BLAND, M. A. (1999). The Influence of Birth Experience on Postpartum Depression: a Follow-up Study. National Undergraduate Research Clearinghouse, 2. Available online at http://www.webclearinghouse.net/volume/. Retrieved January 29, 2020 .
The Influence of Birth Experience on Postpartum Depression: a Follow-up Study
MICHELLE A. BLAND
MISSOURI WESTERN STATE UNIVERSITY DEPARTMENT OF PSYCHOLOGY
Sponsored by: Brian Cronk (cronk@missouriwestern.edu)
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), a 25-item scale combining questions for both birth experience satisfaction and perceived level of control, and a revised 29-item scale also measuring satisfaction and control. Data from the present study were combined with data from the original study in all categories except satisfaction. The surveys were completed as follows: Women in the home delivery group received the surveys from their midwife, and returned them in a self addressed stamped envelope to the researcher. Women who had hospital deliveries 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 experiences, the data regarding their depression levels were inconclusive. When pain was considered as part of labor and delivery satisfaction, the caesarean patients were found to be more satisfied than the traditional hospital patients. However, when pain was not considered, both the vaginal hospital group and the caesarean group scored similarly for satisfaction. 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.
INTRODUCTIONAccording 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 effects, 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. Similarly, Thune-Larsen and Moller-Pedersen (1998) found associations between postpartum depression and a woman�s dissatisfaction with care. 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 study 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 were examined. The questions studied were: 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.
METHODParticipants
Three main groups of women participated in this study. There were two different types of hospital groups from two different health care facilities, and one group of women who had home deliveries. The two health care providers were Women�s Health of Saint Joseph and Kaiser Permanente of Kansas City, both located in north-west Missouri. 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 111 women who had vaginal hospital deliveries, and 22 women who had caesarean deliveries (133 total hospital patients). From this sample, 105 vaginal hospital delivery patients who were from four to eight weeks postpartum and 20 caesarean patients who were four to eight weeks postpartum were used in the analysis. This study combined the collected from women collected in the Fall of 1998 with data collected in the Spring of 1999. Depression and control data were combined, while satisfaction data from these participants were analyzed separately due to the change in the satisfaction scale. The backgrounds of these women were diverse, but all were 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 69 women who had home deliveries. From this sample, 51 women who were from four to eight weeks postpartum participated. 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, New Jersey, New Mexico, 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). MaterialsThis study examined depression, control, and satisfaction in women in three groups: a home birth group, a hospital vaginal delivery group, and a group of women who have had caesarean sections. The goal was to measure levels of depression, control, and satisfaction in each of the three groups of women. In order to measure these constructs, three surveys were used. The first was a 10 item depression scale, called the Edinburgh Postpartum Depression Scale (Cox, Holden, & Sagovsky, 1987). This scale has been validated numerous times, and has been found to be reliable. A person could score from zero to 30 points on the EPDS. Scores above the threshold of 12 indicates the likelihood of a depressive illness of varying severity. Another threshold, those scores 12 or above, was indicated to be a valid indicator of a depressive illness as well. The second and third scales were variations of each other. The first one, which was used in the study conducted in the Fall of 1998 , 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 one used in the study conducted in the Spring of 1999 was a 29 item scale also combining questions for both birth experience satisfaction and perceived level of control. A copy of both of these scales is included in the Appendix. The maximum number of points that participants could score on the control scale of either survey 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. On the original survey, 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. On the revised survey, which contained two additional questions, adding four more possible points, contained the same questions for satisfaction as the original scale, but added two questions pertaining to pain felt during labor and delivery. The satisfaction scale was revised due to comments that some participants made in the study conducted in the Fall of 1888. These women commented that the question was difficult to answer due to the nature of labor itself, being quite uncomfortable. Some women wrote in that they were in much pain, but were comfortable, and vice-versa. Thus, the revised scale separated physical comfort from pain felt during labor. The revised survey also added two questions that were not on the original survey. One question asked the participants to rate how much control they felt they had over their birth experience, from one to 100. The other question asked participants to rate how satisfied they were with their birth experience from one to 100. These questions were analyzed separately from the control and satisfaction scales. ProcedureThe 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 6 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 instructed to not put their names, or any other form of identification on the surveys. 