Effects of an Interpersonal-Psychotherapy-oriented postnatal

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Accepted Manuscript Title: Effects of an Interpersonal-Psychotherapy-oriented postnatal programme for Chinese first-time mothers: A randomised controlled trial Author: Ling-ling Gao Wen Xie Xiao Yang Sally Wai-chi Chan PII: DOI: Reference:

S0020-7489(14)00163-1 http://dx.doi.org/doi:10.1016/j.ijnurstu.2014.06.006 NS 2407

To appear in: Received date: Revised date: Accepted date:

8-1-2014 5-4-2014 12-6-2014

Please cite this article as: Gao, L.-l., Xie, W., Yang, X., Chan, S.W.-c.,Effects of an Interpersonal-Psychotherapy-oriented postnatal programme for Chinese first-time mothers: A randomised controlled trial, International Journal of Nursing Studies (2014), http://dx.doi.org/10.1016/j.ijnurstu.2014.06.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

*Title Page (with author details and affiliations) Click here to download Title Page (with author details and affiliations): Title page for IJNS.doc

Effects of an Interpersonal-Psychotherapy-oriented postnatal programme for Chinese first-time mothers: A randomised controlled trial

Authors

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Ling-ling Gao, PhD, MSc, RN Associate professor, School of Nursing, Sun Yat-sen University, Guangzhou, China

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E-mail: [email protected]

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Wen Xie, MSc, RN

Professor of Nursing and Dean, School of Nursing, Sun Yat-sen University,

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Guangzhou, China

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Xiao Yang, MSc, RN

Assistant, School of Nursing, Zheng-zhou University, Zheng-zhou, He-nan Province,

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China. E-mail: [email protected]

Sally Wai-chi Chan, PhD, MSc, RMN, FAAN

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Professor and Head, School of Nursing & Midwifery at University of Newcastle, Australia. E-mail: [email protected]

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This study was supported by a grant to the first author from Medical Scientific Research Foundation of Guangdong Province, China. (No.A2012164)

Running head: Interpersonal-Psychotherapy-Oriented Postnatal Programme for Chinese First-time Mothers

*Corresponding address Wen Xie, MSc, RN 1

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Professor of Nursing and Dean, School of Nursing, Sun Yat-sen University, Guangzhou, China Mailing address: 74#, Zhongshan Road II, School of Nursing, Sun Yat-sen University, Guangzhou, China, 510089

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Telephone: 86-20-87331700; Fax: 86-20-87333043;E-mail: [email protected]

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*What this paper adds (statement)

What is already known about the topic? 

Social support has a positive impact on new mothers’ transition to motherhood.



Facilitating new mothers’ transition to motherhood is an important concern for nurses and midwives. Nurses and midwives could offer social support to the

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mothers and help them to get social support from their family as well.

This study found an interpersonal-psychotherapy-oriented postnatal

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What this paper adds?

psychoeducation programme was effective in enhancing social support, maternal

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role competence and reducing depressive symptoms at six weeks postpartum as compared with those who received only routine postnatal care.

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This study found that Chinese mothers appeared to accept the interpersonal-psychotherapy-oriented postnatal psychoeducation programme as

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indicated by the high adherence to the intervention protocol. The programme is brief and could be conducted by trained midwives. The programme has the

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potential to be incorporated into the routine postnatal care.

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*Manuscript (without Author Details) Click here to download Manuscript (without Author Details): Gao Manusript.doc

Click here to view linked References

Effects of an interpersonal-psychotherapy-oriented postnatal programme for Chinese first-time mothers: A randomised controlled trial

Abstract Objective: This study aimed to investigate the effects of an

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interpersonal-psychotherapy-oriented postnatal psychoeducation programme on

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postpartum depressive symptoms, social support and maternal role competence in Chinese first-time mothers.

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Method: A randomised, controlled trial was conducted in the postnatal unit of a regional hospital in China. The intervention consisted of a one-hour education session

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before discharge and one telephone follow-up within the two weeks after discharge

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from the hospital. One hundred and eighty first-time Chinese mothers were randomly assigned to the study group (n = 90) or the control group (n = 90). Outcomes of the

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study included symptoms of postpartum depression, social support and maternal role competence which were measured by the Edinburgh Postnatal Depression Scale, the

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Perceived Social Support Scale and the Parenting Sense of Competence ScaleEfficacy subscale, respectively.

