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Page 1: Maternity Blues in Italian Primipara Women Symptoms and Mood States in the First Fifteen Days After Childbirth

8/20/2019 Maternity Blues in Italian Primipara Women Symptoms and Mood States in the First Fifteen Days After Childbirth

http://slidepdf.com/reader/full/maternity-blues-in-italian-primipara-women-symptoms-and-mood-states-in-the 1/22

Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=uhcw20

Download by: [University of Miami] Date: 02 March 2016, At: 19:15

Health Care for Women International

ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20

Maternity Blues in Italian Primipara Women:Symptoms and Mood States in the First FifteenDays After Childbirth

Pietro Grussu & Rosa Maria Quatraro

To cite this article: Pietro Grussu & Rosa Maria Quatraro (2013) Maternity Blues in Italian

Primipara Women: Symptoms and Mood States in the First Fifteen Days After Childbirth,Health Care for Women International, 34:7, 556-576, DOI: 10.1080/07399332.2012.708373

To link to this article: http://dx.doi.org/10.1080/07399332.2012.708373

Accepted author version posted online: 30 Jul 2012.Published online: 11 Mar 2013.

Submit your article to this journal

Article views: 170

View related articles

Citing articles: 1 View citing articles

Page 2: Maternity Blues in Italian Primipara Women Symptoms and Mood States in the First Fifteen Days After Childbirth

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 Health Care for Women International , 34:556–576, 2013Copyright © Taylor & Francis Group, LLCISSN: 0739-9332 print / 1096-4665 onlineDOI: 10.1080/07399332.2012.708373

Maternity Blues in Italian Primipara Women:Symptoms and Mood States in the First Fifteen 

Days After Childbirth 

PIETRO GRUSSUConsultorio Familiare Service of Este, Azienda ULSS 17 Moneslice, National Health Service,

 Monselice; and Faculty of Medicine, University of Padua, Padua, Italy 

ROSA MARIA QUATRARO Hospital Psychology Unit, Gynaecology and Obstetrics Section, Vicenza and Noventa

Vicentina Hospital, National Health Service, Vicenza, Italy 

The maternity blues is the most commonly observed puerperal mood disturbance. In Italy, the mother’s daily affective experience af-ter childbirth has not yet been published. During each of the first 15 days after the birth of the child, 36 primipara women com-

 pleted the Kellner Symptoms Questionnaire (SQ) and the Profile of   Mood States (POMS). We found that the mothers studied showed 

both psychological symptoms and mood disturbances of slight en-tity. Conversely, somatic symptoms were particularly acute in the 

 first few days after childbirth. In this same period, slight anxiety  symptoms, confusion, and bewilderment may develop.

Received 2 February 2009; accepted 14 June 2012.The present research was funded by the  Tutela della Salute Psicologica del Dopo Parto

project (resol. Nr. 72 of 30.03.2000, protocol n◦ 7767) of the Azienda ULSS 10 “Veneto Orien-tale” of San Dona di Piave, National Health Service. Financing was employed by Rosa MariaQuatraro. The authors thank Luigi Casagrande and Maria Gavioli for the support given to theproject. The authors also acknowledge the support of the   ´ equipes   of the antenatal classesof the   Consultorio Familiare  Unit of San Dona di Piave and Jesolo—in particular, Giuseppe

 Vendramin, Gabriella Bertacco, and Nilli Barsi. The authors also especially acknowledge the very important contributions of Maria Grazia Raffa for assistance with data analysis, Gian-Marco Altoe for assistance with statistics, and Donna Wawrykow Spanu for assistance withEnglish grammar and style correctness. A special thanks must also go to all the mothers whoparticipated in this day-to-day study.

 Address correspondence to Pietro Grussu, Consultorio Familiare Service of Este, AziendaULSS 17 Moneslice, National Health Service, Via Marconi 19, 35043 Monselice (PD), Italy.

E-mail: [email protected]

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 Maternity Blues in Italian Primipara Women   557

Changes in postpartum mood are complex and involve biological, psycho-logical, sociological, and cultural components (Halbreich, 2007, 2010). Inreference to such findings, in recent decades numerous studies of women’ssymptomatology in early postpartum have been carried out. Currently in the

literature, there are, in particular, reports of studies conducted in the first daysafter childbirth that have investigated specific associations between certainbiological markers and maternal psychological symptomatology, day-to-day mood changes and symptomatology peaks, and women’s psychological con-dition in a variety of countries and cultural groups.

Maternity blues, otherwise called baby blues, postnatal blues, or post-partum blues, is used to describe the range of women’s symptomatology thatoccurs in the first days after childbirth.

Maternity blues have been related to dysregulated brain responses insusceptible women and to the dramatic changes in hormone levels that

occur after birth (Brunton & Russell, 2008). It is characterized by a range of mild symptoms that include mood lability, sadness, tearfulness, irritability,restlessness, poor concentration, generalized anxiety, worry, and sleep andappetite disturbance. This affective experience of the new mother may begin

 within the first few days after the birth of the child and last from 1 day throughabout 3 weeks postpartum (Henshaw, 2003; Miller & Rukstalis, 1999).

