1. No category

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Editors・in・chief
Denis walsh, phD, RM
KerriD.schuiⅡng, phD, CNM, NR FACNM, FAAN
Divisioh ql'Midwifery
U11iversi砂 qf'Notti"ghα柳
υ"ited Ki"gd01"
C011e8e Qf'Health scie"ceS α11d pr0ルSsi01141 Studies
、
Internationaljournalofchildbirth
NortherH Mich習411 Uπiversiり
Uπited states
Volume 4, Number 3,2014
DeputyEditor
SOO Downe, RM, MSC, phD
Schoolqi'Health
U11iversiり qi'ce11hα1ιαHC4Shire
U"ited Ki"gd0柳
Assodate Editors
ARTICIES
Maria Helena Bastose, MD, MSC, phD
Iudith T. FUⅡerton, phD, CNM, FACNM
Iayne MarshaⅡ, phD, MA, PGCEA, ADM,
Marie Berg, phD, MNSC, MPH, RN, RM
SUS飢 Bewley, MA, MD, FRCOG
Vivette Glover, MA, phD, DSC
MechthⅡd Gross, RM, RN, MSC
RM,RGN
Etsuko Matsuoko, phD
Terese Bondas, phD,1icNSC, MNSC, RN, PHN
Gi11 Gyte, Mphil
Roby11Maude,phD,MA (MidMfew),BN,RM,RN
Sheena Byrom, RM, MA
NgaiFen cheung, phD, MSC, RM, RGN
Eileen Hutton, RM, RN, phD
Ken }ohnson, phD
Chris Mccourt, phD
Marianne Mead, RM, phD
Hannah Dahla11, RN, RM, BN(Hons),
McommN,phD,FACM
H011γPowe11Kennedy, phD, CNM, FACNM,
Iudith Mercer, BSN, MS, DNS
Frances Day・stirk
Patrick Lavery, MD
NickyLeap, DMid, MSC, RM
Antenatalcare and servicesin southern lreland
ノノ
Exploring some s、vedish い10meds Experiences ofsupport During childbirth
AstridNystedt,ιisbeth Kristi411Se11, Kersti11 Ehre11Strale,411d 111ge8erd Hild加8SS011
Saras vedam, RN, MSN, sdD(hc)
Kim 、vatts, phD, PGCAR MSC, RM, RN
RosemaryMarlder, MSC, phD, RGN,SCM, MTD
169
A11πette Murphy, joh11 ヤVe11S, P4trid4 Chesser・S111yth,ιiπd4 She4h411,
4πd Miche11e F01り
ιノノ
Ans Luyben, RM, PGDE, PDM, phD
MargaretMaimbolwa, phD
151
An Exploratory survey ofLOW・Risk pre3nant い10meds perceptions of
Iim Thornton, MD, FRCOG
Kerstin uvnas・Moberg, MD, phD
上isa Kane LOW, phD, RN, CNM, FACNM
Ank de】onge, phD
Eugene Dedercq, phD
Raymond De vries, phD
Declan Devane, phD, MSC, pgDip(stats),
DipHE, RGN, RM, RNT
romen ×1ith
julie A. Kruse, RegA. wi11ialHS,411d /'uli4 S. seπg
NickTaub, phD
FRCOG
134
Postpartum Depression
Iulia seng, phD, CNM, FAAN
Theresa Ann sipe, CNM, MPH, MN, phD
AmaⅡ 10kugamage, MBchB, BSC, MSC, MD,
AtfGherissi, CM, MSC, phD
Considering a Relationa11Vlodelfor Depression in
Verena schmidt, RM
Heloisa l.essa, MS
Ienny Gamble, RM, MHlth, phD
ナ
Mary Newburn, MSC
Kerreen Reiger, MA, phD
FAAN
Marcos Dias, MD, phD
GTaceEdwards,RN,RM,ADM,certEd, M.Ed, phD
Sense ofcoherence and ch丑dbearing: A scopin8 Revielv ofthe Literature
S411), Fel;g1ιS011, Debor4h D4νis, jeπ11y BroW11e,411d 1411 T4ylor
Trauma・1nformed care
International confederation ofMidwives
183
、7ith childhood Maltreatment survivors:
INhat DO Matetnity professionals wantt0 上earn?
Kriste11 Choi 411d luli4 S. seπg
Frances Ganges
Chi旦fExecutive
191
The Nether1411ds
Board Members
NEW'S
Frances Day・stirk
Laurence Monteiro
Sandra oyarzo Torres
Preside11t
Beπi"
Chile
UHited Ki"gd0111
Serena Debonnet
Sue Bree
Address Malata
Bdgl'U形
Newzeα1αHd
Vice・preside11t
M4141νi
Rita Borg・xuereb
Mary Kirk
Malta
Aushalia
Myrte de Geus
IngelawiMund
Rafatlan
S1νedeH
Pakistαπ
Treasurer
The Nether1α11ds
Saving lo,00O Mothers and Newborns
202
Stren号thening the YemeniMidwives Association
202
Twinnins as a Toolfor strengthening 入lidwives' Assodations
203
Irene de la Torre
}emima Dennis・AnNi
Puerto Rico
Ghαπα
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mobilize the resources available to them to prepare for
the changesthat a newbabybrings.
Downe (2008) considers thatto promote normal
birth, maternity services require a shi丘 in focus away
from morbidity and risk toward a focus on the genera・
tion ofhealth.1tis here 杜latthe theory ofsalutogenesis
may be useful. salutogenesis offers a framework for
maternity services (DO、vne,2008) because itis a concept
focused on discovering the causes ofhealth rather than
the causes of i11ness (Antonovsky,1979). The concept
Ofsalutogenesis 、vas developed by the American-1Sraeli
medicalsod010gistAaronAntonovskyin 1979 andpub・
Iished in He41th, stress,411d copiπS (Antonovsky,1979).
Antonovskydevelopedhisideawhileconductinga11epi・
demi010gicalstudy of menopausal women in different
ethnic sroups in lsrael. one ofthese groups shared the
Common experience ofhaving survived the concentra・
tion camps ofい70rld いlar11(Antonovsky, Maoz, Dowty,
& rijsenbeek,197D. Antonovsky expeded to discover
high levels of path010gy and sodal disintegration in
this group (DO、vne,2008), but instead, he found that
Some women not only recovered and survived but also
thrived.1n explaining this phenomenon, Antonovsky
(1993) proposed that there must be health・causing fac・
tors impacting on this situation, and out of his search
for these factors came the salutogenesis model(Becker,
Sense ofcoherence a11d childbeari11g:
ASCOP血gReviewof血elitera加re
S411y Fer8US011, Deborah Davis, jeπ11y BroW11e,侃11dja11 T4ylor
OBIECTIVE: To undertake a scopin3 teview ofthe literature to understand how a womalfssense of
Coherence (SOC) score a丘ects her childbearing.
METHOD: ovid MED11NE, CINAHL, cochrane,andweb ofsdence databasesweresearched to
identify artides published in En名lish 丘'om 20oo t02014 Using combinations ofsped丘ed search terms.
Induded artides、vere assessed using the preferred Reporting ltems for systematic Revie、vs and MetaAnalyses and the criticalAppraisalsMⅡS ptogramme.
FINDINGS: Thisscoping review identi丘ed 15 Studies focusing on soc scores and childbearing.
Childbearing women with stron名 Soc were lesslikely to smoke and more Hkely to seek out use6、11SUP-
Portcompared to women with low soc.women with strong soc demonstrated incteased emotional
health, experiendng less depression, a11Xiety, stress, and posttraumatic stress disorder. women with
Strong soc 、vere more likely to experience uncomplicated birth and birth at home,identify normal
birth astheir prefened birth option in pregnancy and identify a desire to avoid epiduralanesthesia 血
Iaborcomparedto womenwith lowsoc.
CONCI,USION: Thisscoping review ofthe literature identified signi負Cant assodations beNeen stron8
Soc and positive childbearin名,血dudin名 increased emotionalhealth,improved health behaviors, and
亀
increased normalbirtb choices and outcomes.
KEYWORDS: salutogenesis;sense ofcoherence; Antonovsky; childbirth; pregnancy
daimed that people 、vho remain healthy in the face of
tension have acertainwayoflooMn8 atthe world, aspe・
dac relationship with their environment, and a certain
Coping style (Rabin, Matalon, Maoz,&shiber,2005). He
Suggested that a failure to manage tension is correlated
With iⅡness (Antonovsky,1996).1mplicit in the theory
Of salutogenesis is the vie、v that tension is potenuaⅡy
health・promoting Antonovsky (1987) distin号Uishes
between tension a11d stress.刃、1hen demands exceed a
Persods resources, then tension leads to stress, and the
Person moves toward a lowerlevelofhealth.
Salutogenesis is a broad concept that focuses
On resources, competendes, abilities, assets, the indi・
Vidual, groups, and sodety (Lindstr6m & Eriksson,
201の. Antonowb (199D O'knowlodsed th0 虹mi1紅i・
ties bet、veen salutogenesis and other theories of stress
and coping, such as Bandurals self・ef負Cacy, KobaS心
hardiness, and R0廿er'S Iocus of contr01. He recognized
thatmanyofthese theories contain salutogenic elements
(Taylor,2004). Antonovsky's a996)th0ωyofsalutogen・
esis, ho、vever, has two core concepts: generaHzed resistance resources and sense of coherence (Antonovsky,
1996; BiⅡings & Hashem,201の.
Generalized resistance resources (GRRS) are bio・
10gical, material, and psychosodal resources that indi・
Viduals have available to them. TypicalGRRs are money,
Glasc0丘,& Felts,201の.
INIRODUCTION
more screening tests.叉I×1ith this comes the assodated
requirement for discussion and information sharing
Because concern for increasing rates ofcesarean section
that enables parentsto make informed choices (Browne,
and other intervenuons in childbirth mounts, govern・
0'Brien, Taylor, BO、vman,& Davis,2014).1n addition,
ments, service user 3roups, and professionalassodations
Women are exhorted to disdpline their eating, weight
haveresponded with campaignsto promotenormalbirth
(Birin今er, Davies,& Nimrod,2000; BirthchoiceuK,
gain, and multiple 0廿ler lifestyle behaviors so as to
minimize risk, espeda11y risk to the fetus (Ruhl,1999).
Ropeik a11d Holmes argue that risk assessment without
2005; Lothian,2004; NHs lnstitute for lnnovation and
and health context is complex. we are said to live in a
risk focustendsto inaate the potenualfor complications
to arise in childbearing and thus increase the a11Xiety of
Childbearing couples (Browne et al.,2014; Dahlen,201の.
Womeds experiences ofchildbearing (Lee,2008; Lupton,
1999; MacKenzie Bryers &van Teijlin今en,201の.
Antenatal care increasingly 血Cuses on monitor・
ThiS 血Cus on monitoring and riskdoeslitdeto build the
Con6dence ofwomen to give birth normaⅡy, help them
to manage the stressors that come wi杜I pregnancy or
in8 and risk identi負Cation with the introduction of ever
叫、
゛ー'゛ J'
/N7ERIVAT/0IVAι_ JOURIVAι_ OF CH/ι_DB/RTH VO/ume 4,/ssue 3,2014
J
◎ 2014 Springer publishing company, LLC WWW,springerpub.com
h廿P:ガdx.doi.org/10.189ν2156-5287.43.134
134
づ
Sense of coherence (SOC) is an internal resource
that enables people to resolve tension by identifying
and mobilizing their resources (Eriksson & lindstr6m,
2006). soc is composed ofthree components: compre・
hensibility, meaning丘11ness, and mana3eabiliw. people
With a strong soc view lifヒ's activities as comprehen・
Sible, meaningful, and mana号eable, and they have the
ability to manage tension effecuvely and resist health
breakdown (Antonovsb,1979). To operationalize his
Salutogenic theory, the soc concepts Nvere developed
into a quantitative to01(Antonovsky,1993b). origi・
na11y, Antonovsky developed the orientation to Life
Questionnaire, the soC 29, to measure the soc.
It consisted of 29 items measuring the three dimen・
Sions of soc comprehensibility, mana8eability, and
meaningfulness. The 29 items 、vere based on responses
丘om 51 qualitative intervie刃Vs of people who managed
to stay weⅡ despite being subjected to great trauma
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Usethem (Antonovsky,1996; B辺in部&H部hem,201の.
Antonovsky a996) sug3ested that a salutogenic
rather than path08enic orientation is a more viable
Paradi8m for health promotion, research, and practice.
His further studies led him to believe in connectivity
between individuals, their experiences, and their sodal
histories. He also cha11enged the biomedical discourse,
daiming that a salutogenic perspective pressures us to
think in system terms rather than individualistic terms
(Down.,2008). Aotoo0Ⅶky(1993幻 boliowdth飢mony
health professionals are blinkered by pathogenesis.