Results: Women receiving the postnatal psychoeducation programme had significantly fewer depressive symptoms (Mean [SD] = 7.61 [3.43] versus 8.96 [4.55];

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t = -2.24; p = 0.026), higher level of social support (Mean [SD] =65.44 [8.43] versus 61.82 [9.99]; t = 2.63; p = 0.009) and better maternal role competence (Mean [SD] = 35.87 [4.41] versus 32.79 [6.86]; t = 3.59; p < 0.001) at 6 weeks postpartum as compared with those who received routine postnatal care. Conclusion: An interpersonal-psychotherapy-oriented postnatal psychoeducation programme may have the potential to facilitate the Chinese first-time mothers’ transition to motherhood. A larger trial is needed to test for therapist effects, a full 1

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economic evaluation, and whether the intervention is acceptable to staff and feasible to use in current practice.

Keywords: First-time mothers, interpersonal psychotherapy, postnatal care,

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randomised controlled trial

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What is already known about the topic? 

Social support has a positive impact on new mothers’ transition to motherhood.



Facilitating new mothers’ transition to motherhood is an important concern for nurses and midwives. Nurses and midwives could offer social support to the

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mothers and help them to get social support from their family as well.

This study found an interpersonal-psychotherapy-oriented postnatal

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What this paper adds?

psychoeducation programme was effective in enhancing social support, maternal

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role competence and reducing depressive symptoms at 6 weeks postpartum as compared with those who received only routine postnatal care.

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This study found that Chinese mothers appeared to accept the interpersonal-psychotherapy-oriented postnatal psychoeducation programme as

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indicated by the high adherence to the intervention protocol. The programme is brief and could be conducted by trained midwives. The programme has the potential to be incorporated into the routine postnatal care.

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Introduction

Transition to motherhood is an important developmental stage in a woman’s life. A woman needs to make physical and psychosocial changes while integrating her

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sense of self as a mother and in relationship to her new infant (Emmanuel et al., 2008). Achieving maternal role competence and developing a sense of well-being are

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regarded as critical components of maternal adaptation (Gao et al., 2012). A positive

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transition period is known to impact on the quality of parenting behaviour and, ultimately on the child’s psychosocial development (Jones and Prinz, 2005).

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However, the reality of fatigue, the demanding responsibility of caring for a newborn, and the profound changes in roles and relationships may come as a shock

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for most women during the postpartum period (Nyström and öhrling, 2004). Women were often found to express feelings of inadequacy in the mothering role (Nelson,

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2003). Some women might have difficulties in adapting to motherhood and develop depression (Chan et al., 2002).

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Globally, in women of child-bearing age, depression accounts for the largest proportion of the burden associated with mental or neurological disorders (Vos et al., 2012). Postpartum depression (PPD) is a major unipolar depressive disorder occurring within 4–6 weeks after giving birth and lasting for at least 2 consecutive weeks

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(American Psychiatric Association, 2000). PPD is a significant public health concern. PPD was found to affect 19.2% of women in a meta-analysis of 28 studies across diverse countries and cultures (Gavin et al., 2005). In mainland China, PPD affect about 5.45%  17% postpartum women (Gao et al., 2009; Shi et al., 2003). PPD is an important marker of the mother’s risk for subsequent depression (Dennis et al., 2012); a risk factor for depression in partners (Gao et al., 2009); and also has adverse effects

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on the cognitive, social and emotional development in infants (Chun and Panos, 2004). Social support can facilitate women’s transition to motherhood (Gao et al., 2009; 2012; Warren et al., 2012). Social support is defined as the interpersonal resources

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accessed and mobilized when individuals attempt to deal with the everyday stresses and strains of life. Social support consists of the availability and perceptions of social

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support (Gao et al., 2009). As a buffer, social support can protect an individual from

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the potentially adverse effects of stressful events and enhance health outcomes (Taylor, 2003). Women with higher social support tend to report less depressive symptoms

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(Gao et al., 2012; Ngai et al., 2010). Lack of social support has been consistently indicated as a significant predictor of PPD (Gao et al., 2009; Heh et al., 2004).