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 the participant. 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 two separate periods of four to five weeks each 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 6 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 5 weeks, which was also filled out at or around 6 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 213. Of these 213 participants, one had to be dropped because she gave birth at a birthing center, three were dropped because they did not state how many weeks postpartum they were, and three were excluded because their type of delivery could not be determined. (It should be noted, however, that the delivery type of none of the participants who completed the revised Birth Experience Survey (76) except for the caesarean patients (eight) or those who explicitly commented on their delivery (number undeterminable), can be determined with certainty. The revised survey failed to contain the vital question that its predecessor had, which asked the participants where their delivery took place. Thus, type of delivery was determined by where the survey was collected (from an obstetricians office or the mail) and by clues given within the survey. For example, if a survey came in the mail, it was most likely completed by a woman who had a home delivery. However, if she answered the question which asked what type of pain relief she had by circling �epidural,� then it was assumed that she did not deliver at home. Surveys that were coded as �unknown� were received in the mail, but the question asking about their labor experience was answered with, �my labor was induced,� or �I was given pitocin....� Likewise, if a survey was obtained from the physicians office, but the woman wrote in the comment section that she had a home delivery, she was coded as a home birth.) Of the remaining participants, eighteen women in the home delivery group, six women in the vaginal hospital group, and two 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 five 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.)
RESULTSThe data were analyzed for women four to eight weeks postpartum by using six one-way ANOVA tests, five correlational tests, and two general linear regressions In addition, two chi-square tests of independence were done comparing the frequency of depression among the three groups of women. The ANOVA tests measured: a.) postpartum depression as it relates to the birth experience (home, vaginal hospital, cesarean hospital), b.) the patients 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, using both scales to measure satisfaction, d.) the relationship between how much control the patients felt they had and their control score (for the revised survey only), and e.) the relationship between the participants stated satisfaction level and their satisfaction score (for the revised survey only).The five correlational tests measured: a.) the strength of the relationship between a participant�s stated satisfaction level and her satisfaction score, b.) the strength of the relationship between only the vaginal hospital and home delivery group�s stated satisfaction level and their satisfaction score, c.) the strength of the relationship between a participant�s stated level of control and her control score, and d.) the strength of the relationship between a participants satisfaction level (once using the original scale, and once using the revised scale) and her control score.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(2,173) = 5.68, p = .004). 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 = 4.98, sd = 3.54) than participants who had a vaginal hospital delivery (M = 7.54, sd = 4.81). Participants who had caesarean deliveries (M = 7.05, sd = 4.77) 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(2,162) = 411.57, 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 = 65.51, sd = 1.12) had a higher level of control than participants who gave birth vaginally in a hospital (M = 46.00, sd = 5.67) and participants who had a caesarean delivery (M = 36.68, sd = 3.80). 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. This ANOVA was calculated using only the surveys of participants who completed the original satisfaction scale. A significant difference was found between the delivery types (F(2,101) = 14.85, 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 = 38.75, sd = 3.05) than participants who delivered vaginally in a hospital (M = 34.09, sd = 4.80). Participants who experienced a caesarean delivery (M = 35.67, sd = 3.67) were not significantly different from either of the other two groups.Another one-way ANOVA was calculated using only the surveys that were completed by participants who completed the revised satisfaction scale. This ANOVA compared the satisfaction levels of participants who had one of three types of deliveries. A significant difference was found between the delivery types (F(2,56) = 209.56, 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 were more satisfied (M = 44.70, sd = 2.41) than participants who delivered vaginally in a hospital (M = 39.11, sd = 3.97). The caesarean patients (M = 46.75, sd = 3.10) scored higher for satisfaction than the hospital sample did, but were not significantly different from the home birth group. A one-way ANOVA was calculated comparing the reported satisfaction levels of participants in one of three groups. No significant difference was found (F(2,61) = 57.63, p > .05). Women who had different delivery types (home, M = 96.90, sd = 4.72; vaginal hospital, M = 83.36, sd = 25.33; and caesarean, M = 80.57, sd = 36.25) did not differ significantly in their reported satisfaction. A final one-way ANOVA was calculated comparing the reported levels of control of participants in one of three groups. No significant difference was found (F(2, 61) = 1200.29). Women who experienced different delivery types (home, M = 99.70, sd = .48; hospital, M = 83.36, sd = 25.33; and caesarean, M = 80.57, sd = 36.25) did not differ significantly in their reported feelings of control.A Pearson correlation was calculated examining the relationship between a participant�s satisfaction score (revised version) and her stated level of satisfaction. A moderate positive correlation was found (r(58) = .397, p < .01) indicating a significant linear relationship between the two variables. A higher level of stated satisfaction tends to indicate higher satisfaction scores. A Pearson correlation was calculated examining the relationship between a participant�s stated level of satisfaction and her satisfaction score, excluding the caesarean subjects. (The caesarean participants were excluded because the new satisfaction scale gave them additional points for not tearing or having an episiotomy, and for not being in pain.) A moderate positive correlation was found (r(54) = .431, p < .01) indicating a significant linear relationship between the two variables. Participant�s stated satisfaction levels with their birth experience tend to be related to their satisfaction scores. A Pearson correlation was calculated examining the relationship between a participant�s control score and her stated level of control. A moderate positive correlation was found (r(57) = .328, p < .01) indicating a significant linear relationship between the two variables. Reported feelings of control tend to be similar to control scores. A Pearson correlation was calculated examining the relationship between a participant�s level of satisfaction (using the original scale) and level of control. A moderate positive correlation was found (r(99) = .526, p <.01) indicating a significant linear relationship between the two variables. Participants who score higher for control (indicating that they experienced more control over their labor and delivery) tend to have a higher satisfaction score (indicating that they were more satisfied with their birth experience) than women who scored lower for control. A similar correlation was found (r(55) = .452, p < .01) between a participant�s revised satisfaction score and her control score. Multiple linear regression was calculated predicting participants� depression level from their overall satisfaction and level of control (using the original satisfaction scale). A significant (F(2, 97) = 9.031, p < .001) regression equation was found with and R2 of .157. Participants� predicted depression level is equal to 19.244 -.129(control) -.158(satisfaction) when satisfaction and control are measured using the Birth Experience scale and depression is measured using the Edinburgh Postnatal Depression Scale. Participants decreased .129 points of control and .158 points of satisfaction for each point of depression that they increased. While control was a significant predictor of depression, satisfaction was not. In this model, control and satisfaction accounted for 15.7% of the variance in postpartum depression. Multiple linear regression was calculated predicting participants� level of depression from satisfaction level and level of control over the birth experience (using the revised satisfaction scale). A significant (F(2,53) = 4.268, p < .001) regression equation was found with and R2 of .139. Participants� predicted depression level is equal to 18.876-.125(control) -.142(satisfaction) when satisfaction and control are measured using the Birth Experience scale and depression is measured using the Edinburgh Postnatal Depression Scale. Participants decreased .125 points of control and .142 points of satisfaction for each point of depression that they increased. While control was a significant predictor of depression, the satisfaction score was not. In this model, control and satisfaction accounted for 13.9% of the variance in postpartum depression.A chi square test of independence was calculated comparing the frequency of postpartum depression (at the 9/10 cut-off) for women who gave birth in one of three groups. A significant interaction was found (Chi Square(2) = 6.71, p = .035). Women who had home deliveries were less likely to be diagnosed as depressed (17.6%) than women who had vaginal hospital deliveries (37.1%) or women who had caesarean deliveries (40%). A second chi-square test of independence was calculated comparing the frequency of postpartum (depression scores at the 12/13 cut-off) depression among women in one of three groups. A significant interaction was found (Chi Square(2) = 6.73, p = .035). Women who gave birth at home were less likely to score high for depression (3.9%) than women who had vaginal hospital deliveries (19%) or women who had caesarean deliveries (20%).