 A possible link has been suggested between changes in the neuroen-docrine system and postpartum mood, and there have been numerous stud-ies in this regard. Studies of biological correlates carried out in womenin the initial days after childbirth have shown associations between serum

testosterone level and depression and anger (Hohlagschwandtner, Husslein,Klier, & Ulm, 2001); low serum allopregnanolone levels and symptomatol-ogy characterized by low mood (Nappi, Petraglia, Luisi, Polatti, Farina, &Genazzani, 2001); reduced plasma cholesterol concentration and major feel-ings of fatigue and depressed mood (Nasta, Grussu, Quatraro, Cerutti, &Grella, 2002); decreased serum zinc concentration and severity of depressivesymptoms (Wojcik et al., 2006); and an association between an increasedcatabolism of tryptophan into kynurenine and depressive and anxiety symp-toms (Maes et al., 2002). Recently, an increase in interleukin-1 beta has

been found on day 14 after delivery in women with symptoms of depres-sion (Corwin, Johnston, & Pugh, 2008). Additionally it has been found thatmonoamine oxidase A levels are elevated at 4 to 6 days postpartum (Sacheret al., 2010).

These studies show the presence of specific associations between cer-tain biological markers and maternal psychological symptomatology. Thesecorrelations, however, are characterized by different levels of statistical sig-nificance. There is, in fact, no multidisciplinary analysis that brings togetherthis scientific evidence in a clear, descriptive, and coherent framework.

Interesting data regarding day-to-day mood changes after childbirth

have emerged from research carried out in the 1980s. Ballinger and

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558   P. Grussu and R. M. Quatraro

colleagues (1979) found no consistent pattern of elation/depression changesduring the first 5 days after delivery. After delivery, during the first weekspent in the hospital, however, it does seem that most women cry at somepoint during the first few hours after delivery; they report symptoms of de-

pression, headaches, dreaming, restlessness, and irritability that peak at days4–6; other symptoms, such as exhaustion, anorexia, and poor concentra-tion tend gradually to decrease over this period. In a study of the periodcovering the first few weeks after giving birth, with discharge from hospitalbetween the fifth and seventh day, Kendell and colleagues (1981) foundthat depression, tears, anxiety, and mood swings increased in the first few days after childbirth, but, thereafter, they decreased slowly and steadily.Conversely, happiness decreased in the early days after delivery, but then itrose steadily. Depression symptoms, tears, and feelings of weakness peakedsharply on the fifth day after giving birth and irritability tended to worsen

during the second week. In the first 8 days after delivery, with dischargefrom the hospital on the third day, O’Hara and colleagues (1990) found that

 women show higher levels of positive moods on the second day after child-birth, after which their mood tended to worsen until day 8, when overallmood began to improve again. Conversely, negative mood decreased in thefirst 2 days after the birth of the child, then rose over the following few days.

Much more plentiful—the offshoot of studies that were first reportedmore than 50 years ago—is the scientific evidence available in the literatureregarding the maternal psychological condition cited by various researchersas “maternity blues.”

Subsequent to the pioneering work of Maloney (1952), the psychologicalaspects of maternity blues have been studied in a variety of countries andcultural groups (Adewuya, 2005; Condon & Watson, 1987; Hau & Levy, 2003;Manly, McMahon, Bradley, & Davidson, 1982; Murata, Nadaoka, Morioka,Oiji, & Saito, 1998; Stein, 1980).

In general, African mothers are known to somatize their symptoms(Goldberg & Bridge, 1988) and place much emphasis on childbearing(Adewuya, 2005). Asian women—for example, Japanese and Chinese—alsotend to express their postnatal depressive condition through a symptomatol-

ogy characterized predominantly by somatic aspects (Park & Dimigen, 1995).In particular, Japanese women tend to describe their postpartum distress by reporting predominantly physical problems or complaining of concerns re-garding the care given to the newborn (Yoshida et al., 1997). Alternatively,new mothers in Europe and in North America tend, for the most part, toemphasize affective symptomatology (Park & Dimigen, 1995).

Studies of maternity blues peaks also report inconclusive findings. Forexample, peaks of blues have been noted in the first few days after childbirth(Kendell et al., 1981), at days 4–6 (Stein, Marsh, & Morton, 1981), at day 5(Adewuya, 2005), and at days 3–8 postpartum (O’Hara, Zekoski, Philipps, &

 Wright, 1990). The maternity blues peaks seem to depend on the assessment

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 Maternity Blues in Italian Primipara Women   559

method used, timing of the assessment, mode of delivery, and time of dis-charge from hospital.

In that regard, Henshaw (2003) recommends future investigations of maternity blues with particular attention to the methodological aspects per-

taining, above all, to the range of symptoms, timing, and measurement of affective experience. Moreover, the presence of important differences on theaffect of childbirth relates to societal and cultural responses to parenthoodand the existing family structure (Cox, 1999; Stern & Kruckman, 1983), sug-gesting a need to improve the knowledge of women’s early puerperal mooddisturbance in different countries/cultures.

In Italy, studies about the mother’s daily affective experience after child-birth have not previously been published. In the current study involving asample of Italian women, we investigated the daily levels of a wide rangeof symptoms and mood states, and the relationships between these two

 variables.Specifically, we have three main aims. The first is to test the hypothesis

that somatic symptomatology is major in the initial days after the birth of thechild. The second is to verify that psychological symptomatology and mooddisturbance may be major in the 3 to 8 days after delivery. The third is totest the hypothesis that high levels of somatic and psychological symptomsmay be associated with high mood disturbances and vice versa. To test thesehypotheses, women’s somatic and psychological symptoms and mood states

 were measured daily in the first 15 days after childbirth.

METHOD

Sample

The study was carried out in the province of Venice, Veneto Region,in North East Italy. A random sample of 50 primipara women attendingantenatal classes at the   Consultorio Familiare   Unit of San Dona di Piaveand Jesolo, Azienda ULSS 10 “Veneto orientale ” of the National HealthService, were approached during the last trimester of pregnancy and were

asked to participate in a prospective study of the psychological aspectsof the first days after childbirth. All the women involved were primipara;Italian by birth, residence, and culture; 23–38 years old (x   =   31.2); welleducated; employed; and married to, or cohabiting with, the baby’s father.The pregnancy was single and with no medical complications. Participationin the research was voluntary, free of charge, and without compensation.