An individual's salutogenic approach to living is
described as a deep personal 、vay of being, thinMng,
and acting (1'indstr6m & Eriksson,2005). Antonovsky
in今 a 企ar ofthe unlikely 、vhile leaving us unconcerned
aboutthe truly dangerous (Ropeik & Holmes,2003). A
risk society (Adam, Beck,& va11 Loon,2005), and per・
haps nowhere is this focus on risk more evidentthan in
Sods sense of coherence that provides the capability to
health is created and maintained (Becker et al.,201の.
Context is misleadin今 and commonly results in creat・
Improvement,2006,2007; NSW Health,201の. The
Promotion of notmal birth in our medicalized sodal
Sodalsupport, klo、vledse, experience,inte11igence, and
traditions. Antonovsky (1996) believed thatifindividu、
als have these resources available to them, they wiⅡ be
able to mana8e tension in their lives and prevent stress.
Although GRRsidentifyimportant resources,itis a per・
Salutogenesis as a frame、vork focuses on discovering the causes ofhealth rather than the causes ofiⅡness.
Antonovsky's a979) starting point was not unusual:
that health is a combination of many fadors, induding
Physi010gical, psych010gical, sod010gical, cultural, a11d
Spiritualfadors. However, he then use6.111ydifferentiated
Salutogenesis from pathogenesis. The pathogenesis vie、V
is that health is best promoted by identi6Cation and pre・
Vention of disease. salutogenesis takes a differin号 ViewPointbyunderliningtheimpottance ofconsideringhow
,
、、
Sense of coherence and childbearin8 fer8Uson et a/.137
136 Sense of coherence and chⅡdbearing fergU50n et a/
The u.K. Royal c0Ⅱege of Midwives daims the
framework ofsalutogenesis as a good 6t for midwifery
because it focuses on health a11d how to promote it
rather than i11ness and hoNv to cure it (Day・stirk &
Misajon,& cummins,2001; Larsson & Ka11enberg,
1999).1n their systematic revie、v on the validity of the
(Antonovsky,1987). Ten items measure manageability,
8 items measure meaning員11ness, and 11items measure
ComprehensibⅡiw.
Scales, Eriksson and Lindstr6m (2005) condude that
The 13、item short form version (SOC 13) is a
the fadorialstrudure ofthe soc seems to be multidi・
Seledion of items developed from the original scale
mensional rather than unidimensional as Antonovsky
Proposed.
(Morrison, stosz,& cli丑,2008).1n the soc B,4 items
Palmer,2003); ho、vever, there isli杜le research on saluto・
8enesis in relation to childbearing. Most existing studies
focus on soc a11d childbearing.1n this article, the term
Childhe4ri118 indudes the atltenatal,1abor a11d birth, and
Postnatal periods. This scoping literature review aims
A strong soc is related to improved health
measure manageability,4 items measure meaning丘11・
behaviors (Lindstr6m & Eriksson,2010). A person
ness, and 5 items measure comprehensibility (Eriksson,
2007). Each item of壮le soC 13 is measured on a 7・point
Likert scale, creating possible scores of 13 t091 Points.
With high soc consumes less alcoh01, tobacco, and
drugs (Andersen & Berg,2001; Antonovsky, HanMn,&
Stone,1987; Bergh, Bai名i, Fridlund,& MarNund,2006;
Kuuppelom註M & utriainen,2003; Midanik, soghiMan,
Scores of13-63 Points correspond t010W SOC,scores of
64-79Pointscorrespondto moderatesoc, andscores of
80-91 Points correspond to high or strong soc (Eriks・
Son,1'indstr6m,&LⅡja,2007). The scales, used in atleast
33 1anguages in 32 Countries (Eriksson &上indstr6m,
2005),havebecomeimportanttoolsinmeasuringhealth,
especiaⅡy mentalhealth (Eriksson & undstr6m,2006).
In their systematic revie、v on the validity of the
to understand how a womads soc score affects her
Childbearin号
Ransom,& polen,1992); exercises more frequendy
(Hassmen, Koivula,& uutela,2000; Kuuppelom巨M
& utriainen,2002; wainri名ht & surtees,2007); eats
Iindstr6m & Eriksson,201の Compared to a person
With lowsoc. Antonovsky (1990) believed thata strong
(2005) conduded that both soc scales appear to be
reliable, valid, and cross・cultura11y applicable instru・
ments to measure how people manage stresS員11 Situ・
ations and stay 、veⅡ. For example, in their systematic
revie、v of 124 Studies measuring杜le internalconsistency
Ofthe soC 29, they found the cronbacHs alpha range
Ascopingliteraturereviewisamethod010gicalapproach
that examines the breadth of research on a particular
topic (Anderson, AⅡen, peckham,& Goodwin,2008).
Scoping reviews summarize and disseminate research
丘ndings to identify 8aps in the literature (Arskey &
0'MaⅡey,2005). They are a preliminaTy type of sys・
tematic review that focus less on synthesis and more
On examination of a research 6eld (Gough, oliver,&
.
Ieads to improved health.
Soc is strongly associated with good health, espe・
da11y mental health (Eriksson & Lindstr6m,2006).
A strong soc is assodated widl decreased depression
Thomas,2012).
This scoping review aims to answer the question:
How does a womanls soc score affedherchildbearin8?
(carstens & spangenberg,1997; Eriksson,2000; Nto,
1998; Matsuura et al.,2003; seMzuka et al.,2006; SMrka,
2000); decreased a1Ⅸiety (Gibson,2003; Konttinen,
Haukkala,& uutela,2008); increased positive emotions
(Gibson,2003; Kon廿inen et al.,2008; str山npfer, GOUWS,
&viviers,1998); andincreased optimism, hardiness, con・
found the cronbacHs alpha range was very similar at
.70-.92. cronbacHs alpha measures the reliability of an
instrument. The value of alpha varies from o t0 1, and
higher values are more desirable. Reliability is depicted
byvalues of3reaterthan .70 (Nlen & Yen,2002).
Search methods for identjfication of studies induded
electronic searches ofarticles published in Enelish from
20oo in MED上INE, cumula廿Ve lndex to Nursin号 and
AⅡied Health, and The cochrane Library and いleb of
and text using a combination ofthe search terms: salu・
tog", Antonovsky, sense of coherence, M'birth, pregn",
Childbearing, delivery, antenatal(see Appendix A).
Preferred Reporting items for systematic Reviews
and Meta Analyses (PRISMA) was used to guide the
resesarch process. PNSMA provides a useful guide for
There is debate in the literature re今arding the
factorial strudure of both scales. construct validity
determines the factorialstrudures being measured by
a to01. statistical methods such as fador analysis can
measure construd validity and group t0号ether items
in a toolthat measures the same underlyin今 Construd
Soc is also assodated with good physical health: supe・、
decreased overa11 risk of mortality over a 7・year stady
assessment of bias for randomized contr0Ⅱed trials;
σirojwong,10hnson,& W'elch,20ID. Fador analysis
Period (surteesゞwainwright,1,uben, Khaw,&Day,2003).
Ori号inaⅡy, Antonovsky a987) maintained that a
Personls soc waS 6Xed by the time he or she reached
however, assessing risk of bias in observational studies
is more contentious (sanderson, Ta杜,& Hi号gins,2007).
Because this revie、v has idenufled mainly observational
Studies, the appraisal tool developed for the critical
Appraisal sNⅡS programme (CASP) was used to assess
rior circulatory health (poppius, Tenkanen, Kalimo,&
Heinsalmi,1999; surtees et al、,2007), decreased risk of
diabetes (Kouvonen et al.,2008) and cancer (poppius,
Virkkunen, Hakama,& Tenkanen,2006), as weⅡ as a
(polit & BO'k,2008). A'0仇d血g to Antonovsky a987),
adulthood, but later, he revised this view.1mportandy
for midlvives, studies show that major li企 events such
as childbearing profoundly affect a womans soc
(Downe,2008; Habroe, schmidt,& Evald Holstein,
the structure ofboth soc tools is unidimensional, con・
Sisting of the one fador of a global orientation to life
that comprisesthe three dimensions ofcomprehensibil・
ity, meaning員11ness, and manageability.1n some studies,
fador analysis has supported this unidimensionalstruc-
three soc components areconsidered independentfac・
2013; Langeland et al.,2006; Rabin et al.,2005; sack,
tors (Flannery, perry, penk,& Flannery,1994; Germano,
Kunsebeck,& 1'amprecht,1997).
The search identi丘ed 388 artides. A revie、v of article
titles sourced 321 artides relevant to this review. A
revieNv of these 321 abstracts for relevance for soc
Childbearing 、vomeds soc, identi丘ed 13 Studies for
indusion in this revie、V. Reference list searches ofthese
13 artides identi6ed another two relevant artides, mak・
ing 15 ar廿des. Figure l i11Ustrates the ao、v of studies
through the review using the pRISMA aow chart. Risk
Ofbias across the studies waS 号eneraⅡy assessed as lo、V.
See AppendixB forriskofbias assessment ofeach study
The 15 artides originated 丘om sweden, Germany,
the Netherlands, Denmark,1Srael,}apan, poland, united
States, andthe united Kingdom. Fourteen ofthe studies
Ivere observational cohort studjes using the soc scale,
Whereas one study used a mixed method design. The
Studies identi負ed that soc 、vas assodated with emo、
tional health, health behaviors, childbirth choices, and
mode ofbirth.
Emotional Health
The studies found thatchildbearing women with strong
Soc showed improved emotional health compared to
Women with low soc. Tomen with strong soc were
Iess likely to experience symptoms ofa1Ⅸiety (sj6Str6m
et al.,2004), depression (Engelhard, van den Hout,&
Vlaeyen,2003; Kerstis, Engstrom, Edlund,& Aarts,
2013; sj6Str6m et al.,2004), and posttraumatic stress
disorder (PTSD; Engelhard et al.,2003; stramrood et al.,
2011; Tham, christensson,& Ryding,2007). women
、vith a strong soc were also lesslikelyto experience fear
Ofchildbirth (Tham et al.,2007), feelstressed (sekizuka
et al.,2006), have a 刃Vorried state ofmind (Ekelin et al.,
2009), be dissatiS負ed with partner support (Hildings・
Son, TingvaⅡ,& Rubertsson,2008), and/or perceive
their child's temperament as dif負Cult (Kerstis et al.,
2013).
Sj6Str6m et al.(2004) found that women with a
high soc score experienced less a1Ⅸiety and depression
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Ond researcher audited the processindependendy Any
discrepancy was resolved throU号h discussion. A third
researcher was available for consultation if any issues
remained unresolved, although tbis 、vas not required.
Appendix B identi6es the data extracted from each
improve the management oftension, and thusimprove
a multidimensional strudure is supported where the
t
Were robust, one researcher c011ected data and a sec・
that education and therapies can stl'engthen the soc,
health outcomes (Foureur, Besley, Burton, YU,& crisp,
、、
To ensure data c0Ⅱection methods and analysis
2007; sj6Str6m,1"angius・EN6f,& Hjertber今,2004) and
Ruoppila,2003; Gana,20OD,、vhereas in other studies,
、、、
the risk ofbias in the induded studies (CASR 2013).
,
ture (Buchi et al.,199& Feldt, lesMnen, Kinnunen,&
HNDINCS
Science databases. Databases were searched in both title
tr01, and copin8 (Eriksson & Lindstr6m,2006). A strong
Can assess tools as unidimensional or multidimensional
not have a hypothesisthey set outto prove, rather they
focus on observin8 and describing what already exists
(LiampU杜ong,201の.
Further review of fUⅡ artides, for measurement of
Soc leads a petson to enga名e in healthybehaviorsthat
to be .70-.95.1n their systematic review of 127 Studies
measuring the internalconsistency ofthe soC 13,they
data. This framework is 0丑en used 、vhen researchers do
and childbearing research identified 81 eligible articles.
MEIHOD
healthier food (王,indmark, stegmayr, Nilsson, Lindahl,
& 10hansson,2005; wain丘ght & surtees,2007); and
has superior oral health behavior (Bernabe et al.,2009;
SOC 29 and the soc B, Eriksson and Lindstr6m
Study A descriptive framework 、vas used to analyze
＼
、、
＼
入
＼
Sense of coherence and childbearing fe熔Uson et a/.139
138 Sense of coherence and childbearin8 ferguson et a/
Womenwithhighsoc. Thestudyevaluatedpostpartum
Stress by measuring womens soc, depression symp・
toms, and lgA levels. The authors explain that stress
reduceS 1名A levels (rather than increases them) and this
Identi丘Cation
NO. ofrecordsidenti6ed through database searchin名
(388)
meansthat women with low soc were more stressed.
