiences of difficult and upsetting labour and birth.

Childbirth fear, anxiety, fatigue, and sleep deprivation in pregnant women

OBJECTIVE

To explore women's levels of childbirth fear, sleep deprivation, anxiety, and fatigue and their relationships during the third trimester of pregnancy.

DESIGN

A cross-sectional descriptive survey of a community sample.

PARTICIPANTS

Six hundred and fifty English-speaking nulliparous and multiparous women, 17 to 46 years of age and between 35 and 39 weeks gestation, with uncomplicated pregnancies.

METHODS

Wijma Delivery Expectancy/Experience Questionnaire, Spielberger State Anxiety Inventory, Mindell's Sleep Questionnaire, and the Multidimensional Assessment of Fatigue Questionnaire.

RESULTS

Twenty-five percent of women reported high levels of childbirth fear and 20.6% reported sleeping less than 6 hours per night. Childbirth fear, fatigue, sleep deprivation, and anxiety were positively correlated. Fewer women attending midwives reported severe fear of childbirth than those attending obstetricians. Women with high childbirth fear were more likely to have more daily stressors, anxiety, and fatigue, as well as less help. Higher levels of anxiety predicted higher levels of childbirth fear among women.

CONCLUSION

One fourth of women reported high childbirth fear. Women's fear of childbirth was related to fatigue, available help, stressors, and anxiety. Fear of childbirth appears to be part of a complex picture of women's emotional experiences during pregnancy.