The final statistical analysis does not include data for 14 participants(28% of the original sample): three women who partially completed the day-to-day psychological questionnaires, three women with newborn babies withmedical problems, and eight women who delivered with different caesarean

sections.

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560   P. Grussu and R. M. Quatraro

Of the initial 50 primigravida volunteers involved in this study, therefore,only 36 women formed the final true sample that was statistically analyzed(72% completion rate).

Pregnant women who use the services of the   Consultorio Familiare 

Unit of San Dona di Piave and Jesolo usually have their babies in small localhospitals (San Dona di Piave, Portogruaro, Motta di Livenza, and “Villa Salus”of Mestre), where there are between 500 and 1,200 deliveries per year. Whenphysiological delivery is normal, after a full-term pregnancy, these hospitalsusually discharge mothers 4–5 days after the birth.

Furthermore, and importantly, the primipara mothers involved in thestudy all had low social and medical risk profiles. Using low risk as criteriafor inclusion permitted us to evaluate the effects of maternal psychologicalreactions after childbirth while minimizing the influence of confounding riskfactors (e.g., premature birth, caesarean section, single marital status, teen

motherhood, parity) known to affect parenting and infant outcome. Suchobservations are supported by several scientific publications on the subject(Corcoran, 1999; Moore, 2003; Ruchala & Halstead, 1994).

For example, a review by Lobel and DeLuca (2007) showed that in thefirst days after childbirth, women who give birth surgically by caesareansection have a more negative perception of their birth experience, of them-selves, and of their infants; they exhibit poorer parenting behaviors; andthey may be at higher risk for postpartum mood disturbance compared with

 women delivering infants vaginally.Furthermore, different caesarean deliveries were shown to have diverse

impacts on women’s postpartum emotional states. In this regard, Lobel andDeLuca (2007) distinguish “unplanned” and “planned” caesarean delivery to indicate whether women have foreknowledge that they will deliver sur-gically. Planned caesareans are sometimes labeled “elective.” Unplannedcaesareans are divided into two categories: “labored caesareans”—when ce-sarean birth is performed after labor—and “emergency caesareans”—whichare performed prior to labor. Moreover, a smaller portion of planned cae-sareans are performed without medical indication or “on maternal request.”

 Waters and Lee (1996) found that at 1 month postpartum, multiparas

displayed higher functional status, less sleep disturbance, less fatigue, andmore vitality compared with primigravidas.Therefore, this day-to-day Italian postpartum study takes into consid-

eration only first-time mothers with normal at term pregnancies, vaginaldelivery, and a healthy living child.

Procedure

The Committee of the  Consultorio Familiare  Unit approved the study pro-tocol and the assessment procedures. Personal data of participants were

processed in conformity with the Italian Data Protection Act.

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 Maternity Blues in Italian Primipara Women   561

Two psychologists, who were unaware of the reason for the study,asked the women if they would agree to participate during the last threemeetings of their antenatal classes. Participants were informed of their rightsand signed a consent form approved by the institutional review boards of 

the  Consultorio Familiare  Unit. After giving their written informed consent, each pregnant woman re-ceived a 15-page file containing the Italian versions of the Kellner SQ (Fava& Kellner, 1982) and the POMS (Farne, Sebellico, Gnugnoli, & Corallo, 1991),

 which were to be filled in each day starting from the first day after delivery.The women were shown how to fill in the questionnaires and were asked tofill in the forms at the end of each day over the 15-day period after delivery.

 As in Kendell and colleagues’ study (1981), the participants were told that if the baby was born before 12 midday, the day of childbirth was counted asDay 1, but if the baby was born after 12 midday, the following day was Day 

1. When a woman registers for an antenatal class, usually in the sixth

to seventh month of pregnancy, the registered midwife of the   Consultorio Familiare   Unit asks them to fill in a brief background questionnaire thatincludes questions about the number of children they have had and othersociodemographic variables.

Rating InstrumentsThe participants completed a day-to-day self-assessment of their psy-

chological and somatic symptoms using the Italian version of the Kellner SQ(Fava & Kellner, 1982; Kellner, 1987), and of their mood states disturbancesusing the Italian version of the POMS (Farne et al., 1991; McNair, Lorr, &Droppleman, 1981).

 Kellner Symptom Questionnaire (SQ).   The SQ permits identificationof the clinical state, both temporary and modifiable over time, of the sub-ject and makes it possible to distinguish between psychologically suffering

patients and normal asymptomatic individuals. The SQ is a self-evaluationtool designed to reveal symptoms, it is made up of four scales: (a) anxiety,(b) depression, (c) somatic symptoms, and (d) hostility. The anxiety scalemeasures uncomfortable feelings of tension, uneasiness, fear, and worry. Thedepression scale measures the symptomatology characterized by sadnessand/or by feelings of uselessness, inferiority, failure, self-disgust, inability tocope, and guilt. The somatic symptoms scale, identifies a number of symp-toms of psycho-physiological origin such as nausea, lack of appetite, feelingsof suffocation, headaches and feelings of heaviness in the limbs. Last, thehostility scale measures feelings and behavior that express aggression, anger,

impatience, irritability, and disgust with others.