Screenin名
They highlight the signi6Cance of measuring the soc
in early pregnancy to detectthe 、voman at risk ofstress.
In a swedish study of more than 2,ooo parents,
Ekelin et al.(2009) found that parudpants 、vith low
Soc showed a higher level of worried state of mind
as weⅡ as a higher grade of state and trait a11Xiety
Compared to parudpants with high soc. The study
inveS廿8ated parents' experiences of second・trimester
routine ultrasound examinauon with norma1 丘ndings
and found no signi6Cant difference in soc before
and a丘er ultrasound. They condude that women and
meds psych010gical weⅡ・being is affected by routine
NO. ofrecords a丑er duplicatesremoved
(359)
NO. ofrecordsscreened
NO. ofrecordsexduded
(359)
(278)
Eli名ibility
NO. of6、1Ⅱ・text artides assessed
NO. of丘1Ⅱ・text artides exduded
for eⅡgibili智
(68)
(8D
,
Induded
NO. ofadditionalstudies
NO. ofstudiesinduded
identi6ed through othersources
(13)
(2)
dtrasound examination, buttheir soc remains stable.
The 66% dropouttate for men between the 負rst and the
Secondquestionnairemayhave increasedtheriskofbias
in this study
A similar, smaⅡer cohort study in sweden exam・
ined parents' experiences ofa routine ultrasound exami・
nation in the second trimester,、vhen a choroid plexus
Cyst 、vas found (Larsson, svalenius, Marsal,& Dykes,
2009). The study group (π= 22) was matched to a con・
tr018roup (π= 66) where no abnormality was found.
15
FIGURE I The aow ofstudiesthrough thereview.Adapted 丘om Moher, D., libe・
地ti,A., Tetzla丘,j.,&Ntman, D. G.(2009). preferred reporting items for systematic
reviews and meta、analyses: The pNS入IA statement. PιOS Mediciれe,151,264-269.
Perception of their child's temperament. There 凡Vere
393 Swedish・speaMng couples who parudpated in the
Study Tbe parents anS凡Vered three questionnaires at
3 months: the Edinburgh postnatal Depression scale
Compared to women with low soc. Their swedish
Study of177 Women examined the relationship between
Soc and weⅡ・being in pregnancy and the postnatal
Period. They induded three measurement points: t、VO
8.フ% of fathers. Mothers and fathers with depression
Symptoms had a lower soc (P く.001, P く.0OD and
Perceived their childs temperament as more dif丘Cult
difference was not observed a丘erbirthbecause womeds
Soc scores returned t0 10-12・week levels. They con・
dude that a womads soc is a predictor ofweⅡ・being
than mothers and fathers without deptessive symptoms
at 3 (P =.028, P く.0OD and 18 months (P =.145,
P =.012), respectively An unusual asped ofthis study
during pregnancy and that a high soc provides a suc・
CesS丘11 Way of dealing with stress. They also suggest
that the soc scale could be used to identity 、vomen
is that it induded the perceptions of fathers; however,
Who may bene負t from extra support. The risk of bias
in this study stemS 丘om the 32% ofpartidpants lostto
asthe authors state,the EPDs is not weⅡ Validated with
men and this may be a study limitation. A potentiaⅡy
more serious Hmitation is the use of a modiaed three・
f0ⅡOW・UP.
question soc scale that does not appearto be validated
In their study of s、vedish parents, Kerstis et al.
(2013) found that mothers and fathers with depres・
in the literature or within this population group. This
Sive symptoms had a lower soc and perceived their
Child'stemperament as more dif丘Cultthan mothers and
fathers without depressive symptoms. This study aimed
to identify any assodation between soc and moth・
ers' and fathers' postpartum depression symptoms and
mayhave increased the risk ofbiasin thisstudy
SeMzuka et al.(2006) in their longitudinal cohort
Study of 54 Pregnant lapanese women found that
Women with low soc had lower levels of a stress・
related substanceimmunoglobulinA σgA) comparedto
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PTSD in postnatal women with high soc compared
to postnatal women with low soc.1n their prospec・
tive cohort study of soc and pregnancy loss in the
Netherlands, Engelhard et al.(2003) found that a
Stron号er soc in early pregnancy predicted less pTSD
Symptoms a丑er pregnancy loss. The authors tested
the relationship between the soc in early pregnancy
and symptoms of pTSD and depression a丑er preg・
nancy loss. There 、vere l,372 Women who completed
questionnaires in early pregnancy and every 2 months
therea丑er unti1 1 month after the baby's due date. of
these parudpants,126 Women experienced a pre3nancy
10SS, and 118 Women completed measures for crisis
Support, PTSD, and depression about l month afterthe
10SS. Theyfound that a stronser soc in earlypregnancy
Predicted less pTSD symptoms after the loss ofa preg・
nancy This appeared to be caused by the mobilization
Ofcrisissupport. A stronger soc was also related to less
depressive symptoms a丑er pregnancy loss. The authors
SU8gestthat soc is a resilience factor for psych010gical
(π= 272 Couples). Depression symptoms measured
at 3 months were reported by 17.フ% of mothers and
Women had signi丘Cantly lower soc scores at weeks
34-36 Compared to multiparous women:63 士 10 and
68 土 10 points,respedively (mean 士 SD,P く.05). This
＼ーーく'
Three studies found a decreased inddence of
18 months: the lnfant characteristics Questionnaire
8 Weeks a丑er birth. The study found that nUⅡiparous
ノ、、イ、气
Scores and anxiety levels were found. The smaⅡ Sample
Size may have increased the risk ofbias in this study
(EPDS) and the soc scale (π= 308 Couples); and at
during pregnancy in weeks lo-12 and 34-36 and one
{ごノぐて、[
Unlike Ekelin et al.(2009), no assodation bet、veen soc
distress a丘er pregnancy loss. The authors express con・
Cern that simultaneous assessment of crisis support,
SOC, and pTSD symptoms may result in spuriously
inaated correlations because pTSD symptoms such as
Sodal、vithdrawal may in丑Uence the degree of crisis
Supportsought. This mayhaveincreasedthe risk ofbias
in this study
A prospective,10ngitudinal s、vedish study of
Women who experienced emergency cesarea11Section
foundthatwomenwithlowsoc experiencedmorefear
Ofchildbirth and more pTSD compared to women with
high soc (Tham et al.,2007). Thisstudy of122 Women
aimed to examine the assodations bet、veen womeds
Soc andpTSD symptomS3 monthspostpartum.1nthis
Study, the groups of women with low soc were those
、vith an intense fear of childbirth during pregnancy,
immigrants, and sodaⅡy underprivileged women. The
authors condude that soc can be used to identify
Women who would bene負tfrom increased support.
Stramrood et al.(20ID found that women with
high soc have fewer symptoms of pTSD f0110win3
Childbirth.1n their multicentered, cross・sectionalstudy
in the Netherlands, online questionnaires were comPleted 2-6 months after birthby428 Women. PTSD was
in evidence in 12% of、vomen overaⅡ(5/428) and 9.1%
Of women (39/428) experiendng their birth as trau・
mauc. PTSD symptoms were assodated with women
experiendng unplanned cesarean sections,10、V SOC,
and high intensity of pain. As achlowledged by the
authors, not hlowin3 the womelゞs prebirth soc scoTe
and being unable to exdude women with preexisting
PTSD mayhave increased the risk ofbiasin thisstudy.
Health Behaviors
Studies found women with high soc less likely to
Smoke (Abrahamsson & Ejlertsson,2002) and more
Iikely to seek out useful support (Hildingsson et al.,
200& Libera, Darmochwal・Kolarz,& oleszczuk,2007)
Compared to women with low soc.
In their longitudinalcohort study of395 Pregnant
S、vedish women, Abrahamsson and Ejlertsson (2002)
describe a signi丘Cant difference in the soc score
between smoMng and nonsmoMng women.い10men
Completed a questionnaire during the 丘rst trimester of
their pregnancy and 、vere intervie、ved a丑er their baby
Was born. women who smoked showed a lower level
Of soc, particularly in the manageability component,
Compared to nonsmoking women. The authors suggest
that a salutogenic perspective could be used in al)tenatal
、、
、、
＼
、、
、、
＼'
'、、十
＼
Sense of coherence and childbearing ferguson et a/.141
140 sense of coherence and ch"dbearing ferguson et a/
Care as a basis for encouraging pregnant women to stop
Pregnant women completed quesuonnaires measur・
SmoMn号 The authors divided women into five cate80・
ries (nonsmokers, quitters, decreasers, relapsers, and
Continuers),1eaving smaⅡ numbers of 、vomen in each
Category and creating dif6Culties in 負nding statistical
in号 SOC (using the soC 13 Scale) and perceived stress
(using the perceived stress scale lpssD. A correlation
WassoU名htbetween soc and pss as a method ofcross・
Validation as stress increases birth complications (Alder,
Fink, Bitzer, Hosli,& Holzgreve,2007). Nthough per・
Women with a higher soc daimed normal birth as
their preferred mode of birth during pre今nancy They
measures of mental health (Eriksson & 1'indstr6m,
also found German women with alower soc daimed
2006).1t is not yet dear lvhether soc is a construd
Cesarean section as their preferred mode ofbirth. These
distinct from mental health constructs and we should
results were not found in the American cohort, and the
therefore interpret the research literature assodating
Soc with improved mental health with caution.1t is
Proportion ofwomen dissatiS6ed with partner support
artide.刃、10men had birthed either at home, in a birth
in early pregnancy and to identi6r fadors assodated
With dissatisfaction 2 and 12 months a丑er childbirth.
Center, or in a conventionalhospita11abor、vard. X70men
Were asked to complete the soc scale, describe their
authorssU号gestthis mayberelated to the smaⅡ number
Of American partidpants involved in the study The
authors daim that women with higher soc scores may
Prefer normal birth because they see it as a cha11enge
Wortby of investment and ensagement and that they
may have a hisher level of con丘dence in their ability
to manage this chaⅡenge. smaⅡ numbers of America11
Parudpants may have increased the risk ofbias in this
Study
In a German prospective study, jeschke et al.
(2012) found women W北h high soc scoresidentifled a
desire, durin8 Pregnancy,to avoid epidurala11esthesia in
10bω(P =.037). Th.■tudy 毎mod to idontifyP鵡did0郡
Ofepiduraluse among 193 Pre3nant women attending a
German generalhospital. only 6.フ% ofwomen planned
to use an epiduralin labor,13% ofwomen planned not
to use an epiduralin labor, and 803% of women did
not make a dedsion during presnancy lnterestingly,
adualepiduraluseinlaborwas notassodatedwith soc
Scores. As suggested by the authors, a limitation ofthis
Studymaybethatsome ofthe 39% ofwomen choosing
notto completethesecond surveymayhave been inau・
enced by their epiduraluse.
The authorssuggestthatthe soc may be used by mid・
Wivesto identifywomen lacMn名 Support.
birth experience, and list fadors they experienced as
Salutogenic and helP6.11during theirbirths.凡I×10men who
DISCUSSION
di任erences. Anotherlimitation relatesto the hi8h mean
Soc levelin the whole 名roup ofpregnantwomen (71.8)
Compared, for example, to Antonovsky's a993b) mean
Scores of55-68.フ.
Ceived stress was negatively correlated with soc, per・
Ceived stress lvas not independently assodated 、vith
Uncomplicated birth. The authors condude that higher
Libera et al.(2007), in a polish study of 、vomen
Soc scores are predictive ofuncomplicated birth. They
Who have gavebirthpreterm, describewomenwith high
Soc seeMng out more support a丘er their birth com・
Pared to women with low soc. Their study compared
負ndings of 33 Women a丘er givin名 birth to premature
intimate that、vomen with high soc may make differ・
babies and l02 Women a丘er giving birth 丘111・term.