DISCUSSIONIt 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 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. For the original survey, the results were inconclusive for the caesarean patients. However, women who experienced a caesarean delivery received higher satisfaction scores on the revised survey than women who delivered vaginally in the hospital. This anomaly can best be explained by pointing out that the revised satisfaction scale added two questions regarding pain, which were separated from the original questions inquiring only about physical comfort in general. Since all of the caesarean patients had pain medication (the minimal being an epidural, and the most being general anesthesia), these participants received more points for these questions. Additionally, similar to the original scale, caesarean patients were given 11 points for not undergoing an episiotomy or tearing. These questions, while applicable to vaginal deliveries, do not well define satisfaction for caesarean patients. This may describe the inflated satisfaction scores of the caesarean participants. This being the case, as supported by the current literature, the caesarean patients were not more satisfied than the home birth sample. As was found when analyzing the first scale, home-birthers who completed the revised satisfaction scale scored significantly higher than those who had vaginal deliveries in a hospital, even though pain was added to the new scale. (This is interesting to note, since women who give birth at home generally do not have access to pain medications of any sort.)The results that the type of delivery does not have a significant influence on the participant�s stated and perceived level of satisfaction or control are not consistent with the current literature. Shield, Reid, Cheyne, Holmes, et. al. (1997) found that women who received midwife managed care rated their care more highly than those cared for by physicians, and reported that they received better advice and support than those who had traditional care. Additionally, Cohan, Pimm, and Jude (1998) point out that invasive treatments may leave the patient feeling a lack of control. Stated feelings of satisfaction or control are related to perception, which may have much to do with expectations. For instance, a woman intending on having a hospital birth with Demerol expects to not be fully cognizant, and therefore may report that she indeed did have a high degree of control over her birth experience. Likewise, a woman who undergoes an emergency caesarean may feel relieved and grateful, and thus report a high level of satisfaction. Thus, control and satisfaction is reported as it happens proportionally to expectations of control and satisfaction. Although the results were not statistically reliable, it should be noted that women who had caesarean deliveries reported the lowest levels of satisfaction and control, and women who delivered at home reported the highest levels of satisfaction and control. What can be stated from this study, however, is that women who gave birth at home scored significantly higher on both satisfaction scales than the vaginal hospital group, which included questions that rated the participant�s level of pain, physical comfort, hunger and thirst, treatment by the medical staff or midwife and attendants, how well her needs were met, how many exams she underwent, and if and how she tore, as well as her feelings regarding her tear. Likewise, this study does conclude that all three groups were significantly different from each other (caesarean scoring lowest and home birth scoring highest) on the control scale. This scale considered the participant�s freedom to move or change positions, consume food or liquids, make informed decisions and have the time to make them, if they played an active role in labor/delivery decisions, how soon they were given access to their infants, etc. 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 questions on the satisfaction scale which take into account tearing acts as a limitation to this study. These two questions, which give a possible 11 points, generally do not apply to caesarean patients, thus decreasing the reliability of the satisfaction scores in regards to the caesarean participant�s standing in comparison to both vaginal delivery groups. Another limitation to the present study is the limited number of both home-birthers and caesarean subjects who completed the revised survey. There were only ten participants who delivered at home, and seven caesarean participants. Thus, the analyses done with the new satisfaction scale, as well as the two questions asking the participants to rate their satisfaction and control should be considered in this light. Thus, further research should be conducted to increase the sample sizes of these groups in respect to the revised survey before firm conclusions are drawn. Finally, a major limitation to this study as it pertains only to the analyses done using the revised survey, is that the revised survey failed to include a question asking the participants where their birth took place. Thus, women were coded for their delivery type based on external factors (for example, where the survey was obtained from served as an indicator for the type of delivery, etc.). This flaw only applies to vaginal deliveries, as the caesarean participants were asked in another question if they had a caesarean delivery. Grouping was decided for the other two groups, and ones that could not be determined were marked as �unknown.� However, most surveys were marked in such a manner that made them a likely candidate for the grouping they were put under. For example, a survey which was obtained from the hospital, and in which the participant had marked that they had an epidural for pain relief was coded as a hospital birth. Likewise, a survey received in the mail, and in which the participant had commented on her home birth, was coded as a home delivery. Further research that takes into consideration these concerns should be conducted. Additionally, 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.