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562   P. Grussu and R. M. Quatraro

 Women were asked to respond to each, item taking into considerationthe symptoms felt during the day they were reporting in the questionnaire.For each of the 92 items that make up the SQ, the subject could answerchoosing from either yes/no or true/false options. Each answer scores either

0 or 1. The value of the specific symptomatology is obtained from the sumof the scores of each single item. The four main SQ scales of evaluationare each made up of 23 items. A high final score reveals a high level of psychological suffering in the individual and a low score indicates a lowerlevel of suffering.

The total score of the symptoms (SQ total) was calculated for each woman using the arithmetical sum of the scores obtained from every subjecton the four SQ scales.

The results obtained in the Italian validation of SQ and the Englishoriginal are similar. In particular, the findings of Fava and colleagues (1983)

suggest that the Italian translation of SQ is a valid and sensitive scale of distress and can apparently be used as effectively in research as the original.

 As indicated by the authors (Kellner, 1976; Pollina et al., 1992), there isa cut-off score of 8 for the anxiety scale, 8 for the depression scale, 7 for thesomatic symptoms scale, and 9 for the hostility scale.

Often SQs have been used for research on motherhood in order to ex-plore the apparent social mediation of postpartum illness (Becker, 1998);determine the impact of partner support in the treatment of mothers suf-fering from postpartum depression (Misri, Kostaras, Fox, & Kostaras, 2000);and to evaluate the effectiveness of   Venlafaxine   in the treatment of major

postpartum depression (Cohen et al., 2001). Profile of Mood States (POMS).   The POMS consists of 65 adjectives,

describing feelings and moods, to which the subject responds answering ona 5-point scale. It was designed specifically for use as a research instrument

 when assessing changes in affective states during events or during interven-tions in psychologically normal adults. The 65 items are distributed into sixsubscales: five negative mood states and one positive. It is also possible tocalculate a total score of mood disturbance, known as the POMS total, by adding the scores of the five subscales for the negative mood states and

subtracting the score for the vigor–activity subscale from this total.The five negative mood state subscales follow: (a) tension–anxiety thatdetermines both the subjective state and the somatic experience of anxi-ety; (b) depression—dejection, which taps feelings of inadequacy, isolation,guilt, futility, and sadness; (c) anger–hostility that examines overt hostility and irritability; (d) fatigue-inertia, which draws upon feelings of weariness;and (e) confusion—bewilderment, which assesses efficiency and clarity of thinking. The single positive mood state subscale is VI, vigour–activity, whichexamines well-being, enthusiasm, liveliness, energy, and optimism.

The participants were asked to respond to each item, taking into consid-

eration the feelings and moods felt during each day they were completing

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 Maternity Blues in Italian Primipara Women   563

the questionnaire. For each of the 65 adjectives that make up the POMSitems, the range of responses was from 0 (not at all) to 4 (extremely). In the

 vigor–activity subscale, which is related negatively to the other five POMSsubscales, high score is given for a greater level of enthusiasm and optimism.

Conversely, greater levels of mood disturbance correspond to high scores onthe remaining five POMS subscales and on the POMS total. At the moment we do not know the appropriate cut-off scores for the POMS total, POMSsubscales, or all of these.

In the study to evaluate the psychometric properties of the Italian versionof POMS, the result of construct validity and reliability obtained by Farne andcolleagues (1991) overlap those of the original version of the POMS used

 with U.S. populations.The POMS has been used in motherhood research to compare the stress

and birth outcomes of women who experienced preterm labor during preg-

nancy with those who did not (MacKey, Williams, & Tiller, 2000); to investi-gate the associations between the levels of serum testosterone and maternalperipartum mood states (Hohlagschwandtner et al., 2001); and to exploreemotional reactions in infertile couples who have received fertility treatment(Hsu & Kuo, 2002).

Thus, in this research we used two self-evaluation questionnaires withspecific psychometric characteristics: POMS, which allows a study of emo-tions through the analysis of subjective aspects connected to sensations,affection, and moods, and SQ, which is more oriented toward the evaluationof symptoms.

RESULTS

The POMS and SQ data were analyzed using the Statistical Package for theSocial Sciences (SPSS) 11.5 for Windows (2003). A probability level of  p  < .05

 was used as the criterion for statistical significance in all analyses reportedbelow.

SQ Data

The first step in this analysis was to use the Cronbach   α   in order to calcu-late the reliability between the four SQ scales (anxiety, depression, somaticsymptoms, and hostility) on single days. Overall, the global construct couldbe considered reliable in that, over the 15-day period studied, the Cronbachα  between the four SQ scales varied from 0.77 to 0.90.

The total SQ obtained over the 15-day period was then used to calculateconstruct stability using the Pearson correlation. This analysis revealed goodstability. In particular, subjects with higher scores on the first day also had

higher scores on the fifteenth day (r   = 0.53,  p  < .01,  n   = 36).

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564   P. Grussu and R. M. Quatraro

Five repeated ANOVA measures were then made. Each dependent vari-able SQ total, anxiety, depression, somatic symptoms, and hostility was con-sidered separately, with one within-subject factor “Time.”

Given that the hypothesis of sphericity (Keppel, 1991) was not satisfied

in any of the five analyses, the Greenhouse-Geisser criterion was used toevaluate the results. This criterion revealed that the effect of the time factor was significant for the variables: SQ total,  F (6.51, 227.86),  p  <  .001; anxiety, F (6.86, 240.04)   =  4.1,   p   <   .001; and somatic symptoms, F(7.71, 217.61)   =

15.66,  p   <  .001. Both means and standard deviations of the SQ’ scores areshown in Table 1.