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Social support also has a positive effect on maternal role competence (Gao et al., 2012; Warren, 2005). According to Bandura (1997), social support may influence

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maternal role competence through processes involving opportunities to observe significant others’ parenting and verbal persuasion and encouragement. Bandura

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(1997) comments that watching others function successfully in their parenting role may shape expectations for women’s own performance, and maintaining maternal role competence beliefs is easier for an individual when their significant others believe in their capacities and say so. Women who perceived themselves as being well supported

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are more likely to report higher level of maternal role competence (Gao et al, 2012; Ngai et al., 2010).

Family members are the most important sources for the new mothers to get social support. At present in mainland China postpartum practices “doing the month” are still common, in which the new mother is accompanied by her mother-in-law or mother. The mother-in-law or mother helps the new mother in household chores and

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baby care. However, because of the ensuing modernization and ingress of Western values, the younger women and their mothers-in-law or mothers may have different values and belief systems (Gao et al., 2010b). These differences are manifested explicitly in

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postpartum customs, baby care and the preference for a male baby, which may cause deterioration of the relationship between the women and their old generations or

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husbands during the postpartum period (Gao et al., 2010a; 2010b; 2012). Many

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studies revealed that “doing the month” was not always perceived as supportive to Chinese women or meeting their true needs (Gao et al., 2013; Wong and Fisher,

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2009).

In addition to family members, most women feel a need for psychosocial support

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during their transition to motherhood from health professionals such as midwives (Darvill et al., 2010; Teeffelen et al., 2011; Wilkins, 2006). Besides information, the

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new mothers want their midwives’ appraisal and emotional support as well, such as reassurance, more contact with their midwives (Teeffelen et al., 2011). It is

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recommended that psychosocial support should be integrated into routine midwifery care, giving all women access to support during the transition to motherhood (International Confederation of Midwives, 2013). Facilitating women’s transition to motherhood is an important concern for nurses

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and midwives. Nurses and midwives could be a source of social support for new mothers. They could also provide knowledge and skills to help new mothers to acquire social support from families and friends (Gao et al., 2013). Parenting in the early postpartum period is a time of maternal learning and adaptation. A recent meta-analysis indicated that one of the effective interventions with a clear effect on decreasing depressive symptomatology was intensive

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postpartum support by a health professional, and exclusively postpartum interventions were more successful than interventions that also incorporated a prenatal component (Dennis and Dowswell, 2013). Now in mainland China, women in the cities usually give birth in the hospitals.

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After delivery, they generally stay in the hospital for 2-3 days. It is good timing for nurses to initiate psychoeducation programme to new mothers. However, the present

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nursing care in the postnatal ward centres on women’s physical recovery and

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breastfeeding skills. There is very little content on psychosocial issues related to transition to motherhood, such as new role adaptation, communication skills and skills

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in maintaining satisfied interpersonal relationships (Li et al., 2008).

Evidence suggested that the interpersonal psychotherapy (IPT) might work as a

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potential framework for developing postnatal psychoeducation programme for Chinese new mothers (Gao et al., 2010a; 2012). IPT is a manual-based, time-limited

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psychotherapeutic approach. It is based on the hypothesis that depression, regardless of etiology, is initiated and maintained within an interpersonal context (Klerman et al.,

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1984; Stuart and Franzcp, 2003). Target depressive clients’ social functioning problems are conceptualized as one or more of four areas: interpersonal disputes, role transitions, grief, and interpersonal deficits. IPT is primarily concerned with interpersonal relationships and has a specific focus on social interactions,

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communication, social supports, and interpersonal functioning. Previous studies also demonstrated that the IPT oriented intervention was

effective in enhancing social support, maternal role competence and reducing depressive symptoms (Gao et al., 2012; Zlotnick et al., 2001; 2006). However, postnatal intervention based on the principles of IPT has not been examined in mainland China. Therefore, it is significant to evaluate an IPT oriented postnatal

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psychoeducation programme for Chinese first-time mothers.