Although no difference 、vas found in the soc scores of
Used to predict birthing outcomes but also sug号est that
the study should be repeated in a larger population.
the two groups, women with high soc in the preterm
Borrman et al.(2002), in their German mixed
birth sroup soU今htoutmoresodalsupportcomparedto
Women with low soc. ThesmaⅡ Samplesize mayhave
increased the risk ofbias in this study
In a large, national swedish cohort study of
ent choicesin theirpregnancies and labors compared to
Women with low soc, buttheirstudywas not designed
to investigate this. They condude thatthe soc may be
methods study, examined the salutogenic factors that
affed birth and found women birthing at home had
higher soc scores compared to women who birthed
in hospital. purposive sampling methods 、vere used to
2,430 women, Hildingsson et al.(2008) found an asso・
dation between low soc and dissatisfaction with part・
ner supportin the childbearing period (RR 3.フ,95% CI
recruitpartidpants. This mayhaveledto aⅡPartidpants
2.5-5.フ, P く.0OD. This study aimed to investigate the
ber ofwomen lostto f0ⅡOW・UP 、vas not disdosed in the
being described as "middle dassl' Thirty・one postnatal
Womenwereintervie、ved,2-8 months a丘erbirth. Num・
Chose an out・of・hospitalbirth expected more individu・
Only fourstudies examined the e丘ed ofsoc on birth・
ing women. AⅡ four studies found women with high
Soc made choices hlown to enhance the potentialfor
normal birth compared to women with low soc. The
Studies found that women with bigh soc were more
Creating an atmosphere ofemotionalsafe可. Regardless
Of Nvhere they 名ave birth, the salutogenic fadors iden・
tifled by the 、vomen were safety, self・determination,
SchucMng,& MUⅡer・Rockstroh,2002),identify normal
In their prospective cohort study of pre企rred
birth as their preferred birth option while pregnant
(HeⅡmers & schuecMn3,2008), and idenU61 a desire
mode of birth in German and American women,
during pregnancy to avoid epidural anesthesia in labor
σeschke et al.,2012).
Oz et al.(2009) identi負ed 、vomen lvith low
Soc experienced more complicated labors and births
(67.7 士 1.19 VS.722 士 132, P =.014) compared to
those with high soc when the authors conducted a
Prospective, observationalstudy of145 Women in lsrael.
behaviors, and increased normal birth choices and
Outcomes. An assodation, however, does not indicate
and congruence. The authors suggest 丘lrther research
Peleg,& sheiner,2009) and birth at home (Borrmann,
Iikely to experience uncomplicated birth (OZ, sarid,
Thisscopingrevie、v oftheliterature identi6ed 15 Studies
exploring soc and childbearing. A strong soc is asso・
dated 刃Vith positive outcomes for childbearin名 Women,
induding increased emotional health,improved health
Continuity ofcare as one ofthe mostimportant fadors
is required to establish the relationship between soc
and birth place. purposive sampling techniques and the
Undisdosed number of women lostto f0ⅡOW・up may
have increased the risk ofbias in this study
also not dear from the research undertaken to date the
de号ree to which other variables induding sodoeco・
nomic status, general healtb status, and level of educa・
tion mi8htconfound the relationship between soc and
health behaviors, childbirth choices, and mode ofbirth.
Although we need to treatthese research 丘ndings with
Caution, the relationship bet、veen soc and these out・
Comes are interesting for midlvifery
OriginaⅡy, SOC 、vas thought to be a stable con・
Cept, but there is evidence that educauon and therapies
Can strengthen the soc. This suggests that midwives
may be able to improve womeds health outcomes by
WorMng on interventions that seek to strengthen a
Womads soc. Herein laysthe potenualofsalut08enesis
for midlvifery Althoush the theory of salutogenesis
has been suggested as a 80od 丘t for midlvifery and the
research evidence shows some promising assodations,
there is a dearth of literature that operationalizes the
theory for midwifery practice. The antenatal period is
Particularly open to salutogenic interventions that aim
to focus the woman on health, build her confldence to
give birth norma11y, assist her to manage the stressors
thatcomewithpregnancy, andto mobilize theresources
necessary to prepare for the changes that a new baby
brings.
The current content and strudure of standard
alized and continuity forms of care.凡I×10men described
Childbirth choices and Mode of 剖rth
and depression suggests that soc may overlap with
Causality, and although the theory of salutogenesis may
Offer midwifery an avenue for promoting 、veⅡness and
normal birth,、ve need to tteat these assodations lvith
Caution.
Research has established that a strong soc is asso・
dated with increased emotionalhealth for childbearing
Women,induding less depression, a11Xiety, stress, worry,
and pTSD.1t is 、ve11 established in the literature explor・
in名 Salutogenesisin the 8eneralpopulation that a strong
Soc is assodated with good emotionalhealth (Eriksson
et al.,2007), so it is no surprise that the same assoda・
Uonwasfound forchildbearingwomen. Theassodation
With constructs indudin80ptimism, hardiness, a1Ⅸiety,
HeⅡmersandschuecMng(2008)foundGermanwomen
With a higher soc daimed normal birth as their pre・
ferredmode ofbirth duringpregnancy Thestudyevalu・
ated the preferred mode ofbirth for 負rst・time mothers
and determined if preferred mode of birth 、vas related
to soc scores. The partidpants-366 German and
67 American, healthy,10w risk, primi今ravid womenhad singleton pre号nandes. The study found German
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antenatal care focuses on monitoring and risk identi6・
Cation,1eavin今 li廿le opportunity for midwives or other
health carers to focus on these potentia11y health pro・
moting strategies. A study into the practices of expert
midwives in Australia (Browne et al.,2014) found
that midwives 、veⅡ Understand the bene負ts of such an
approach and indeed incorporated elements ofa saluto・
genic approach into their practice. This 、vas more easily
achieved in continuity ofcare models ofpractice. struc・
turalissues, in usual antenatal care, induding length
Of antenatal appointments and structure of antenatal
record card, presented significant barriers.
CONC【.USION
The theory ofsalutogenesis ali8ns with midwifery phi・
10sophy Research to date examining soc and child・
bearing sU8geststhatthere maybe benefitin exploring
＼
Sense of coherence and chⅡdbearing ferguson et a/.143
142 Sense of coherence and childbearing Fer8Uson et a/
intervenuons that aim to strengthen a womads soc.
Although midwives are charged with the responsibil・
ity for promoting normal birth by the 111terπ4ti01141
D旦f'iπiti0π qf'the ハ1idwife qnternauonal confedera・
Uon ofMid、vives,20ID, the complexity ofthe task in
today's society cannot be overestimated. A salutogenic
approach may provide the necessary shift a、vay from
Antonovsky, A.(1991). The struduralsources of salutogenic
S廿engths.1n c.上. coope,& R. pa抑e (Eds.), pers0π41・
ity 411d stress:111dividU41 diが'ereπCes m the stress process
(PP.67-104). NewYork, NY. wiley
a focus on risk toward a focus on health (sindair
the sense of coherence scale. sod41 ScieπCe 6 Medi・
& stockdale,20ID. Although more research on the
theory of salutogenesis and the relationships betNveen
Soc and childbearing is required, this approach
Shows promise for midwives and the women with
Whom theywork.
d11e,36(6),725-733. h壮Pゾ/dx.doi.org/10.1016/027フ
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Correspondence regarding this article should be directed to
Sa11γ Ferguson, Buildin号 10,1'evelB, Room 38, Disdplines of
Nursing and Midwifery, university of canberra, ACT,2601.
E・mail: [email protected]
APPENDIXA
Sa11y Ferguson, RM, MMid, phD candidate, assistant pr0企Ssor
Ofmidwifery, Disdplines ofNursing 飢d Midwifery, Faculty of
Health, university ofcanberra, ACT,2601, Australia.
INCI.UDED
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AFTER
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REMovfD
REV1モ、V
REV1モ、N
REV1モ、N
REvlf、N
185
185
172
39
11
13
込
Deborah Davis, RM, phD, professor ofmidwifery, Disd・
Plines ofNursing and Midwifery, Faculty ofHealth, univer・
Sity ofcanberra, ACT,2601, Australia.
jennyBrowne, RM, phD, assodate professor ofmidwifery,
Disdplines ofNutsing and Midwifery, Faculty ofHealth,
University ofcanberra, ACT,2601, Australia.
Databases,searchTerms,飢dNumber ofArtidesldenti丘ed,Revie、ved,知dlnduded
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Ian Taylor, assodate professor ofmidwifery, DisdP1加es of
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PURPOS亘: To extend testing of a relationaltheory that a low sense ofbelongin8, delayed or impaired
bonding, and loneliness are salientrisk factors for postpartum depression (PPD)in women.
METHODS: Data for 血istheow・testing analysis came 丘om a lar8er prospedive longitudinalcohort
Study and induded 、vomen wbo were retained to the end ofthe study atthe 6-week postpartum interView (N = 564). struduralequation modeling was used to testthe 丘t ofthe modeland determine sig、
ni丘Cance ofdirect and indired paths.
RESUI"TS: The modelexplained 35% ofthe variance in ppD, with impaired bonding and loneliness
asthe strongestindicators.工Ower sense ofbelon名ing,1ess perceived sodalsupport 丘om a health care
Practitioner and a partner, and lo、ver parenting sense of competence were additionalpredictors.
CONCI,USION: study 6ndings cl)a11enge currentthinking abouttherelationship between impaired
bondin8 and ppD because thisstudy raisesthe possibility thatimpaired bonding is a risk for ppD
as opposed to the reverse relationship. This study provided evidence ofthe importance ofhealth
Care practitioners' aⅡiance with patients and contributesto advandng the science ofwomen's mental
health in relation to depTession by considering additionalpredictors, that might be amenable to
Intervention.
KEYWORDS: bonding; conaict;10neliness; postpartum depression;sense ofbelonging;sodalsupport
INTRODUCτ10N
Postpartum depression (PPD) is a serious and com・
Plex mood disorder affecung approximately l out of 8
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Consideri11g a RelationalModelfor Depression
i11Womenwith poS中ar加m Depression
2007) ofthe more than 4 miⅡion 、vomen who give birth
in the united states evety year (centers for Disease
Control and prevention (CDC],2010a). This common
health issue not only affects the mental we11・being of
the mother, causing poor postpartum physical health
(Beck & watson・Drisc0Ⅱ,2006) and bondin8 Problems
(MCMahon, Barne杜, Kowalenko,& Tennant,2006;
Wilkinson & Mulcahy,201の, but it also may have
nesative effects on the infant induding dysre名Ulation
Pa杜erns that make the infant prone to depression in
the future (Beck,1998; Brennan et al.,200の. The lon8、
tel'm effects of ppD in children indudes the display
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Of overanxious and depressed symptoms as we11 as
behaviors related to de6ance, aggression, and conduct
Problems (Ashman, Dawson,& panagiotides,2008;
Murray, HaⅡigan, Adams, pa杜erson,& Goodyer,2006).
Evidence has accrued showing that significant
Predictors of ppD indude low social support,1ife
Stress, depression history, prenatal anxiety, marital dis・
Satisfaction, infant temperament, maternal childhood
maltreatment, POS廿raumauc stress disorder (PTSD) in
Pregnancy, dissociation in labor, and lower overaⅡ qual・
ity oflife in pre8nancy (Beck & Tatson・Drisc011,2006;
0'Hara & swain,1996; sen今 et al.,2013). The 、vork of
Ha3erty and wiⅡiams a999) on sense ofbelonging in
relation to depression has been overlooked in tbe ppD
Iiterature but seems worthy of consideration, espedaⅡy
in light of the extent to which a 、vomads sodal situa、
Uon issubjed to change durin号 the post-birth recovery
//VTE月IVAT/0/VAI_ JOUR/VAι. OF CH/ιDB/R7、H VO/ume 4,/ssue 3,2014
◎ 2014 Springer publishing company, LLC WWW.springerpub.com
h廿P://dx.doi.org/10.189ν2156-5287.4.3.151
151
A Relational Modelfor Depression Kruse et a/.153
152 A Relational Modelfor Depression Kruse et a/
and early parenting time period. Hagerty and wiⅡiams
examined the relationshゆ of perceived sodalsupport,
Sense of belonging, conaict, and loneliness on depres・
Sive symptoms in a depressed clinical sample a11d in
C011e号e students and notedthatthesevariables explained
64% ofthe variance ofdepressive symptoms with sense
Of belonging explaining the most variance (R2 =.52),
maMng it the stron8est predictor of depressive symp・
toms (Hagerty & xui11iams,1999). The impad ofsense
Ofbelongin名 on depression had been noted by others as
We11(Anant,1967; MCLaren & chaⅡis,2009; sargent,
WiⅡi抑S, Hagerty、上ynch・sauer,& Hoyle,2002).
Nthough chan号es in hormone levels is a widely
accepted vie、v regarding why women experience the
baby blues immediately postpartum, the exact eu010gy
Of ppD has not been established and no bi010号ical or
h01'monal cause has been identi6ed (Baker, Mancuso,
Montenegro,&ιyons,2002; MaⅡikarjun & oyebode,
2005). PPD appears to be a complex mood disorder
Composed of internal and external factors.1t is theo・
retica11y possible that psych010gical and psychosodal
interventions may prevent or decrease ppD symptoms
(MaⅡikarjun & oyebode,2005). considering the lim・
ited evidence regardins the use of pharmac010今ical
interventions in the treatment ofppD and the concern
Ofthe possible effects on newborns, a杜en廿on to inter・
nal and external factors assodated with depression that
、vould suggest efncadous psychosodalinterventions
Seems warranted.
