The duration of the postnatal period is professionally and socially defined as extending to six weeks after birth. After this time the mother is presumed to have recovered from pregnancy and birth and can fully resume her roles. Yet up to 94% of mothers report ongoing health concerns six months after birth (Brown & Lumley, 1998) and these concerns may persist for years (MacArthur, Lewis, & Knox, 1991b). Postnatal maternal morbidity is largely hidden, it is under-reported by mothers, remains untreated, and is neglected in the provision of maternity services. Given that in Australia, over a quarter of a million women give birth each year (Australian Institute of Health and Welfare, 2003) the potential impact of ongoing health problems for women and their families represents a serious public health problem. This study sought to address two fundamental questions. Firstly, what is the nature, extent, severity and duration of maternal
morbidity in the year after childbirth? And secondly, can social support improve maternal morbidity in the year following birth?
A randomised controlled trial was performed in Ipswich and Redcliffe/Caboolture Health Districts of Queensland, Australia to determine the effect of a programme of postnatal emotional social support provided by Research Midwives on the prevalence, severity and duration of maternal health concerns in the first year after birth. One hundred and thirty five women gave informed consent to participate in the trial, and these women were eligible for inclusion, as they had all given birth to live term infants during the specified recruitment period. Simple randomisation was performed resulting in balanced groups. The retention rates at completion of the trial were 71% and 61% for the intervention and control groups respectively.
The intervention was a programme of home visits and telephone calls by, and twenty-four
hour telephone access to. Research Midwives and was aimed at providing emotional social support to women. Only anxiety status appeared to be affected by the intervention with significantly more women in the intervention group remaining non-personally disturbed than in the control group at the post intervention point in time (x2.6.31, df 2, p<0.04). The intervention did not demonstrate an effect on the perceived social support, on the prevalence, nature and severity of health concerns, or on postnatal depression reported by women. The majority of women (87.7%) in the intervention group were compliant with the programme of support, however the analysis was performed on an intention to treat basis.
Women experienced diminished general health after birth and this persisted with respect to the Role-Physical (t=-2.75, df 88, p=0.007) and Vitality (t=-4.54, df 89, p<0.001) transformed scales of the SF-36 at fifty-two weeks
postpartum. Thirteen health concerns were prevalent in greater than twenty percent of women at both points in time and the severity of concerns remained stable between two and twelve months postpartum. Of the mothers who reported health concerns, 40-78% did not seek professional advice and the majority did not undertake any treatment.
Extreme tiredness was the most prevalent health concern and persisted to affect 58.1% of mothers at twelve months. Urinary incontinence was the only concern that increased in prevalence over the study period from 35.3% at eight weeks to 46.0% at fifty-two weeks postpartum. Painful perineum and haemorrhoids were significantly associated with assisted vaginal delivery, specifically, painful perineum (OR 9.55) at eight weeks postpartum and haemorrhoids at both eight and fifty-two weeks postpartum (OR 8.80 and OR 12.00). Mothers who described the birth as "difficult" at fifty-two weeks were more likely to report
sexual difficulties (OR 7.00).
Method of delivery was significantly associated with pelvic health concerns at eight weeks (χ2 9.20, df 2, p=0.010) and fifty-two weeks (χ2 7.86, df 2, p=0.020) and with bowel concerns at eight weeks (χ2 10.93, df2, p=0.004). Primiparas were more likely to report sexual difficulties at eight weeks (χ2 6.44, df 3, p=0.040).
Women with persistent neck or shoulder pain at eight and fifty-two weeks (OR 3.46 and OR 2.80) or bowel problems at eight weeks (OR 2.70) were more likely to have lower Mental Component Summary scores. At fifty-two weeks those mothers who had urinary frequency (OR 5.10), bowel problems (OR 7.32), extreme tiredness (OR 9.51), or teeth or gum problems (OR 4.62) were more likely to have lower Physical Component Summary scores.
that social support declines over time was supported by the trend that fewer women reported increased support and more women reported diminished support. While this trend was significant for emotional social support (McNemar's p=0.009) it was evident for informational and functional subscales of social support. While the social support intervention did not produce a statistically significant effect, no negative impacts were demonstrated. The experiences of the key stakeholders in the study provide evidence of the positive non-quantifiable outcomes of study involvement. The positive impact of social support was evident in that women who reported high levels of social support reported low levels of health concern severity and this trend was significant for informational support (χ2 6.48, df 88, p<0.01). Postnatal depression and anxiety were also associated with high health concern severity; the latter was significantly associated
(χ2 19.63, df=124, p<0.01). High levels of emotional social support and low levels of anxiety appeared to enhance mental health measured by the Mental Component Summary score.
The results of the study are unlikely to be attributed to bias or confounding and appear to be generalisable to other populations of pregnant women who exhibit the same maternal and birth characteristics and fulfil the eligibility criteria. The extent and persistent nature of, and lack of treatment seeking behaviour for ongoing health concerns in the postpartum year strongly supports the urgent need for systematic data collection and appropriate screening of women postpartum. When the results of this study are examined in light of existing research, it provides increasing support for the need for more focused research trials, and for social support interventions to be targeted to those groups who have diminished social resources.