Further analyses, the planned comparison of the main effects, revealedstatistically significant linear-type effects for the following variables: SQ total,

 with F(1, 35)   =   19.93,   p   <   .001, and anxiety, with   F (1, 35)   =   18.62,   p   <

.001; while for the somatic symptoms factor there was a linear-type effect,

 F (1, 35)   =  58.34,  p   ≤ =   .001, and a quadratic-type effect, F(1, 35)   =  7.11,

 TABLE 1  Means and Standard Deviations of SQ Scores

Scales days Anxiety Depression Hostility Somatic symptoms SQ total

1 x 6.58 4.11 1.72 9.58 22SD    (5.17) (3.11) (2.04) (4.31) (11.78)

2 x 5.94 4.22 1.83 8.47 20.47SD    (5.5) (4.4) (2.44) (4.42) (14.06)

3 x 6.25 3.89 1.47 7.56 19.17

SD    (6.18) (4.35) (2.44) (4.7) (15.28)4 x 7.42 4 2.22 6.83 20.47

SD    (5.94) (4.06) (3.09) (4.88) (14.78)5 x 7.28 3.58 2.06 7.08 20

SD    (5.99) (3.89) (3.25) (5.37) (16.23)6 x 5.64 3.44 1.78 6.17 17.03

SD    (5.19) (3.64) (2.53) (4.88) (14.11)7 x 4.75 3.11 2.03 5.44 15.33

SD    (4.38) (2.95) (3.23) (4.33) (12.35)8 x 5.67 4.06 2.81 4.92 17.44

SD    (4.96) (4.02) (3.89) (4.18) (14.27)9 x 4.94 2.97 2.36 4.72 15

SD    (4.81) (3.52) (3.68) (4.13) (13.4)10 x 4.94 3.89 2.53 4.5 15.86

SD    (5.09) (4.29) (3.29) (4.48) (15.15)11 x 4.56 3.44 2.36 4.14 14.5

SD    (4.75) (3.62) (3.06) (4.3) (13.15)12 x 4.36 2.78 2.36 4.22 13.72

SD    (4.62) (3.49) (3.56) (3.98) (12.91)13 x 4.5 2.89 4.47 4.47 14.47

SD    (5.37) (3.76) (5.03) (5.03) (15.53)14 x 3.61 2.64 1.78 3.22 11.25

SD    (4.5) (3.36) (3.02) (3.7) (12.4)15 x 3.28 2.31 1.58 3.14 10.31

SD    (3.75) (2.77) (3.01) (3.59) (10.59)

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 p   =   .01. Given these results we decided to explore the effect of the timefactor on these three variables in greater depth. Graphs and relative couplescomparison of SQ total, anxiety, and somatic symptoms scores in time levelsusing the Bonferroni correction are shown in Figure 1.

Thus, day-to-day compilation of the SQ by the women in the samplerevealed a significant level of psychological and somatic symptoms, which

Couples comparison of SQ total scores in time levels

SQ total (p <.001)

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Days after delivery

   L  e  v  e   l  o   f  s  y  m  p   t  o  m  s

* p<.05

  Couples comparison of SQ Anxiety scores in time levels

SQ Anxiety (p <.001)

0

2

4

6

8

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Days after delivery

   L  e  v  e   l  o   f

  s  y  m  p   t  o  m  s

* p<.05

Couples comparison of SQ Somatic symptoms scores in time levels

SQ Somatic symptoms (p <.001)

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Days after delivery

   L  e  v  e   l  o   f  s  y  m  p   t  o

  m  s

  * p<.05

 Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1 -- * *

2 -- * *

3 --

4 -- *

5 -- *

6 --

7 --

8 --

9 --

10 --

11 --

12 --

13 --

14 * * --

15 * * * * -

 Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1 -- * *

2 --

3 --

4 -- * *

5 -- * *

6 --

7 --

8 --

9 --

10 --

11 --

12 --

13 --

14 * * * --

15 * * * -

 Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1 -- * * * * * * * * * * *

2 -- * * * * * * * * *

3 -- * * * * * * *

4 * -- * * * * *

5 -- * *

6 * -- * *

7 * * --

8 * * --

9 * * * --

10 * * * --

11 * * * * --

12 * * * * --

13 * * * * --

14 * * * * * * --

15 * * * * * * -

FIGURE 1   Graphics of SQ total, SQ anxiety, and SQ somatic symptoms day-to-day scores,and relatives couples comparison of this scores in time levels using the Bonferroni correction

(color figure available online).

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566   P. Grussu and R. M. Quatraro

starting from the first day after birth gradually decreased in linear terms.Overall, the symptomatology recorded on the fifteenth day after birth wassignificantly lower than that on the first, second, fourth, and fifth days afterdelivery.

During the first few days after giving birth anxiety symptoms also de-crease significantly and have dropped to their lowest levels by the four-teenth/fifteenth day after delivery. To the same extent, somatic symptoma-tology is particularly marked in the first 3 days after delivery but decreasesgradually to its lowest point by the fifteenth day after delivery.

POMS Data

Much of the same is true for the data obtained using POMS. The first step

in this analysis was to use the Cronbach   α   in order to calculate the reliabil-ity between the six POMS subscales (tension–anxiety, depression–dejection,anger–hostility, fatigue–inertia, confusion–bewilderment, and vigor– activity) on single days. Overall, the global construct could be consideredreliable in that, over the 15-day period studied, the Cronbach   α between thesix POMS subscales varied from 0.83 to 0.92.

The total POMS obtained over the 15-day period then was used to cal-culate construct stability using the Pearson correlation. This analysis revealedgood stability. In particular, subjects with higher scores on the first day alsohad higher scores on the fifteenth day (r   = 0.44,  p  <  .01,  n   = 36).