The purpose ofthisresearch studywasto examine
the multiple variables ofperceived socialsupport, sense
Of belongin8, conaict in relationships, parentin号 Sense
Of competence, maternal bondin8 With the infant, and
10neliness for their assodations in a relationalmodelfor
depression with women experiendng ppD (Fi3Ure D.
Based on the Hterature, a hypothesized modelis pro・
Posed to guide the analysis ofthe data.
REV1モ、1V OFTHモⅡTERATURE BASED ON
MOD壬1, PATHS
a992) de丘ned perceived sodal support as "the 員lnc・
tion of sodal relationshゆS-the perception that sodal
relationships 、viⅡ(if necessary) provide resources such
as emotionalsupport or informatiod'(P I09).
Researchers tend to emphasize ho、v positive
received sodalsupport affects health outcomes and tend
to focus on the btight side ofsodalsupport. There are,
however, occasions when levels of received sodalsup・
Port are lacMn30r contain costs that are negative. The
dark side ofsodalsupport, as conceptualized by Tilden
and Gaylen a987),indudes costs, conaict, redprodty,
and equiw.
A cost related to the dark side of sodal support
may indude unhappy marriages, as Tilden and Nelson
(1999) state,"an unhappy marriage tends to restrid
accessto othersources ofsodalsupportbecause unmarried people often have large networks of supportive
friends"(P.867). The assumpuon that partnered status
Conveys greater support has been questioned (Kruse,
LOW,& seng,2013), given klowledge aboutthe lack of
equi智 in household work (schwartz & Lindley,2009)
and the chronidty ofdomestic violence against married
Family
Sense of
Competence
Friendships
Impaired
Bonding
Pattner
Health care
Practitioner
Nliance
PPD
Sense of
Belongins
Women (wiⅡiams, Ghandour,& Kub,2008).
Research supports the path 丘om perceived sodal
Support and sense of belonging in the proposed path
model. perceived sodal support and sense of belong・
ing had a positive, moderate correlation in 、vhich a
greater sense ofbelonging resulted in greater perceived
Sodal support (Hagerty,叉I×1i11iams, coyne,& Early
Current
Domestic
Violence
1996; MCLaren & chaⅡis,2009). Dennis and letour・
neau (2007) examined globalperceptions ofsupportin
Postpartum depressed 、vomen and noted that sense of
belonging with other women and children was a major
Predictor ofperceived globalsupport.
Loneliness
Childhood
Family
Violence
Banti et al.(2009) reviewed literature related to
Perinatal mood disorders and anxiety atld noted that
inadequate sodalsupport 、vas nearly the strongest pre・
dictor ofppD and had a strong to moderate effect size.
The only predictor that was stron名er was a history of
depression in the prenatal or antenatalperiod. The next
Predictor (independent variable)jn the modelindudes
the variable ofsense ofbelonging.
Iifetime
Domestic
Violence
FIGUREI
Perceived social support
The concept "sodal support" has been de丘ned in
many dif企rent ways; however, the most commonly
accepted components of sodalsupport indudes emo・
tional, appraisal, informational, and instrumentalsup・
Port as conceptualized by House and Kahn a985).
Perceived sodalsupportis a board framework ofsodal
Support that exists in sodal support research. cohen
Parenting
APGAR
Sense of Belongin琴
Sense ofbelongingis a conceptthathasreceived increas・
in今 a廿enuoninthe mentalhealthliteraturebutno atten・
tion in the ppD literature. Maslow (1954) recognized
belonging as a basic hum如 need and ranked it just
above basic physi010gical and safety and security needs.
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The theoreticalmodelofpostpartum depression.
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A Relational Modelfor Depression Kruse et a/.155
154 A Relational Modelfor Depression κ地Se et a/
Sense ofbelonsing had been defined as"the experience
Of personalinvolvement in a system or environment
So that persons feel themselves to be an integral part
Ofthat system or environmenf'(Hagertヌ 1,ynch・sauer,
Patusky, Bouwsema,& C0Ⅱier,1992, P 172). Fitting in
With other individuals, systems, and/or environments
and feeling valued are important concepts related to
Sense ofbelonsin号
The relauonship bet、veen Sense Of belong・
ing and depression 刃Vas researched by Ha号erty and
WiⅡiams (1999) who assessed 379 Community c0Ⅱege
Students and a depressed clinical sample. The stron・
gest predictor of depression in their study popula・
tions was sense ofbelongin号, which explained 52% of
the variance on depression. The relationshゆ between
Sense of belon3ing and depression has been noted
by others as we11(MCLaren,2006; MCLaren,1Ude,
& MCLachlan,2007). The next relationships in the
modelindude the independent variables of conaict
and violence.
Support (Golding, wilsnack,& cooper,2002), which
(sodal support from family and friends) in turn is a
PTedictor ofppD (Hung,2007; Kuscu et al.,2008). The
Path from parentingsense ofcompetenceto ppD wi11be
described next.
Parenting sense of competence
Parentin名 Sense of competence is the degree to which
Parents feel con6dent and self・ef負Cadous in their role
as a parent (Gilmore & cuske11y,2008; Mildon, wade,
& Ma廿hews,2008). High levels of parenting sense of
Competence are assodated with responsive and nutritive
Conaict is de6ned as "perceived discord or stress in
relationshゆS caused by behaviors of others or the
absence of behaviors of others, such as the withhold・
加g ofhelp"(Tilden, Nelson,& May,1990, P 338). one
extreme form of con丑ict is intimate partner violence
(1PV), which has been de6ned as physical force or
the intent of physical harm a8ainst someone by cur・
rent or former husbands, unmarried male or female
domestic partners, or other persons where an intimate
relationship is shared (Golding,1999; Koss et al,,1994;
Straus,199D.
Dennis and ROSS (2006) examined womeds per・
Ceptions of relationship conaict in the development of
PPD in 396 mothers at l,4, and 8 、veeks postpartum
and noted relauonship conaict was signi丘Ca11tly higher
in women with depressive symptoms at 8 Weeks when
Compared with women who 、vere not depressed.1n
addition, mothers who experienced depressive symp・
toms were more apt to report havin8 a partner 、vho
"made them angry, tried to change them,、vas critical
board σRB) approval. The sample for this secondary
analysis study induded the 564 Women recruited for a
Cohort study of pTSD who completed the postpartum
Ivave of data c0Ⅱection who had a range of relational
risk factors (e.g., abusive family oforigin,interpersonal
SensitiⅥty). They were recruited via prenatal care cHn・
ics in three health systems (one in a university to、vn and
two in an urban area)in the state ofMichigan. A11three
to talkto (Beck,1992; Nahas & Amasheh,1999a,1999b;
health systems approved this research projed through
Ugarriza, Brown,& chang・入,1artinez,2007).
their respective lRBS. The timeline for recruitment was
fTom AU3Ust 2005 through May 2008. Eligible research
Partidpants induded women who were 28 Weeks' ges・
tation or less, expecting their arst・born infant, could
Speakand understand English, and、vere atleast 18 years
Of a8e. Detailed descriptions ofrecruitment and survey
methods have been described elsewhere (seng, LOW,
Sperlich, Ronis,& Liberzon,2009).
Additional Depression Risks
behaviors that result in better maternal-child a廿ach・
The aforementioned variables aⅡ have an in丑Uence on
ment(Ngai, cha11,& 1P,201の.
depression; however, there are additional risk fadors
for depression worth noting. 、70men aged 18-24 years
have depression rates of 11.1%, lvhich is greater than
any other childbearing a3e cate今ories (25-34 years:
9.3% and 35-44 years:8.フ%; CDC,2010b). Additional
risk factors indude having an annualincome of less
than $15,000, having a high school education or less,
and living 加 high・crime neighborhoods (CDC,2010b;
The Attachment Bond
A廿achment is described as an everlasting emotional
bondthatexistsbetween an infantandone ormore care・
Conflid and violence
a "discrepancy between desired and achieved levels of
Sodal contacf'(paloutzian & E11ison,1982, PP 4-5).
The relationship between loneliness and depres・
Sion has been 、veⅡ established over the years, with
research grounded in relational designs. Multiple
Phenomen010gical research studies revealed loneliness
as a major theme in ppD. 、10men revealed in these
Studies feelings of loneliness and isolation lvith no one
ノ
givers (Main,1996). A廿achment theory also indudes
the notion thatsecurity, safety, and satisfaction compose
the attachment relationship and termination of this
relationship causes distress (Goldber号, Muir,& Kerr,
1995). A杜achment may be vie、ved as a characteTistic of
a relationship bet、veen a caregiver and child 、vhere the
Child feels safe, protected, and secure,、vhereas bonding
maybevie、ved as aprocessthat occurs a丘erbirth where
Cutrona, Russe11,& Brown,2005; Galea et al.,2007;
Latkin & curry,2003). These risk fadors are important
to note because cumulative sododemographic disad・
Vantage (SDD) increases risk for poor mental health
Outcomes as opposed to any one risk fador alone (sam・
er0丘& Rosenblum,2006).
(Myers,1984).
Mother-infant bonding disorders occurin 29% of
motherswho havebeen diagnosedwith ppD (Brocking・
MATERIALSAND MfTHODS
ton et al.,20OD. Moehler, Brunner,凡Viebel, Reck, and
Design
Resch (2006) noted a strong assodation of decreased
quality of maternal-infant bonding in women 、vith
PPD at 2 Weeks,6 Weeks, and 4 months postpartum in
a sample of lol mother-infant pairs.1t is important to
The research desi名n for the parent study was prospec・
Uve, and this secondary analysis study 、vas prospecuve
as 、veⅡ and considered the model variables in relation・
＼veis &ιederman,201の. The finalrelationship in the
modelindudesthe path from ppD and loneliness.
Ship to time. Data from awave l"(<28 Weeks' gestation),
"wave2"(28-35Weeks'gesta廿on), and"wave3"(6Weeks
Postpartum) were analyzed in a predictive model using
multiple regression, path analysis, strudul'al equation
modeling (SEM), and strati丘ed approaches.
【oneliness
Sample
note that almost a11 research studies to date state that
PPD causesimpairedmother-1nfantbondin号(Edhbor3,
Nasreen,& Kabir,2011; Liberto,2012; patel et al.,2012;
2013).1n addition, childhood maltreatment survivors
Of sexual assault report less family of ori8in and friend
Sisto determine the sample size required to test 廿le pro・
Posed model. A sample size of at least 20o partidpants
Wasrecommended as a goalfor sEM to ensure adequate
Statistical poNver for data analysis because goodness
Of 6t is overestimated with most 丘t indices for smaⅡ
Sample sizes oflessthan 200 (Kenny,2011; Tomarken &
WaⅡer,2005).
Procedure
凡Vomen who were interested a11d eligible for the st口dy
(N = 2,689) provided their contad 血formation, were
given a copy ofthe consent form, and then contacted by
a survey research or今anization who obtained informed
Consent and completed the structured computer・assisted
telephone interview (N = 1,581; seng et al.,2009). Data
from 、vave l (<28 Weeks' gestation), wave 2 (28-35
Weeks' gestation), and wave 3 (6 Weeks poS中art口ln) were
analyzed. A description of the instruments and model
Variables are listed in the 血ⅡOwin号 Sections.
Measures used in the parent study
IV4νe 11nstrU柳e11ts
Conaict and/or violence related to a mother'S
Childhood maltreatment history has been noted as a
Predictor ofppD as we11(R'=.035,P く.001; seng et al.,
Cohelfs a988) frameworkwas used in the power analy・
a mother has an affectionate attachment to her infant
Ofthem, and made them work hard to avoid conaict"
(Dennis & ROSS,2006, P 593).
Sample size
This secondary analysis study 、vas part of a larger pro・
Spedive longitudinal cohort study (psychobi010gy of
PTSD & Adverse outcomes of childbearing, NIH R01
Loneliness is the "unpleasant experience that occurs
When a persods network of sodal relations is de丘・
Cient in some important lvay, either quantitatively or
qua1北a廿Vely" and occurs as an emotionalresponse to
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Instruments induded life stressor checNist (1,SC;
Cusack, Falsetti,& de AreⅡa110,2002), Nationa1凡I×10menls
Study pTSD Module (NWS・PTSD; Resnick, Kilpat・
rick, Dansky, saunders,& Best,1993), pre名nancy Risk
A Relational Modelfor Depression Kruse et a/.157
156 A Relational Model for Depression Kruse et a/
Assessment Monitoring system (CDC,20ID, a11d tbe
Symptom checMist 90・Revised (SCL・90・R; Derogatis,
1997). AⅡ of壮lese instruments are established and reli・
able measures. Reliability coef丘dents were calculated for
each of仕leinstruments as appropriate, andthescl-90・R
had a coe丘ident of.84.