REFERENCESAppleby, 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.Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of Postnatal Depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.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. Thune-Larsen, K. & Moller-Pedersen, K. (1998). Childbirth experience and post-partum emotional disturbance. Journal of Reproductive and Infant Psychology, 6, 229-240. 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.
APPENDIXESAuthor Note	The Birth Experience Survey shown in Appendix B is intact and contains the question asking where the participant�s birth took place. The actual surveys that the participants received were missing this question (number 23). This was likely due to a printing error. Appendix ACopy of Instrument Used (The Birth Experience Survey)Below is a list of questions that relate to your most recent birth experience. Please read each statement carefully, and decide the extent to which you agree with it. Circle one appropriate response for each item.
LABOR (from the start of contractions until the head showed):
1. How comfortable were you (physically) during your labor?very comfortable	comfortable	O.K.	uncomfortable	very uncomfortable
2. Throughout your labor, did you have the freedom to move about as you pleased?always	most of the time	some of the time	not at all
3. Throughout your labor, did you have the freedom to be in any position that you pleased?always	most of the time	some of the time	not at all
DELIVERY (from the time the head showed until the placenta came out):
4. How comfortable were you (physically) during your delivery?very comfortable	comfortable	O.K.	uncomfortable	very uncomfortable
5. Throughout your delivery, did you have the freedom to be in any position that you pleased?always	most of the time	some of the time	not at all
LABOR and/or DELIVERY:
6. Were you permitted to drink liquids during your labor/delivery?always	most of the time	some of the time	not at all
7. Did you get thirsty during your labor or delivery?yes, I was thirsty a lot	yes, sometimes	no, not really	absolutely not
8. Were you permitted to eat during your labor or delivery?always	most of the time	some of the time	not at all
9. Did you get hungry during your labor or delivery?yes, I was hungry a lot	yes, sometimes	no, not really	absolutely not
10. Were you able to make informed decisions about your labor/delivery experience?always	most of the time	some of the time	not at all
11. Do you feel that you had enough time to consider those decisions?always	most of the time	some of the time	not at all
12. Did you play an active roll in deciding how to handle your labor/delivery (i.e.: drugs to use or avoid, positions to be in, who was with you, room arrangements, etc.)?yes, throughout	yes, mostly	yes, sometimes	not really	not at all
13. What type of pain relief did you have during your labor and/or delivery?nothing	local anesthesia	epidural (stomach down)	general anesthesia (�asleep�)other (please specify) ____________________
14. To what extent did you anticipate that level of pain relief?I planned it that way.I knew it might happen, and sort of anticipated it.I knew it might happen, but didn�t want it.I didn�t think it would be that way.I didn�t want it, but it had to be.
15. How much access to your significant others (family, friends, labor coach, etc.) did you have during your labor/delivery?unlimited	most of the time	some of the time	not very often	not at all
16. All in all, did you feel that you were treated kindly by the nurses, doctor(s), and staff during your labor/delivery?yes	for the most part	sort of	not really	no
17. Which best describes your labor/delivery experience?I had a planned c-section.I had a non-emergency c-section that I didn�t anticipate throughout my pregnancy.I had an emergency c-section.My labor was induced (started for me).I went into labor naturally, but was given pitocin (or other drug) to assist in the labor/delivery.I only got pitocin (or other drug) to assist in the delivery of the placenta.I didn�t have any of the above interventions, but felt pressured to meet time constraints (i.e.: 2- hour pushing limit, 20 minutes for the placenta, etc.)I didn�t have any of the above interventions, and did not feel pressured to meet time constraints.