Seven repeated ANOVA measures were then made. Each dependent variable POMS total, tension–anxiety, depression–dejection, anger–hostility,fatigue–inertia, confusion–bewilderment, and vigor–activity, was consideredseparately, with one within-subject factor, “Time.”

Given that the hypothesis of sphericity (Keppel, 1991) was not satis-fied in any of the seven analyses, the Greenhouse–Geisser criterion wasused to evaluate the results. This criterion revealed that the effect of theTime factor was significant for the variables: tension–anxiety, with   F (6.52,228.31)   = 2.17,  p  <  .05; fatigue–inertia, with  F (4.88, 170.7)   = 2.85,  p  < .05;

and confusion–bewilderment, with F(5.39, 188.49)   =  4.36,  p   = .001. Meansand standard deviations of the POMS scores are shown in Table 2.Further analyses, the planned comparison of the main effects, re-

 vealed statistically significant linear-type effects for the following variables:tension–anxiety, with   F (1, 35)   =   6.56,   p   <   .05; fatigue-inertia, with   F (1,35)   =   7.6,   p   <   .001; and confusion–bewilderment, with   F (1, 35)   =   17.2,

 p  <  .0001. Given these results we decided to explore the effect of the timefactor on these three variables in greater depth. Graphs and relative couplescomparison of tension–anxiety, fatigue–inertia, and confusion–bewildermentscores in time levels using the Bonferroni correction are shown in Figure 2

below.

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 TABLE 2  Means and Standard Deviations of POMS Scores

Scales Tension- Depression- Anger- Fatigue- Confusion- Vigour- POMSdays anxiety dejection hostility inertia bewilderment activity total

1 x 45.22 43.67 42.31 51.33 48.56 49.03 182.06

SD    (9.23) (4.76) (3.76) (11.07) (8.93) (13.79) (42.62)2 x 44.78 44.42 42.56 48.5 47.39 45.64 182

SD    (8.25) (6.4) (5.11) (11.6) (9.92) (12.13) (47.11)3 x 45.5 45.19 42.25 47.11 46.33 46.94 179.44

SD    (9.84) (6.26) (4.85) (10.44) (11.71) (13.98) (50.54)4 x 47.75 45.06 42.81 47.83 46.97 44.78 185.64

SD    (9.97) (6.69) (4.68) (10.91) (11.95) (11.58) (48.07)5 x 47.69 44.81 43.38 48.25 48.08 44.53 187.69

SD    (10.91) (6.41) (6.09) (11.69) (12.17) (11.75) (51.08)6 x 45.44 45.31 42.47 46.75 47.44 46.19 181.22

SD    (9.13) (8.16) (7.09) (10.73) (10.66) (12.42) (50.34)7 x 44.19 43.78 43 46.53 46.5 45.81 178.19

SD    (8.25) (4.86) (7.63) (9.49) (10.07) (11.1) (43)8 x 45.92 44.89 44 47.56 46.5 44.78 184.08

SD    (9.3) (8.88) (10.38) (11.66) (11.24) (12.08) (55.02)9 x 44.61 44.22 43.42 45.75 45.28 46.22 177.06

SD    (8.88) (5.91) (5.87) (8.45) (10.71) (12.08) (44.65)10 x 45.11 44.14 43.58 45.58 45.39 45.72 178.08

SD    (9.16) (5.92) (6.09) (8.37) (9.97) (12.56) (44.19)11 x 44.53 44.14 43.08 45.56 43.97 46.56 174.72

SD    (9.09) (5.27) (4.46) (8.56) (9.17) (11.97) (39.08)12 x 42.5 43.47 42.39 45 43.44 46.44 170.36

SD    (6.15) (4.52) (4.09) (8.61) (8.79) (11.21) (35.35)13 x 43.61 43.83 43.11 44.83 43.22 47.97 170.64

SD    (8.92) (6.96) (5.66) (8.88) (9.45) (11.54) (42.01)

14 x 42.94 43.67 42.44 44.42 42.17 47.92 167.72SD    (7.88) (6.86) (4.98) (9.21) (8.48) (11.97) (39.48)15 x 42.92 43.86 42.47 44.72 42.08 47.86 168.19

SD    (6.54) (6.17) (4.99) (8.6) (8.41) (13.03) (37.09)

Thus the POMS questionnaires filled in day-by-day by the women inthe sample showed how, as time passed, the somatic experience of anxiety and feelings of weariness tended to decrease progressively. In particular,they were at their lowest on the fourteenth and fifteenth days after delivery,

 while many new mothers revealed problems associated with efficiency andclarity of thought in the first few days after delivery.

SQ/POMS Data

Last, the Pearson correlation between SQ total and the POMS total scoresobtained over the 15-day period was calculated. This analysis revealed ahigh correlation between the two scores, which, over the 15-day period,pass from a minimum of  r   = 0.86 to a maximum of  r   = 0.93. In other words,the primipara women in our study showed that high scores on symptoms

are directly associated with high mood disturbances and vice versa.