AmoS19 Was usedto testan sEM to determinethe
EDS, and Q0王1. Theseitemswereselectedfrom thesur・
best modelto explain the theoretical model variables.
SEM is based on prindples related to regression and
Path analysis (Byrne,2010); however, SEM aⅡOws one
to test more complicated path models with intervenin8
Variables connecting the independent and dependent
Variables (UⅡman,2007). SEM analysis involved assess・
in号 for mode16t. There are many indices that may be
Used to assess for mode1 負t, W北h great discrepancy
among researchers regarding the bestindices as weⅡ as
Whatthe cutoffs are (Hooper, COU号lan,&MUⅡen,2008);
therefore, only the mosdy widely accepted model fit
indices and cutoffs 、vere used to evaluate the proposed
Vey scripts based on the Hagerty et al. a992) de6nition
Of sense of belonging cited previously content valid・
ity was established by using an expert panel, including
Hagertywho created the sense ofBelonginglnstrument.
The ori8ina1 13 Potentialitems were reduced t03. The
飢Pha reliability for this smaⅡ Scale was .61.
IV4νe 2111StrU柳e11ts
The instruments used induded Experiences ofDiscrimi・
nation scale (EDS; Kessler, Mickelson,&叉VⅡlialns,1999),
F血ilyAPGAR (smilktein,1978), Health care 肌ia11Ce
QuestionnaiTe (HCAQ; Hiser,2004), atld the Quality
Ofl'ife lnventory (QOLI; Frisch, corneⅡ, viⅡanueva,&
Retzla伍 1992). ReliabⅡity and validi智 testin8 had been
established wi仕l aⅡ instruments. cronbacHs alpha coef・
6Cients for this study ratlged from .79 to .93.
IV4νe 31πStrU机e11ts
Instruments induded parenting sense of competence
C011jlict
The "conaict in relationships" proxy 、vas created using
items from the Lsc to operationalize three differ・
ent conaict variables, induding childhood family vio・
Ience before age 16 years (six items),1ifetime domestic
These instruments are considered vaHd and/or reliable.
In this study, the cronbacHs alpha for the instruments
ra11ge from .80 to .95.
Violence (three items), and current domestic violence
Dired effects in the path model are displayed by
the regression coefadents, whereasto estimatethema号・
(six items). The childhood family violence items are
related to physical neglect; witnessed violence bet、veen
family members; a11d physical, emotional, and sexual
each indirect pathway was considered. The bootstrap
abuse, whereas the current and lifetime domestic vio・
method was used to determine the standard error, con・
Ience items are related to physical, emotional, and sexual
abuse and 、vere answered in a yes/no format.
丘dence intervals, andp values ofthe paths.
Strati6ed testin号 Using the multigroup moderation
test、vas conducted to determine 、vhether the mode1 丘ts
Se訟Se ofBel011giπg
The sense ofbelonging proxy variable was constructed
Using selected items from the NWS・PTSD, SCL・90・R,
R更SU[1S
Thedemographicsofthepr0号rampartidpants(N= 564)
are discussed 刃Vith consideration ofthe dependent vari・
able, PPD (Table D. of these 564 Women,202 (35.8%)
had pDss cut0丘Scores of 60 or above,indicating mild
and/or major depression,釘ld 121 (21.5%) had pDSS
Loneliness was measured using a single item from the
NWS・PTSD."(1n the past month) have you felt cut 0丘
from other people?" The cut0丘time point used in the
modelis in the postpartum period to f0110、v the time
Sequence ofthe model.
TABI、E I
Dem0名raphicsbypostpartum Depressivesymptoms: chi-squareTestforlndependence 加 Postpartum
Women(N= 564)
CHARACτモRISTIC
Daね Analysis
CUT0仟
CUTOFF
SCORESOF60-
SCORESOF80-
NO PPD
MINORPPD
MAIORPPD
N (ツ0)
N WO)
N6脚
N (%)
241 (42.フ)
202 (35.8)
121 (21.5)
564 (10の
X2(2)
62 B6.5)
67 (39.4)
41 (24.1)
170 BO.1)
3.92
3 (42.9)
3 (42.9)
1 (14.2)
＼
10TAL
P
Race/ethnlcity.
Rates and degree of depressive symptoms 、vere deter・
mined by examining the pDss cut0丘 Scores ofpartid・
Pa11ts and determining how many partidpants scored
in the not probable, mild, and severe depressive symp・
tom categories. Means and standard deviations 、vere
American lndian/Alaska Native (n =フ)
Asians (n = 46)
European Americans (n = 324)
HawaⅡanノ距Cific lslander(n = 3)
Latinas (n = 31)
フ(12)
027
3,14
16 (34.8)
22 (47,8)
8 a 7.4)
46 (82)
155 (47.8)
102 (31.5)
67 (20.刀
324 (57.4)
1 β33)
2 (66.フ)
0 (00.0)
3 (0.5)
1.51
17 (54.8)
10 (323)
4 a 2.9)
31 (5.5)
4.58
19 (3,4)
5.94
8.86
Obtained for aⅡ model variables. A summative (0-5)
Middle Eastem (n = 19)
5 (263)
8 (42.1)
6 BI.6)
index of sDD risk variable was created from the 6Ve
Other race/ethnicity (n = 23)
8 β4.8)
9 B9.1)
6 (26.1)
23 (4,1)
0.67
Sododemographic fadors (African American race,
bein3 Pregnant as a teen, havin号 high school educa・
tion or less, having income く$15,000, and living in a
nei今hborhood with a crime rate higher tharl the u.S.
average). This index Nvas c0Ⅱapsed to having fe、ver (0
Or l) versus more (20r greater) SDD I'isks. The t・tests
Teens (18-20 years of age; n = 89)
39 (43.8)
36 (40.4)
14 a 5.8)
89 (15.8)
228
Income く$15,000 (n = 85)
31 (36.5)
32 (37.6)
22 (25.9)
85 (15.1)
193
High scho010r less (n = 183)
Urban or high・crime residence (n = 18刀
74 (40.4)
68 B72)
41 (22.4)
183 (32.4)
0.58
66 B53)
76 (40.6)
45 (24.1)
187 (33.2)
633
More sDD Risk
70 B63)
76 (39.4)
47 (243)
193 B42)
5.06
1,1 (1.6)
1.4 (1.フ)
13a.刀
13 (1.刀
Ivere conducted on aⅡ of the model variables in rela・
Mean age (SD)
273 (5.4)
26.9 (5.フ)
27.1 (5.1)
27.1 (5.4)
Mean number ofsDDS(SD)
tion to less and more sDD risk. Regression residuals
OfaⅡ dependent variables were normaⅡy distributed as
required to meetthe assumptions forregression model・
in8 住ewis・Beck,198の.
Note. PPD = postpartum depression; SDD = sododemogTaphic disadvanねge, which is a sum ofbein号A丘ican American, a teen, with low income, and
a hi号h schooleducation orless; more sDD risk = two or more sDD risk factors; SD = standard deviation
'some dem08raphics do nottotalto the fU11Sample size of564 because ofsmaⅡ numbers ofparticipants dedinin8 the question or because of、vomen
giving more than one race/ethnic identity
48
82
10
ー4
フ3
32
07
23
23
87
50
40
84
94
6
1
Perceived socinlsupport
Perceived support from family,丘iendships, a partner,
and health care providers were four variables used to
Operationalize perceived received sodalsupport from
Sodal network members. The Family APGAR instru・
ment and the HCAQ assessed perceived support from
family and health care providers, respectively perceived
Sodalsupportfromfriendsandapartnerweremeasured
Using single items from the Q011(Frisch et al.,1992).
groups as weⅡ aS 杜le estimated regression weights for
both groups.
ι011eliπess
African Americans (n = 170)
Variables constructed to operationalize
Components ofthe lheory From the Measures
Used in the parent study
Ofthe parameters in the model compared against both
nitude ofthe indirect effects ofone variable on another,
Permission to use the aforementioned instru・
mentslvas obtained priorto the study implementation.
table,、vhich contained the z score 血r the dif企rences
model.
Questionnaire・Modi6ed (Gibaud・、、raⅡSton &いlanders・
man,2000; Mowbray, Bybee, H0Ⅱingsworth, Goodkind,
&oyserman,2005),postpartumBondingQuestionnaire
(BrocMngton et al.,20OD, and postpartum Depression
Screen加g scale (PDSS; Beck & watson・Drisc011,2006).
equaⅡyweⅡforpoS中artumwomenwhohadlowormore
SDD 飢d was performed by running No models (an
Unconstrained and a constrained modeD. A chi・square
for each model was obtained a11d a di丘erence test per・
formed to determine ifthe modelfits di丘erendybetween
血e sDD 名roups of women (HO×& Bechger,1998).
A stats Tool package (GasMn,2012) usin8 eroup di丘er・
ence calculated the path di丘erences ofthe two groups by
taMn3 into considerauon the criticalratio for dif企rences
、
ノノく
、
A Relational Modelfor Depresslon Kruse et a/.159
158 A Relational Model for Depression Kmse et a/
TABIE2
Descriptivestatistics andDistributions oftheModelvariablesin postpart山nw'omen (N = 564)
22.0
Healthcare A1Ⅱance
THEORE11CAI.
OBSERVED
Family
RANC重
RANCE
APGAR
21.6-223
3.6
5-25
5-25
4.6
4.64'フ
0.6
1-5
2-5
3.6
3.6-3.フ
0.6
1-5
1-5
603-61.5
6.5
16-80
34-79
609
==
Sense of belon号ing
(for l month or more)
SD
Yes
24.1%
(π
136)
Feeling others do not understand
NO = 759ツ。
0-1
0-1
-0.49
Friendships
0.30
-0.12
02
Impaited
Bonding
0.09
(π= 428)
32
3.1-33
1.1
0叫.
04
3.8
3.フ-3.9
0.フ
04
0→
Partner
Feeling 小at people are un介iendly
Or dislike you
0.36
-0.10
0.08
Conflict
Hlstory offamily violence
(before age 16 years)
0.5
0.4●.6
09
0-6
0-6
035
Health care
Ufetime domestic vlolence
1.1
0.9-12
1.フ
0-3
0-3
Practitioner
Current domestic violence
0.1
0.0●.1
02
0-6
0-2
Nliance
533
53.0-53.5
29
11-55
35-55
17.4
16'フ-18.1
フ.9
0-115
8-55
NO = 862ツ。
1.0
0-1
O and l
35-175
35-146
Parentln名 Sense of competence
Impaired bonding
Yes
13.8ツ0
仇
PPD
Sense of
Competence
0.15
γOu or are unsyrnpathetic
[oneliness (Yvave 3)
Parenting
-0.09
Perceived social support
Family APCAR
FriendshiP5
fねrtner quality
Feelin8 Cut 0仟 from other people
959、O CI
解
VARIABLE
78)
64.1
-0.11
037
PPD
Sense of
Belon8in8
-0.09
(π= 486)
62.3-65.8
19.4
-0.16
Note. M = mean; CI = con6dence interval; SD = standard deviation; PPD = postpartum depression.
029
Current
Cut0丘Scores of80 or above,indicatingmajor depression.
Partidpa11ts with more sDD risk experienced symptoms
Of minor and major depressive sylnptoms greater 杜lan
that ofthe overa11group
Table 2 displays a11modelvariables.1n terms ofthe
independent variables, most women had more support
than the neutral category for sodal support, sense of
belonging, and parenting sense ofcompetence and had
Iessthan 壮)e neutralcategoryforimpaired bondin号 and
Conaict.
入lissing data emer8ed for a felv reasons. some
Partidpants did not answer items such as race/ethnic・
ity. There were als085 Pre8nant women who gave birth
early and had missing data in wave 2 in relation to the
interim assessment ofonsoing abuse because labor had
already occurred. This a丘ected the "current domestic
Violencd' and "1ifetime domestic violencd' items and
Would have reducedthe sample size availableformodel・
ing Data 、vere imputed for the abuse items and a ded・
Sion tree forimputation ofmissing data was constructed
based on partidpantresponse to abuse questions atfour
Other time points in lvaves l and 3.
Differences were examined in mean scoresrelated
to aⅡ model variables for partidpants 、vith less and
more sDD. A11 but t、vo variables (perceived sodal
Support from friends and loneliness)、vere statisticaⅡy
Signi負Cant. According to the coheds d e丘ect size, it
appeared that perceived sodalsupport from family and
health care practitioners,1ifetime domestic violence,
Parenting sense of competence, and ppD had smaⅡ
e丘ectsizes; perceived sodalsupport from a partner and
Sense of belon号ing had moderate effed sizes; and cur・
rent domestic violence, childhood family violence, and
impaired bonding had dose to medium effectsizes.
