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DOI 10.1007/s00737-016-0614-8
ORIGINAL ARTICLE
* Yvonne J. Fontein-Kuipers
j.a.c.a.fontein-kuipers@hr.nl; defonteintjes@gmail.com
Introduction
Maternal distress refers to different psychological constructs
occurring during pregnancy, most commonly identified as depression and anxiety in general or specifically related to pregnancy that are significantly correlated (Heron et al. 2004;
Fontein-Kuipers et al. 2015b). Maternal distress has adverse
health consequences. Maternal distress is associated with maternal short and long-term (chronic) postnatal mental health
problems, including post partum depression. Maternal distress
is also associated with the physical, neurobehavioral, and cognitive development of the child (Brouwers et al. 2001; Mulder
et al. 2002; Heron et al. 2004; Mennes et al. 2006; Van den
Bergh et al. 2008; Loomans et al. 2012).
It is difficult to report exact prevalence rates of maternal
distress because it is a compilation of different psychological constructs with no validated psychometric tool
for measurement (Nast et al. 2013). Using a maternal
distress score compiled from different one-dimensional psychological constructs, we found a prevalence rate of 22 % in a
Dutch population of women with healthy pregnancies
(Fontein-Kuipers et al. 2015b).
April 2013 and 7 March 2014 for the control group, and between 14 April 2014 and 9 March 2015 for the experimental
group (Fig. 1). The control group received antenatal care-asusual, provided by the midwifery practices. The data for both
cohorts were collected during the first trimester of pregnancy
(T1) and during the third trimester (T2). T1 was at 7 (SD 2.2,
range 414) weeks gestation, before women had their first
physical appointment (a booking appointment and/ or scan)
with their midwife. T2 took place at 37 (SD 1.53, range 35
42) weeks gestation. Each questionnaire was followed up by
two reminders with 1 week interval for each reminder.
Midwives or practice assistants approached women about
the study during womens registration telephone call. Women
were verbally informed about the topic of the study and were
told that their involvement would consist of filling out two
questionnaires at two time points during pregnancy. If women
were willing to participate, their email addresses were
forwarded to the researcher (Y.F.). Additional information
about the study and an invitation to participate in the first
Control group
Experimental group
T1 215 completed
ques onnaires returned
(response 72.8%)
T1 218 completed
ques onnaires returned
(response 80.1%)
25 pregnany losses
32 pregnancy losses
T2 165 completed
ques onnaires returned
(response 55.9%).
Reasons for a ri on:
immature birth (2);
intra uterine death (1);
premature birth (3);
maternal illness (8); too
busy (7); no specific
reason (4)
T2 178 completed
ques onnaires returned
(65.4%). Reasons for
a ri on: immature birth
(1); premature birth (1);
transfer to other prac ce
not par cipa ng in the
study (3); incorrect
emailaddress (1): no
specific reason (2)
Methods
Design and sample procedure
When we drew the project plan, we considered conducting a
randomized trial to test the effect of the intervention. Power
calculation showed that a minimum of 46 midwifery practices
would be necessary to conduct the study. We decided that is
was more feasible to conduct a non-randomized pre-post intervention study with a sequential control and experimental
group. Using the design, we needed a more manageable number of midwifery practices, 16, to detect a small effect.
In our study, we included two cohorts of healthy Dutchspeaking women in midwifery-led care. Women with (pre-)
existing medical conditions at the point of registration, requiring medical and/ or obstetric care were excluded. Pregnant
women from 17 midwifery practices, situated in the
Southern, Mid-Eastern, and Northern regions of the
Netherlands were recruited for the study. Midwifery practices
were recruited using convenience sampling.
Recruitment of the participants and data collection for the
control and experimental group were carried out in two sequential time periods in the participating practices, between 24
(PRAQ), and maternal distress (MD). To justify our multidimensional approach, we measured the degree of relationship
between the EDS, STAI, and PRAQ scores with Pearsons
correlation coefficient (one-tailed), which showed significant
moderate to very strong positive correlations (Table 1). We
calculated descriptive statistics for the socio-demographic factors and personal characteristics. We compared socio-demographic, personal characteristics, and the baseline maternal distress scores between the two groups, using chi-square tests and
analysis of variance. We conducted logistic regression to evaluate the factors that are related to responding and nonresponding participants in both groups. We used the observed
data for the comparison of baseline characteristics and for comparison of responders and non-responders.
To handle the at random missing values in the response
process of our study, we imputed missing values using maximum likelihood methods (expectation maximization) (Field
2009). In addition, we performed a multivariate repeatedmeasures design to examine the within-group changes of maternal distress among pregnant women who received antenatal
care-as-usual (control group) and women who received the
intervention WazzUp Mama?! (experimental group). The conjunction of these methods is fully consistent with intention-totreat (ITT) (Molenberghs et al. 2004).