2. Aims The primary aim of this study was to examine the impact of an IPT-oriented

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postnatal psychoeducation programme on postpartum depressive symptoms, social support and maternal role competence in Chinese first-time mothers at 6 weeks

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postpartum. The secondary aim of this study was to explore the relationship among

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social support, maternal role competence and postpartum depressive symptoms. The primary hypotheses of this study were: at 6 weeks postpartum when

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compared with women received the routine postnatal care, Chinese first-time mothers

1. less depressive symptoms;

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in the study group would report statistically significantly

2. higher levels of social support; and

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3. better maternal role competence.

The secondary hypotheses of this study were: among Chinese first-time mothers

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the postpartum depressive symptoms would be significantly correlated negatively with perceived social support and maternal role competence; and perceived social support would be significantly correlated positively with maternal role competence.

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3. Method

3.1 Design and setting A randomised, controlled trial was conducted from September 2012 to February 2013 at a regional teaching hospital in Guangzhou where the birth rate was more than 5,000 babies per year.

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3.2 Participants, recruitment and randomisation The inclusion criteria were: first-time mother who had given birth with single full-term health baby (gestation age 37-40 weeks, body weight over 2500g and Apgar

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score equal or above 8), married and living with their husband. Women with past or family psychiatric history and major postnatal complications, such as puerperal

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infection, postpartum haemorrhage and amniotic fluid embolism were excluded.

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Women who had received IPT-oriented childbirth education programme during pregnancy were also excluded.

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One research assistant identified women who met the inclusion criteria from the labour ward records and approached them on the postnatal ward at least 24 hours after

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delivery. Potential participants were given written and verbal information about the study and written informed consent was then obtained.

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The mothers who agreed to participate in the study were asked to complete the demographic questionnaires and the baseline measurement and then randomised to the

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study group or the control group. The randomisation sequence was generated using a computerized random number generator and the allocation was kept in sealed opaque consecutively numbered envelopes. This simple randomisation scheme was independently prepared by a research assistant who was not involved in determining

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eligibility, providing care, or assessing outcome.

3.3 Intervention Women in the control group received a brief visit from a nurse in the postnatal ward to give them a pamphlet on sources of assistance for mothers on discharge from hospital. Women in the study group received the pamphlet and the IPT oriented

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postnatal psychoeducation programme. The intervention was consisted of a one-hour education session before discharge and one telephone follow-up within the two weeks after discharge from the hospital. Specific IPT techniques, such as information giving, use of affect, clarification,

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signalling what is significant, reviewing relationship and communication patterns, and providing social support were applied throughout the programme (Klerman et al.,

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participant individually in an interview room in the ward.

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1984; Stuart and Franzcp, 2003). The session was conducted by the midwife to the

At the beginning of the session, the midwife gave the new mother information

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about her physical recovery and encouraged the new mother to take care of her infant after discharge from the hospital. Then the information about the nature and course of

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PPD was provided (information giving). The new mother was encouraged to express the emotions attached to each of her new roles in motherhood and to explore any

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ambivalent feelings (use of affect). Maternal role attainment and how to cope with the difficulties the new mother would encounter in the postnatal period were clarified

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(clarification). Then the importance and sources of social support were signalised (signalling what is significant). The new mother’s current and past interpersonal relationships and communication patterns were reviewed (reviewing relationship and communication patterns). Strategies to improve the relationships with husband and the

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mother-in-law were discussed and communication skills were provided (providing social support). Issues related with Chinese postpartum practice “doing the month” were also discussed (providing social support). After the session, the new mother was given the written material for the programme. The education session was administered according to the protocol of our previous study (Gao et al., 2010a), with some modifications on learning activities to

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accommodate the individual context. Group activities such as role play, demonstration and return demonstration, brain-storming were not used in this programme. Before implementation, the modified protocol has been validated by five experts in PPD and psychoeducation.

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The telephone follow-up was conducted by the midwife within two weeks after discharge. The focus of the telephone follow-up was to help the first-time mothers to

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review what they had learnt at the education session and encourage the mothers to

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apply the knowledge and skills into their lives. The telephone follow-up was

administered according to the protocol of our previous study (Gao et al., 2010a).

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Both the education session and the telephone follow-up were provided by the first author, a midwife educator, who had experiences in delivering IPT oriented

3.4 Outcome measures

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intervention. This was to ensure consistency in delivering the intervention.