The sEM path model(Figure 2) displaysthe paths
in the proposed model with the path coef6Cients and
R2 results displayed using AmoS 19. R2 Values which are
10cated near the upper right hand corner of each vari・
Domestic
Violence
0.23
-033
-0.19
-0.10
0.17
王oneliness
Childhood
Family
Violence
Lifetime
Domestic
Violence
FIGUR電 2 The theoreticalmodelfor postpartum depression tested by using sEM with standardized regression coef、
丘Cients (above straight arrows) and R2 Values (above end08enous variables,top right corner). observed variables are
able box indicated that 35% ofthe variance in ppD was
explained by the modelvariables, with impaired bond・
in今 and loneliness explaining the most variance. sense
Ofbelon8in8 as an end08enous variable had 37% ofthe
Variance explained by the model, with family violence
and perceived sodal support from friends explain・
ing the most variance. percentage of the variance in
impaired bonding (30%)、vas explained by the model,
With parenting sense ofcompetence explainingthe most
Variance. Fina11y,17% of the variance in loneliness was
represented by squares.
、 J^ー^ー
A Relational Modelfor Depression Kruse et a/.161
160 A Relational Model for Depression κ川Se et a/
explained by the model.1mpaired bonding contributed
more t010neliness than sense ofbelonging. childhood
family violence had the greatest impad on sense of
belonsing and also signi6Canuy impacted ppD、 NSO,
more sodal support from a partner resulted in more
impaired bonding. Mode1 負t statistics indicate that the
modelis a very good 丘t:×2 = 10.52,中'= 14, P =.72;
Of competence on impaired bonding waS 名reater for
Women with less sDD when compared to women wi壮1
RMSEA = 0.000; NFI = 0.99; and cFI = 1.00.
This secondary analysis study 、vas designed to be廿er
Understand the impad of relational variables on ppD.
There wete 27 dired pathstested in the model, with lo
Paths that 、vere not si8nincant. The signiacant paths to
Sense of belon8ing 、vere supported by other research
(Hagerty &wi11iams,1999; MCLaren et al.,2007; sar号ent
et al.,2002), and it also was noteNvorthy that lifetime
domestic violence did not impact sense of belongin号.
The examined research suggests that current conaict
in relationships affects sense of belonging more than
Conaict in the past.
The next paths examined were the paths thatled
to impaired bonding. perceived sodal support from
falnily, friends, and a partner impacted 廿le motherinfant dyad in terms of bonding; however, the vari・
ablethat had the 8reatestimpact on impaired bonding
Was parentin3 Sense of competence, with a re号ression
Wei8ht of -0.49. This is espedaⅡy use丘11information
as hea1廿I care practitioners could easily assess for sense
Ofcompetence prenata11y and build competence to pre・
Vent impaired bonding in the postpartum. Two paths
to impaired bonding that were not signi負Cant 、vere
Sense of belonging and current lpv The insigni負Cant
relationship between sense of belonging and bondin名
is noteworthy because whether or notthe new mother
feels "valued" or α負ts" with family, friends, and com・
munity does not have an impad on therelauonshゆ the
mother has with her ne、v infant.1n terms of the path
from conaictto impairedbonding, conaictis associated
With insecure attachment(Bowlby,1980; pietromonaco,
Greenlvood,& Barrett,2006); ho、vever, bonding is an
intimate relationship between a mother and infant, and
therefore, in this research study, current domestic vio・
Ience does not appear to destroy or even inauence the
Table 3 indudesthe standardized dired and indi・
Support from 丘iends, sodalsupport from family, and
Iifetime lpv to depression.
The strongest predictors of ppD 、vere impaired
bonding (.43) and loneliness (.23). parenting sense of
Competence (-2D, sense of belonging (ー.15), and
Perceived sodalsupport from a health care practitioner
(ー.11) and a partner (ー.07) were additionalsigni丘Cant
Predictors ofppD.
An analysis of the hypothesized model (see
Figute D using sE入l multi8roup moderation with
Women who had both less and more sDD was also per・
formed. The unconstrained modelindicated a relatively
good mode16t as evidence by X2 = 25.89,4f= 22,P
.26; RMSEA = 0.02; NFI = 0.9& and cFI = 0.99. The
0.04
Total e仟ed
-0.33***
0.04
Sι
0.02
0.01
0.02
0.01
PDSS
SID.
Sι
0.06
0.04
0.1 1 **
0.07***
0.01
0.06***
0.01
0.13**
0.05
0.17***
0.04
0.02
0.04
-0.02
0.03
0.01
0.01
0.02
0,01
0.03
0.05
0.00
0.04
0.05
0.04
-0.04
0.04
STD.
Sι
-0.06
0.04
0,03
【ife"me lpv
Direde仟ed
Indired e仟ed
Total e仟ed
-0.06
0.04
-0.16***
0.04
Currenupv
Direde仟ed
Indired e仟ed
Total e仟ed
-0.05
0.04
0.02
0.01
0.01
-0,16***
0.04
-0.04
0.19***
0.04
-0.12**
0.03
-0.01
0.01
-0.08***
0.02
-0.08***
0.02
0.04
0.07
0.04
-0.03
0.04
-0.01
0.03
-0.08**
0.01
-0.09*
0.04
Friends
Direct e仟ed
Indirect e仟ed
Total e仟ed
0.19***
0.04
-0.13**
0.04
0.15***
0.04
-0.09*
0.03
-0.01
0.01
-0.06***
0.02
-0.06***
0.02
Family
Direde仟ed
Indired e仟ed
Total e仟ed
0.15***
0.04
-0.10**
0.04
0.08*
0.03
0.09**
0.04
-0.01
_0.06***
0.03
0.01
-0.07*
0.04
-0.10**
0.03
Partner
Direde仟ed
Indired e仟ed
Total e仟ed
Paren"n3 SOC
Direde仟ed
Indired e仟ed
0.08*
0.03
Total e仟ed
Sense of belon3ing
Direde仟ed
Indired e仟ed
Impaired bonding
Dired e仟ed
Indired e仟ed
0.09**
0.04
0.01
0.01
0.03*
0.01
0.01
0.01
-0.07*
0.04
0.03
-0.14***
0.02
-0.21***
0.02
-0.49**
0.03
-0.14***
0.02
-0.21 ***
0.02
-0.05
0.04
-0.19***
0.04
-0.08ネ
0.04
-0.01
0.01
-0.07***
0,01
-0.20***
0.05
-0.15**
0.05
029***
0.04
-0.05
0.04
一一一
Total e仟ed
Total e仟ed
029***
0.04
036***
0.02
0.07***
0.01
0.43***
0.03
-0.11***
0.04
-0.11***
0.04
023***
0.04
0.23***
0.04
Healthcare a11iance
一一一
一一一
一一一
Indired e仟ed
一一一
Direde仟ed
Total effed
【oneliness
一一一
一一一
一一一
Total e仟ed
一一一
Indired e仟ed
一一一
Dlred e仟ed
一一一
The 6nal paths that were examined induded the
Pathsto ppD. Nl ofthe paths noted in the modelwere
Supported in the literature as having an effed on ppD;
however, this path model demonstrated that perceived
Sodalsupport from friends and family had no dired
impad on depression.1t is important to state that both
Of these variables signi負Cantly a丘ect ppD; ho、vever,
this occurTed along an indired path. There Nvere two
Indired e仟ed
一一一
mother-infant bond.
Direde仟ed
一一一
Signi6Cant dif企rences noted bet、veen women W北h less
and more sDD in terms ofpath coefficients. The paths
between childhood familyviolence and sense ofbelong・
in今 and a110fthe conaict variables and loneliness had a
greater effect on women with more sDD as opposed to
Iess sDD.1n addition,the path from sodalsupportfrom
friends to ppD had a path difference that 、vas greater
for women with more versusless sDD. The impad of
impaired bonding on ppD, perceived sodal support
from family on impaired bondin& and parenting sense
-0.33***
STD.
【ON更UNESS
Family violence
一一一
With less versus more sDD (Table 4). There are several
Sι
一一一
Path esumates were compared to determine ifthe
Various paths in the model were dif企rent for women
SID.
IMPAIR辰D BONDINC
一一一
Iess versus more sDD.
CAUSAI.VARIABtES
一一一
X2 = 85.16,中'= 27, P く.001, which indicated that the
model explains depression differendy in women with
DISCUSSION
一一一
0.95. The difference of the t、vo models resulted in a
S壬NS更 OF BEI.ONCINC
一一一
^
fNDOCENOUSVARIAB【ES
一一一
next step 、vas to constrain the path modelso diffヒrences
in sDD could be examined and resulted in χ2 = 111.05,
0 = 49,P く.001; RMSEA = 0.05; NFI = 0.92;and cH
moresDD.
一一一
Conaict items t0 10neliness; and current lpv; sodal
Women(N= 564)
一一一
red path coe缶Cients as we11 as standard errors. There
Were 27 dired paths tested in the model, with lo paths
that 、vere not signi丘Cant. The paths that were insignifl・
Cantin the modelinduded the paths from lifetime lpv
to sense of belon名ing; sense of belon8ing to impaired
bondin号; current lpv to impaired bondin名; a11 0f the
StruduralEquationModelingE丘ects ofthe causalvariables ontheEnd0名enousvariablesinpostpartum
TABIE3
Notes: PDSS = postpattum Depression screenin名 Scale; std.= standardized; SE = standard error;1PV = intimate paTtner violence; SOC = sense of
Competence
"P く.10."P く.01."""P く.001.
162 A Relational Model for Depression κ脚Se et a/
TABIE4
A Relational Modelfor Depression Kruse et a/.163
PathEsthnateswithzscoresforpathDi丘erencesBe加eenwomenw'1thlesS 如dMore
maternal care providers was protective against ppD
Port people that direcdy affed ppD for women with
SododemographicDisadva11ta客e(SDD)(N= 564)
has a para11elin the research. According to seng et al.
more sDD indude friends a11d the obstetric health care
(2013) and Fisher (1994), a positive perception of the
Care received in labor also has a protecuve effed on
Practitioner.
Postpartum mentalhealth.
Ships that are important to highlight.1n terms of
Variables that impad sense of belon名ing, the variable
With the strongest relationship to sense of belonging is
Childhood family violence, with a standardized regres、
征SS SDD (n = 371)
Sense of belon8ing
Sense of belonging
Sense of belon8ing
↑↑↑↑↑
Sense of belonging
Sense of belon8ing
Impaired bonding
Impaired bonding
Impaired bonding
Loneline5S
Loneliness
LonelineS5
Loneliness
PDSS
PDSS
PDSS
PDSS
PDSS
PDSS
PDSS
PDSS
略ΠMATE
-0376
.008
Family APCAR
0.086
001
距rtner
0.043
Friends
P
ZSCORE
-0.071
.824
0,870
0.085
.016
-0.012
direction 、vas the path from perceived partner support
フ73
0217
.180
0.796
to impaired bondin号 lt、vas expected that more support
0.630
.000
0.733
.001
0393
-0390
.000
-0.695
<.001
from a partner would result in less impaired bonding;
however, the reverse was true, mea11ing the more per・
-2302
.095
-0995
.020
0.906
0.514
.467
0.549
224
0'042
Farni1γ APCAR
-0.491
.000
-0.087
380
2.549**
Friends
-0.970
.134
-1.734
.006
-0.843
Sense of belonging
-0.492
.036
-0.195
284
1.002
Currentlpv
-1.565
.809
0.295
.780
0.283
Fねrentlng soc
-1.541
.000
-0.518
<.001
Sense of belonging
-0.044
.000
-0.022
.040
0.062
.059
-0.097
.047
-2.704***
-0.004
825
0.046
.022
1.フ76*
-0.521
.100
0.155
.019
2.088**
0.012
.000
0.014
<.001
0.468
15.089
.000
9.836
.01 1
-1.139
距rtner
-3,887
.018
-0.846
.538
Currentlpv
21.715
.159
-4321
Friend5
2.616
、095
Family APCAR
0.075
Lifetime lpv
PDSS
-2.029**
Violence
Current lpv
Rlr[ner
Ufetime lpv
5.639***
1.448
Violence
Currentlpv
A path that wassigni丘Cantbutnotin the expected
Ceived support from a partner, the more bonding was
impaired. This finding is counter to the intuition that
Posiuve partner relationships would be assodated lvith
Positive mother-baby relationships. More research is
needed to understand why this might be.