Our effect analyses focused on the within-group and
between-group differences of MD scores in change from baseline (T1) to post-intervention (T2), to describe and compare
the change of direction in both groups and to assess the
between-group difference. We examined the within-group
changes by comparing baseline (T1) and post-test (T2) means
for EDS, STAI, PRAQ, and MD scores within both the control
and experimental group with multivariate repeated-measure
analysis. We compared the proportion of women with scores
above the cut-off levels of the respective measures using chisquare tests (Field 2009) in both the control and experimental
group at T1 and T2.
To select the dependent variable to determine the effect of
the intervention without losing statistical power, we checked
the assumptions for multicollinearity with Pearsons correlation coefficient (two-tailed) between MD and EDS, STAI, and
PRAQ (Field 2009). As expected, there were very strong positive Pearsons correlations between MD and the respective
measures depression (r = 0.802, p < 0.001), anxiety
(r = 0.925, p < 0.001), and pregnancy-related anxiety
(r = 0.718, p < 0.001). We therefore chose MD as our dependent variable and performed analysis of covariance
(ANCOVA) to determine the effect of the intervention and
significance of differences between the control and experimental group for the post-test MD scores. We entered the
baseline MD scores and parity, planned pregnancies, lifeevents 1 year prior to pregnancy, history of miscarriage, income, use of medication, and history of psychological/
psychiatric problems as covariates to control for initial
Control T1
Control T2
r = 0.75 p = <0.001
r = 0.89 p = <0.001
r = 0.32 p = <0.001
r = 0.65 p = <0.001
r = 0.36 p = <0.001
r = 0.68 p = <0.001
Experimental T1
r = 0.79 p = <0.001
r = 0.42 p = <0.001
r = 0.49 p = <0.001
Experimental T2
r = 0.86 p = <0.001
r = 0.6 p = <0.001
r = 0.66 p = <0.001
Results
Participants
Figure 1 shows the flowchart of the participants in both control and experimental group. Baseline characteristics of the
participants from both control and experimental group are
presented in Table 2. There were no significant differences
between the participants in the control and experimental
group. Reasons for non-responses are presented in Fig. 1.
Logistic regression was conducted to evaluate which independent baseline variables were predictors for responding to both
questionnaires at T1 and T2 (see a in Table 2). Analysis
showed that the having a planned pregnancy significantly predicted responding at T1 and T2. Having an unplanned pregnancy showed decreased likelihood to responding at T2 (OR
0.26, 95 % CI 0.120.55, p < 0.001).
Changes in maternal distress scores within control
and experimental groups
The within-group changes are reported in Table 3. In the control group, the mean EDS, STAI, and MD scores significantly
increased from baseline (T1) to post-intervention (T2)
(p < 0.001, p < 0.001, p < 0.001). Mean PRAQ scores increased but did not reach statistical significance (p = 0.12).
The proportion of EDS, STAI, and PRAQ scores above cutoff level significantly increased from baseline (T1) to postintervention (T2) (p < 0.001, p = 0.045, p = 0.03). The MD
scores above cut-off level increased but not significantly
(p = 0.13). There was 5.6 % increase in the proportion of
MD scores above cut-off level from T1 to T2.
In the experimental group, the mean EDS scores decreased
at T2 compared to T1 but did not reach statistical significance
(p = 0.13). The mean STAI, PRAQ, and MD scores in the
experimental group were significantly lower at T2 compared
Discussion
Main findings
We evaluated the effect of the intervention WazzUp Mama?!