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568   P. Grussu and R. M. Quatraro

  Couples comparison of POMS Confusion-Bewilderment scores in time levels

POMS Confusion-Bewilderment (p <.001)

38

40

42

44

46

48

50

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Days af ter delivery

   L  e  v  e   l  o   f  m  o  o   d   d

   i  s   t  u  r   b  a  n  c  e  s

  * p<.05

POMS Tension-Anxiety (p <.05)

38

40

42

4446

48

50

1 2 3 4 5 6 7 8 9 10   11 12   13   14 15

Days after delivery

   L  e  v  e   l  o   f  m  o  o   d   d   i  s   t  u  r   b  a  n  c  e  s

POMS Fatigue-Inertia (p <.05)

40

42

44

46

48

50

52

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Days af ter delivery

   L  e  v  e   l  o   f  m  o  o   d   d   i  s   t  u  r   b  a  n  c  e  s

 Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1 -- * *

2 -- *

3 --

4 --

5 --

6 --7 --

8 --

9 --

10 --

11 --

12 --

13 --

14 * * --

15 * -

There was no significant difference revealed by couples

comparison of POMS Tension-Anxiety scores in time

levels

There was no significant difference revealed by couples

comparison of POMS Fatigue-Inertia scores in time levels

FIGURE 2   Graphics of POMS confusion–bewilderment, POMS tension–anxiety and POMSfatigue–inertia day-to-day scores and relative couples comparison of these scores in timelevels using the Bonferroni correction.

DISCUSSION

 We investigated the daily level of psychological and somatic symptoms andmood disturbances after childbirth in a sample of Italian women. The study population was made up of 36 primipara mothers with a low social andmedical risk profile, with normal full-term pregnancies, vaginal delivery, anda healthy living child.

 We have three main aims. The first is to test the hypothesis that somatic

symptomatology is major in the initial days after the birth of the child. The

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second is to verify that psychological symptomatology and mood disturbancemay be major in the 3 to 8 days after delivery. The third is to test thehypothesis that high levels of somatic and psychological symptoms may be associated with high mood disturbances and vice versa. To test these

hypotheses, women’s somatic and psychological symptoms and mood states were measured daily in the first 15 days after childbirth.In this study, in the first 15 days after childbirth primipara women with

more marked psychological and somatic symptoms revealed greater moodswings and, vice versa, those with lower scores on one had lower scoreson the other as well. Furthermore, primipara women who reported higherlevels of emotional distress and symptoms on the first day were still reportinghigher levels of psychological suffering on the fifteenth day.

Thus, in primipara women, the level of symptoms and emotional distressare closely linked and the mothers who suffer most on the first day continue

to suffer most during the first 15 days after delivery.It should be emphasized, however, that during the first 15 days following

childbirth, both psychological symptoms and mood disturbances among theprimipara women in the sample were relatively mild.

This is supported by the information gathered through the Italian valida-tion of the POMS (Farne et al., 1991), by the cut-off scores of the SQ (Kellner,1976; Pollina et al., 1992), and by some results from earlier research on thepsychological health and well-being of Italian women during the immediatepostnatal period (Grussu, Nasta, Quatraro, Sichel, & Cerutti, 2001; Grussu,Nasta, & Quatraro, 2005).

Beyond these initial elements, the data of our research reveal furtheraspects. In fact, during the first 15 days after the birth of the child, mooddisturbances of primipara women followed a linear path, while psychologicaland somatic symptomatology scores were much higher in the first few daysafter delivery and then decreased significantly over the following days.

More specifically, the new mothers in our study reported only slightchanges in symptoms of depression and hostility. The same is true for aspectsof the vigor–activity mood, which remained low and stable for the entire 15-day period after delivery.

 Vice versa, somatic symptoms scored particularly high in the few daysimmediately after childbirth and then decreased significantly in the daysfollowing discharge from the hospital. In the period immediately after de-livery, the new mothers reported physical sensations such as nipple pain,perineal discomfort, fatigue, breast engorgement, and difficulties with urina-tion (Martell, 2001), which probably added to the physical distress we noted.This physical suffering linked to motherhood is confirmed by scores abovethe SQ somatic symptoms cut-off during the first few days after giving birth.

Likewise, the scores obtained from the primipara women in our study show how, as time passes, the somatic experience of anxiety and feelings of 

 weariness tend to decrease progressively. In particular, when compared with

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570   P. Grussu and R. M. Quatraro

the fourteenth and fifteenth days after childbirth, in the first few days afterdelivery, new mothers revealed generalized psychological distress and hadsome difficulty with efficiency and clarity of thought, all important symptomsof anxiety. Moreover, numerous symptoms of anxiety were reported by the

 women studied during the 2 days immediately preceding discharge from thehospital.It is possible that these specific psychological states are closely linked to

“not thinking clearly” and the reaction to postbirth events that seemed unreal, which is a typical reaction of new mothers on the day of delivery (Martell,2001). On the other hand, it is also important to take into considerationthe fact that in the immediate postdelivery period, the experiences with thenewborn child take on a special salience (Fleming & Corter, 1988) and,according to Martell (2001), during the first week after delivery, many first-time mothers do not trust in their own abilities to care for their newborn.

It is therefore possible that in the first few days after giving birth, partic-ularly as the time for leaving the hospital gets nearer, the woman feels lessprotected: she will no longer be able to rely on the constant information andadvice from hospital personnel. Thus we believe that the peak in maternalanxiety in the days directly preceding discharge from the hospital could berelated to this feeling of inadequacy and women’s lack of trust in their ownability to cope, but research is needed to test this idea.

The data used in our study confirmed some results of English, Cana-dian, and U.S. research on day-to-day psychological reaction after childbirth(Ballinger et al., 1979; Kendell et al., 1981; O’Hara et al., 1990) that have re-

 vealed maternal psychological distress in the first days directly after delivery, with a marked presence of somatic symptoms and accentuated anxiety symp-toms that increase as the time of discharge from hospital approaches. Thesesymptoms and mood disturbances are, however, generally minor, short term,and transitory.