18. Were your needs met after the baby was born?no, they seemed to forget about me and focused on the baby (or someone/something else)not as much as I would have likedO.K.	yes, enough	yes, well
19. How soon after delivery did you have access to your baby?immediately	very soon (a couple of minutes)soon (a few minutes)	not for a while (several minutes)a long time (an hour or so)	a very long time (a day or more)
20. If you were given an episiotomy, did you want it?I was not given an episiotomy.	yes	not really, but I thought it would be bestnot really, but I felt that there was no other choice	no
21. Did you tear?yes, it was an extension of my episiotomy (after the episiotomy)	yes, before my episiotomyyes, and I did not have an episiotomy	no
22. How do you feel about your tear?I didn�t tear.I resent the episiotomy that �made� it happen.I wish I would have been given the episiotomy sooner so that I wouldn�t have torn.I wish I would have had an episiotomy so that I wouldn�t have torn.I�m glad the tear was �my fault� rather than a choice that the doctor made for me.I don�t mind.	other (please specify)______________________________
23. Where did your birth take place?hospital	home	birthing center/clinic	Other (please specify)_______________
24. How many pelvic exams were you given during your labor? (Please write the number if you can remember, and if not, please guess to the best of your knowledge.) _______
25. Is there anything else about your labor/delivery experience, or something about this questionnaire that you would like to add?
Thank you! Your input is appreciated!
***Please place this survey back in the envelope.*** Appendix BCopy of Revised InstrumentBelow is a list of questions that relate to your most recent birth experience. Please read each statement carefully, and decide the extent to which you agree with it. Circle one appropriate response for each item.
1. Not considering pain, how comfortable were you (physically) during your labor?very comfortable	comfortable	O.K.	uncomfortable	very uncomfortable
2. How much pain were you in during your labor? hardly any	mild	moderate	severe
5. Not considering pain, comfortable were you (physically) during your delivery?very comfortable	comfortable	O.K.	uncomfortable	very uncomfortable
6. How much pain were you in during your delivery:hardly any	mild	moderate	severe
10. Were you permitted to eat during your labor or delivery?always	most of the time	some of the time	not at all
11. Did you get hungry during your labor or delivery?yes, I was hungry a lot	yes, sometimes	no, not really	absolutely not
15. What type of pain relief did you have during your labor and/or delivery?nothing	local anesthesia	epidural or spinal (stomach down)	Demerol or morphine general anesthesia (�asleep�)	other (please specify) ____________________
18. All in all, did you feel that you were treated kindly by the nurses, doctor(s), and staff (or midwife and attendants) during your labor/delivery?yes	for the most part	sort of	not really	no
19. Which best describes your labor/delivery experience?I had a planned c-section.I had a non-emergency c-section that I didn�t anticipate throughout my pregnancy.I had an emergency c-section.My labor was induced (started for me).I went into labor naturally, but was given pitocin (or other drug) to assist in the labor/delivery.I only got pitocin (or other drug) to assist in the delivery of the placenta.I didn�t have any of the above interventions, but felt pressured to meet time constraints (i.e.: 2-hour pushing limit, 20 minutes for the placenta, etc.)I didn�t have any of the above interventions, and did not feel pressured to meet time constraints.
22. How many weeks postpartum are you? (How long ago did you have your baby?) _________
23. Where did your birth take place?hospital	home	birthing center/clinic	Other (please specify) ____________
26. How do you feel about your tear?I didn�t tear.I resent the episiotomy that �made� it happen.I wish I would have been given the episiotomy sooner so that I wouldn�t have torn.I wish I would have had an episiotomy so that I wouldn�t have torn.I wish I didn�t tear, but I�m glad that I didn�t have an episiotomy.I�m glad I tore rather than had an episiotomy.I don�t mind.	other (please specify)______________________________
27. How many pelvic exams were you given during your labor? (Please write the number if you can remember, and if not, please guess to the best of your knowledge.) __________
28. Rate your satisfaction with your total labor and delivery experience on a scale from 1-100, with one meaning, �not at all satisfied,� and one hundred meaning, �completely satisfied.� __________
29. Rate how much control you had over your total labor and delivery experience on a scale from 1-100, with one meaning, �none,� and one hundred meaning, �complete.� __________
Thank you! Your input is appreciated!*****
***Please place this survey back in the envelope.***
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 5/12/99 1:34:46 PM
Last Edited 1/30/2009 1:27:49 PM