on antenatal maternal distress by examining the changes in
maternal distress among pregnant women after receiving the
antenatal intervention WazzUp Mama?! compared to women
receiving antenatal care-as-usual. Levels of maternal distress
of the participants in the control group significantly increased
Characteristics and baseline maternal distress scores control and experimental group
Control group N = 215
Mean (SD )
Age in yearsa
Gestational age in weeks
Paritya
Nulliparous
Multiparous
N (%)
0.117
1.36
0.385
105 (48.8)
110 (50.2)
103 (47.2)
115 (52.8)
Partnered
Ethnicity respondent a
Respondent born in the Netherlands
Respondent born in other western country
215 (100)
218 (100)
211 (98.1)
3 (1.4)
212 (97.2)
2 (0.9)
1 (0.5)
4 (1.8)
210 (97.7)
205 (94)
4 (1.9)
1 (0.5)
7 (3.2)
6 (2.8)
211 (98.1)
3 (1.4)
1 (0.5)
207 (95)
5 (2.3)
6 (2.8)
69 (32.1)
146 (67.9)
205 (95.3)
82 (37.6)
136 (62.3)
202 (92.7)
16 (7.4)
89 (41.5)
24 (11)
74 (34)
Constant
1.982
4.429
Ethnicity father
4.089
4.081
110 (51.1)
2.92 (1.25) 110 sig/day
None
X2
0
193 (89.8)
40 (18.6)
101 (47)
None
136
3.090
3.395
118 (55)
10 (4.6)
0
195 (89.4)
42 (19.3)
93 (42.7)
2 (0.9)
0.458
0.012
0.031
0.815
1.982
47 (21.9)
35 (16.3)
59 (27.1)
34 (15.6)
1.585
0.038
5 (2.3)
9 (4.1)
1.693
0.05
17 (7.8)
30 (13.8)
18.58 ( 7.01) 1042
5.8 (3.37) 315
7.5 (3.43) 420
0.284
0.311
0.231
0.210
0.034
0.067
0.265
25 (11.5)
1.54
Mean (SD )
MDa
Heightened levels of MDc
a
N (%)
N (%)
X2
0.001
49 (22.5)
0.477
Heightened scores on one of more levels of EDS 11, STAI 41 and/or PRAQ >90th percentile
Table 3
heightened levels of maternal distress after receiving the intervention. Receiving the intervention had a significant moderate
positive effect on maternal distress when compared to those
not receiving the intervention.
Changes within experimental and control group from first trimester (T1) to third trimester (T2)
Measure
T2 (post)
Mean SD ()
7.21
4.69, 126
28.9
9.38, 2062
31.6
10.17, 2072
18.59
5.43
7.66
5.4
7.07, 1042
3.3, 315
3.69, 420
3.08, 315
19.43
6.1
7.68
5.65
7.17, 1042
2.67, 314
3.54, 318
2.85, 315
F (4.21)
17.32
6.65, 062
45 (20.9)
Experimental group (n = 218)
T1 (baseline)
Mean SD (), range N (%)
4.55
3.52, 018
17 (7.8)
28.72 9.58, 2260
30 (13.8)
18.58 7.01, 1042
5.8
3.37, 315
7.5
3.43, 420
5.28
3.11, 315
25 (11.5)
17.28 6.64, 060
49 (22.5)
F (4.21)
9.85, 2063
15.32
6.55, 063
4.42
0.03
<0.001
0.13
p
1.55
X2
0.313
11.1
27 (12.4)
6.42, 1041
2.83, 315
3.19, 317
2.52, 315
0.045
0.12
N (%)
14 (6.4)
15.04
4.68
6.05
4.31
3.27
11.94
57 (26.5)
26.93
<0.001
1.47
7.34, 172
T2 (post)
Mean SD (), range
4
3.4, 024
<0.001
<0.001
16.6
37 (17.2)
19.41
14.74
70.23
43 (20)
22 (10.2)
N (%)
42 (19.5)
29 (13.5)
X2
0.182
47.4
8 (3.7)
9.48
28.69
29 (13.3)
Heightened scores on one of more levels of EDS 11 (T1)/ 10 (T2), STAI 41 and/or PRAQ >90th percentile
6.25
0.13
0.4
0.001
0.4
<0.001
0.002
<0.001
0.009
References
Conclusion
Our non-randomized pre-post intervention study showed
that the intervention WazzUp Mama?! had a significant
effect on maternal distress. In the control group, measuring depression, anxiety, and pregnancy-related anxiety moved in the negative direction while in the experimental group these scores moved in the positive direction. WazzUp Mama?! has a promising effect on maternal
distress when carried out by midwives among healthy
pregnant women.
Acknowledgments The authors would like to thank all the participating midwives, practice assistants, and women who made this study possible and we would like to thank the Promoting Healthy Pregnancy consortium members for their support.
This study is part of the research project Promoting Healthy
Pregnancy, funded by the Regional Attention and Action for
Knowledge (RAAK PRO, ref. 2014). RAAK is managed by the
Foundation Innovation Alliance (SIA) with funding from the Ministry
of Education, Culture and Science (OCW).
Contribution to authorship MN and MA designed the study and YF
collected and analysed the data. YF drafted the first manuscript. All authors interpreted the data, contributed to discussion and reviewed or
edited the manuscript. All authors take responsibility for the integrity of
the data and the accuracy of the data analysis. RdV supervised the study
and is the guarantor.
Compliance with ethical standards Ethical approval was obtained by
the Medical Ethical Committee Atrium-Orbis Medical Centre Zuyd (registration no. 13-N-45 (11-N-101)/11-4-2013). The study was registered
with the Dutch Trial Registration (TC 4688).
Conflict of interest BAll authors declare that: no support from any
organisation for the submitted work; no financial relationships with any
organisations that might have an interest in the submitted work in the
previous 3 years, no other relationships or activities that could appear to
have influenced the submitted work.^