It is important to point out, however, that the data of this study shouldbe viewed in a national social and cultural context where Italian women haveaccess to health care without charge during pregnancy, during the period of hospitalization related to childbirth, and, subsequently, after the birth of the

child. Additionally, pediatric health services are also provided free of chargein Italy. With regard to employment benefits for working mothers, before and

after childbirth, Italian woman can take extended parental leave and receivecompensation; at the same time, women who do not work outside the homemay receive government subsidies, depending on their local jurisdiction of residence.

Moreover, the most current available census data indicate a noticeablesocial and cultural transformation. In the recent past, Italy has seen an in-creasingly pronounced change in the structure of the family from the tra-

ditional patriarchal extended model to a smaller and smaller nuclear family 

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(Istituto Nazionale di Statistica [ISTAT], 2005). In this change from extendedto nuclear family, new Italian fathers usually stay at home during the firstdays following the mothers’ release from hospital after childbirth, and thenew mothers frequently receive support and significant assistance at home

from their own mothers or from their mothers-in-law.Therefore, in comparing and analyzing the results of studies on mater-nity blues carried out in different national contexts, it is essential, accordingto several authors (Affonso, De, Horowitz, & Mayberry, 2000; Dennis et al.,2007; Goldbort, 2006; Posmontier & Horowitz, 2004), to keep in mind themany and various models of motherhood proposed by diverse cultures andthe different practices and types of assistance offered to women both duringpregnancy and in the period immediately after delivery. This is also due tothe significant impact that cultural factors have on an individual’s emotionalstate (Kirmayer, 1989; Lazarus & Folkman, 1984) and the important preven-

tive role played by cultural beliefs and practices in life transitions, such aspregnancy and birth (Raphael-Leff, 1991).

Moreover, understanding the local idioms that the new mothers utilizedto describe their own early puerperal affective experience is crucial for theknowledge of maternity blues expression in different cultures. In fact, re-searchers seem to agree that each culture has its own emotional lexicon thatencodes socially and morally significant values and its own idioms of distress(Bhugra & Mastrogianni, 2004). For example, people from traditional culturesmay not distinguish among the emotions of anxiety, irritability, and depres-sion because they tend to express distress in somatic terms (Leff, 1977). In

particular, research in transcultural psychiatry confirms that somatic symp-toms serve as cultural idioms of distress in many ethnocultural groups, con-trary to the claim that non-Westerners are prone to somatize their distress(Kirmayer, 2001). Besides, cultural idioms of distress may employ symp-toms related to affective disorders to express sentiments and perceptionsthat do not in themselves indicate psychopathology (Kirmayer & Groleau,2001).

Globally, the possibility of expanding the current boundaries of theunderstanding of the typical day-to-day postpartum symptomatology in a

nonclinical sample could, for example, permit identification and insight intothe early signs that predict the subsequent presence of puerperal psychosesand other psychopathologies that can occur in women after the birth of thechild.

Of additional importance is the potential detection of psychologicalsensitivity present in new mothers of different countries/cultures. From theperspective of modernization and globalization, and in the current contextof population mobility, the knowledge of the specific day-to-day postpar-tum psychological symptomatology may have significant implications inthe planning and implementation of culturally competent health care. In

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572   P. Grussu and R. M. Quatraro

addition, as previously reported by Dennis and colleagues (2007) with re-spect to traditional postpartum practices and rituals, “at the individual health-care provider level, increased awareness of, and knowledge about   typical 

 postpartum psychological reaction in women of different countries/cultures 

can avoid causing undue distress to those receiving care” (p. 499).Our findings from this study should be applied with caution. First, thesmall homogeneous sample size of primipara women who attended antenatalclasses at the local Consultorio Familiare  Unit of the National Health Serviceand the lack of clinical observations limit generalizing the findings to otherpopulations. Furthermore, interpretation of the data should be confined toprimipara women’s experiences with somatic symptoms and subjective sen-sation of mood states. For these reasons it will be necessary, in the nearfuture, to check these results with a much larger sample of Italian women,including pluripara mothers, using further psychometric evaluations, struc-

tured interviews, clinical observations, or all of these methods. Moreover, it would be helpful to link these psychological indicators with some daily neu-rophysiological tests in order to better understand, for example, whether themany neuroendocrine and endocrine modifications in the immediate post-natal period significantly affect symptomatology and mood in new Italianmothers.

Finally, the following further limitations of the study should also beconsidered: (a) a possible response bias linked to the repeated administrationof the SQ and POMS questionnaires and (b) the statistical analysis modelselected for the processing of the data. In fact, any response bias may be

due to the participants having to answer so many questions every day for2 weeks in a row. This shortcoming could perhaps be mitigated in futurestudies by, for example, a daily random ordering of the 92 items that makeup the SQ questionnaire and the 65 adjectives of the POMS questionnaire.Moreover, some portions of the variance emerging from this study also couldbe due in part to the statistical method used (see Conway & Lance, 2010;Podsakoff, MacKenzie, Lee, & Podsakoff, 2003).

In conclusion, our results substantiate the extreme complexity of early puerperal affective experience in the personal history of even low-risk Italian

primipara women. Informing local obstetric unit professionals, health visitors,and pediatricians about these issues is important in order to safeguard thepsychological health of new mothers and to foster a significant level of well-being in all components of the affected nuclear family.

In addition, the data brought to light by this research and the observa-tions reported in certain sections of this article can be useful information forany healthcare professional caring for Italian patients. The world’s fluid bor-ders mean that, potentially, they could care for people from many cultures

 who may be vacationers, expatriots, or first-, second-, or third-generationimmigrants.

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