There are a few other relationsh中S worth men、
tioning in terms of the path differences in the model
based on sDD. A surprisingresdtfor、vomen with more
SDD Nvas the fad thatthe partner relationship did not
have a signi丘Cant impact on the dependent variables
Ofimpaired bonding, sense ofbelonging, and ppD and
therefore did not impad the model at a11.1nitia11y, it
Was believed thatthese women did not rely on a part、
ner and instead sodalsupport from friends was what
There are a fe、v additional significant relation、
Sion wei号ht of -33. Therefore, to enhance sense of
belonging, health care practiuoners wi11need to explore
Ways to enhance a woma11feeHng valued and 丘ttin号 in
because these characteristics pertain to the childhood
maltreatmentthewoman experiencedin the past.1Ssues
related to childhood family violence are important to
addressin pregnancybecause it appearsto impadlone・
Iiness (indirecuy) and depression postpartum (direcdy).
In fad,the total effed ofchildhood family violence on
PPD was .17, and this variable had the fourth largest
totalimpad on ppD.
Another signi6Cant relationship to note lvas that
Parenting sense of competence in the postpartum 、vas
the 今reatest predictor variable ofimpaired bonding and
had almost 6Ve times the impad on impaired bonding
Compared to perceived support from family, friends,
impacted impaired bondin3, sense of belon3ing, and
and apartner. Thisfinding is noteworthybecausehealth
PPD; however, a posthoc analysisrevealed that 883% of
Women with more sDD had no partner, whereaS 87.6%
Care practitioners may assess for parentin号 Sense of
Competence in pre8nancy and enhance those women
1'418
Ofwomen W北h less sDD had apartner. FinaⅡy,the path
237
-1.644
-4.667
.016
-2,915***
With low perceived competence sMⅡSthrough informa・
tional and emotional support strategies (e.g., parentins
education dasses). parenting sense of competence is
.807
-0.079
.794
-0357
-0.968
.545
-1217
.652
-0.079
importantto enhancein women who perceivelow com・
Petence asthe path to impairedbondinghas a standard、
1.867
.066
1.469
.182
-0265
丘om perceived sodalsupport 丘om 丘iends to ppD
Was different for、vomen with more sDD as opposed to
Women with less sDD. Again, women with more sDD
in this study appeared to rely on friends more than a
Partner or even family, and this perceived support from
friendships (orlack of)、vas、vhat had a directimpad on
1.069
.000
0.583
.007
-2.025**
depression.1tis also importantto mention thatthe path
bonding).
Sense of belonging
-0.759
.198
-0.545
.368
0253
Healthcare A川ance
-0312
021
-0386
026
-0333
Impaired bonding
Loneliness
Ufetime lpv
Childhood family
↑↑↑
PDSS
P
Childhood family
↑↑↑↑↑↑↑↑↑
Loneliness
ESTIMAT圧
ChⅡdhood family
↑↑↑↑↑↑↑↑↑↑
Sense of belonging
Impaired bonding
Impaired bondin8
Impaired bonding
MORESDD (n = 193)
Violence
Impaired bonding
Notes:1PV = intimate partner violence; parentin名 SOC = paTentin名 Sense ofcompetence; PDSS = postpartum Depression screening scale;
←= direction of壮le relationship
re号arding women with more sDD isthatthe trajectory
Ofviolence for these women continues from their own
"P く.10.""P く.05."""P く.01.
Perceived sodalsupportpathsthathad a dired effed on
depression and induded the quality ofthe love relation・
Ship (partneT quality) path and the health care aⅡiance
Path. There certainly lvas research that supported the
notion that partner support (or lack of) affects ppD
(described earlier); hoNvever, the surprisin号 direct path
result was the strength of the standardized regression
from health care practitioner a11iance to ppD affected
both groups; howeve二 for women with more sDD,the
inauence waS 40% greater.
The overa11 message that is important to note
estimate for health care aⅡiance (ー.1D because this
Variable 刃Vas the third strongest predictor variable to
PPD. This result is important for health care practitio・
ners because their relationship with their pauents mat・
terand to the extentthat postpartumwomen who share
an a11iance 、vith their practitioner have less depressive
Symptoms. ThiS 丘nding that a positive a11iance with
birth until pregnancy because 11% of these 、vomen
experience current lpv as compared to women with
10W SDD who essentiaⅡy do not experience lpv at
ized beta wei8ht of -.49 and the path from parentins
Sense ofcompetenceto ppD .21(indired e丘ed through
Another signi負Cant 6nding ofthis study was that
10neliness in the postpartum period had a direct effed
On ppD as weⅡ as on impaired bonding ltisimportant
to hi8hlightthatloneliness Nvas measured a丑er the birth
Ofthe baby and a possible explanation for the relation、
Ship between loneliness and ppD is that the mother
may feelcut 0丘from her normalroutine and prior way
Oaife.
With more sDD do not have partners, which may be
Impairedbondin3hadthe号reatestimpadonppD
Of a110f the independent variables, with a standardized
regression 、veight of 36 for the dired ef企d.1mpaired
a healthy situation 迂 these 、vomen severed an abusive
bonding also indirecdy affected ppD through loneli、
a11(1 0ut of 371 Women).1n addition,
n)any wolnen
relationship (Kruse et al.,2013), which meanstheyneed
to rely on others to meet their sodal support needs.
Data 丘om this analysis indicate that the primary sup・
ness for a total effed of .43.1tis very important to note
that the diredion of this relationsh中 is in the opposite
direction from most theories,、vhich consider that
164 A Relational Model for Depression Kruse et a/
impaired bonding, that is, subjecuve lack of doseness
With the infant, is an outcome of maternal depression.
Results of this sEM indicate that it is also a risk fador
for maternal depression. This is consistent with this
relational theory of depression,、vhich posits that dif・
負Culties in or inadequate relauonships increase risk of
depression,induding difflculties in the maternal-infant
dyadic relationship. Because bonding be名ins during
Pregnancy (Klaus, Kenne11,& Naus,1996), assessing
both parenting sense ofcompetence and prenatal"tak・
加g m"(Rubin,1967) ofthe child would aⅡOw for both
depression and parenting preventive work ahead ofthe
birth. Recognizing, achlowledging, and addressing the
mother's concerns or feelings ofdetachment might have
the additional bene6t of strengthening her sense of
being cared for,the aⅡiance with the care providers, and
Sense of belonging to the proportion of mothers who
Strug号le W北h such experiences.
There are severa11imitations to this study The
6ndings may not be generalizable to multiparous
Women, women who are not pregnant, and men.1n
addition, because this 、vas a secondary analysis ofdata,
there were several proxy variables that wel'e created.
This is notto say thatthese proxies 、vere not reliable or
Valid; ho、vever, the variables of sense of belongin3 and
10nelinessin particular mayhave been more true to the
Concept had an established, reliable measure been used.
That being said, feelin号 Cut'0丘is related to the Di4S110S・
tic and st4tistiC41 ハ1411U41 qf入le11t41 Disorders (4th ed.;
DS入1-1V) criteria 血r pTSD of feeling detached from
Others, and it was hypothesized that this description
might be a more accurate reaection ofa 、vomads situa・
tion immediately a丘er birth.
Despite these Hmitations, there were some major
Stten8ths of this research. The proposed model pro・
Vides evidence that 35% of the variance in depres・
Sive symptoms may be explained by the independent
Variables and that impaired bonding and loneHness
explained the most variance with estimates of 036
and o.23, respectively The novel result, that impaired
bonding might be a cause ofppD ratherthan an e丘ed,
is supported by the sEM model fit statistics. Another
major strength ofthis research was thatsodalsuppoTt
Was examined according to "wpe of helperl' This was
important because it was very dearin the analysis what
type of helper had the most inauence on each of the
Variables. A 丘nalstren8th ofthis research Nvas thatthis
Studywas prospecuve;therefore,the data forthe model
Variables on the left side of the model 、vere c0Ⅱected
before the data on the right,1ending support to causal
reasonlng.
A Relational Modelfor Depression 1ぐruse et a/.165
Another major strength of this research is that
it has the potentialto impad practice. For example,
interpersonal psychotherapy σPT) is one ofthe major
Psychotherapeuuc treatments used for women with
PPD, with a focus on the four treatment areas of srief
and loss, role transitions, interpersonal sensitivity, and
interpersonal disputes (いleissman, Markowitz,& Kler・
man,2007). solving interpersonal disputes is a priority
Step, although addressing the root of the relationship
Problem when lpT dients have a history of lpv and
Childhood maltreatment is a more long・term proposi・
Uon. Results ofthis study suggestthatlpT and parent・
ing education programs could have even be廿er ef企Cts
ifthey were modified to prioriuze the needs ofwomen
reporting feelings of detachment 丘om their upcoming
infant during pregnancy
CONCLUSION
The proposed relationalmodelofppD testedwith these
data gives insight into the additional risk fadors for
PPD: sense ofbelon3ing and impaired bonding. There・
fore, a 61ture research direction would indude examin・
ing these variables, with established reliable and vaHd
instruments, t0 丘lrther validate the theory that sense
Of belonging and impaired bonding truly impad ppD.
Meanwhile, the results of this research give health care
Practitioners insight into the key variables for ppD and
enrich options for assessment duringpregnancyand for
PotentiaHnterventionsto decrease the t0Ⅱ ofdepression
in the postpartum.
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Correspondence regarding this article should be directed
to lulie A. Kruse, phD, RN,1.ourdes university c011ege of
Nursing,6832 Convent Blvd., sylvania, OH 43560. E・mail:
[email protected]
AnE^10ratorysuNeyofl,OW'・Riskpre名na11t
叉VomenlsperceptionsofAntenatalcareand
Julie A. Kruse, phD, RN, assistant professor,1,ourdes
University c011ege ofNursing, sylvania, OH.
SeNicesi11Southern lreland
Reg A. wiⅡialns, phD, RN, FAAN, professor emeritus,
University ofMichigan scho010fNursing, Ann Arbor, MI.
、
Iulia s. seng, phD, CNM, FAAN, assodate professor,1nsti・
tutefor Research on women and Gende二 Universityof
Michigan, Ann Arbor, MI.
Aπ11ette 入11ιrphy, joh11 Wre11S, patricia chesser・S111yth,ιi11d4 She侃h侃11,
n11d Miche11e Foley
Ireland curTendy hasthe hi8hest birthrate ofthe 27 European union countTies which hasled to an
increase in demand for maternity services.1n the lrish Republic, most maternity units have tradition・
a11y f0ⅡOwed the medical-1ed modelofcare, which, as a result, haslimited 、vomel)'s choice for mater・
nity care. Nthough various different midwifery・1ed schemes are available, concerns existregarding the
knowledge and accessibility ofthese schemes.
The aim ofthis descriptive, exploratory surveywasto explore and determine the vie、vs of"10W・risk"
Pregnant women (π= 394) re8ardin8 their antenatalcare and services. A purposive homogeneous
Sample comprised the 6rst phase ofa mixed methodsstudy and data were analyzed using predictive
Ana1γtics s0丘Ware. The findingsidenti丘ed a lack ofawareness and understanding ofthe concept ofa
10W-risk pregnanq. consequent1γ, women identi負ed an overalHack ofinformation 飢d an inability to
access available options for their care.
KEYWORDS:10W・risk women; accessto midwifery・1ed care; choices for antenatalcare; provision of
information
INTRODUC110N
』1
In lreland, maternity care is provided free of charge
Usingthe Maternity and lnfant care schemeto aⅡ those
residing in lreland since 1954. The ptovision ofantena・
talcare under this scheme involves alternating antenatal
Visits with a 3eneralpractitioner and a hospital obstetri・
dan. other models ofcare exist such as midwifery・1ed
Units also opeTate antenatal clinics run exdusively by
midwives in the hospitals, and midwifery・1ed clinics are
also provided in communitysettings klown as outre4Ch
diπics. These midwi企ry・1ed schemes are not yetincor・
Porated underthe Maternityand lnfant care schemein
the provision ofantenatalcare forlow・risk women.
Midwives are spedalists in normal pregnancy
and provide woman・centered care (Nationa11nstitute
Care schemes that have been available in lreland since
for Health and clinical ExceⅡence [NICE],2008).
2000. The establishment offour "DOMINO"(DOMi・
Midwifery・1ed care is recommended as being the best
type ofcare for low・risk pregnant women (Be81ey et al.,
Ciliary care lN and out of hospital) schemes was in
response to the requests of pregnant mothers (Health
Service Executive [HSE},2004).1reland now operates
two midwifery・1ed units whicbwere established in 2004,
and a randomized contr011ed trialhas been undertaken
exploring the provision care for the low-risk woman in
the lrisb context (Begley et al.,20ID. some maternity
2011; Hatem, sanda11, Devane, soltani,& Gates,2008;
NICE,2008). The evidence is dearthat women in mid・
Wife・1ed units spend shorter periods in labor, had fewer
interventions, and more likely to have a norma11abor
(Mead & Kornbrot,2004; symon, paul, Butchart, carr,
& Dugard,2007; walsh & Devane,2012).1ndeed,it has
U五
゛、三
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169