The primary outcome was postpartum depressive symptoms. It was measured by

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the Edinburgh Postnatal Depression Scale (EPDS, Cox et al., 1987). It is a 10-item self-report instrument. The EPDS has been validated in Chinese mothers (Guo et al., 1993). Sensitivity of 82% and specificity of 86% (using a cutoff score of 13 or above; range 0-30) at the sixth week postpartum (Jin et al., 1995) have been reported. The

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prevalence of depression was identified using the recommended cutoff point of 13 or above (Cox et al., 1987; Guo et al., 1993). Secondary outcomes were perceived social support and maternal role competence. Perceived social support was measured by the Perceived Social Support Scale (PSSS, Zimet et al., 1988) which contains 12 items. Each item is rated on a 7-point scale ranged from “strongly disagree” to “strongly agree”. Possible scores range from 12 to

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84 with higher total scores indicating greater perceived social support. The original PSSS has good reliability and validity (Zimet et al., 1988). The Chinese version has also demonstrated good psychometric properties, with test-retest reliability of 0.81, internal consistency of 0.85 (Huang et al., 1996).

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The 17-item Parenting Sense of Competence Scale (PSOC) consists of two subscales: Efficacy subscale (PSOC-E) and Satisfaction subscale (PSOC-S)

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(Gibaud-Wallston and Wandersman, 1978). In this study, maternal role competence

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was measured by the 8-item PSOC-E. Each item is rated on a 6-point ranging from 1 (strongly disagree) to 6 (strongly agree). Higher scores indicate higher maternal role

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competence. The Chinese version of the PSOC has been reported good psychometric properties. Construct validity was demonstrated by significant correlations with

reliability was 0.84 (Ngai et al., 2007).

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measures of self-esteem; reported internal consistency was 0.82 and 4-week test-retest

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Outcomes were measured at two points: before the intervention (pre) and at 6 weeks postpartum (post). At 6 weeks postpartum, when the participants attend the

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postnatal clinic to have their routine examination, they were asked to fill in the PSSS, PSOC-E and EPDS again. The Obstetric data were collected from the mothers’ medical records.

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3.5 Ethical consideration Ethical approval was obtained from the university and from the study venue. All

participants were assured that their participation was entirely voluntary and that they could withdraw at any time. Their data were kept confidential. If the women obtained an EPDS score of 13 or above at 6 weeks postpartum, then this information would be shared with their obstetricians with women’s consent. They would also be referred to

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a psychiatrist for further clinical assessment and/or treatment by the principal investigator, but it would be up to the women to decide whether they would accept these services. Of all of the twenty participants in this study who had an EPDS score

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of 13 or above, only two accepted the referral to the psychiatrist.

3.7 Sample size and data analysis

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Sample size estimation was based on our previous study with a medium- to

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small-effect size (Gao et al., 2010a; 2012). With an effect size of 0.35 for the primary outcome of PPD (EPDS scores), an alpha set at 0.05 and a power of 0.80, each group

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required 90 women (Cohen, 1992).

Analyses were carried out by intention to treat. Data were analyzed by using the

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Statistical Package for Social Sciences (SPSS) for Windows version 16.0. Descriptive statistics were used to summarise the data. Chi-square analysis and independent t-tests

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were used to detect any significant differences between the two groups on the baseline variables. T-test was used to compare the differences between the two groups in the

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post-test outcome measures and changes in these outcome measures over the study period. The correlations amongst the baseline measures of outcome variables were examined by Pearson’s correlations. Data analysis was conducted by a research assistant who was blinded to the study protocol.

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4. Results

Figure 1 shows the flow of the participants through the trial. Three hundred and sixty-eight first-time mothers were screened and 180 agreed to participate in the study. All the mothers in the study group received the education session before discharge 13

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and 86 mothers received the telephone follow-up within two weeks after delivery. One hundred and sixty-six women (92.2%) had responded to the post-test measurement at 6 weeks postpartum. A comparison of the baseline characteristics for the participants who completed the post-test measurement and those who did not revealed no

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significant differences (p > 0.05). Buck’s method of conditional mean imputation

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was used for intent-to-treat analysis. All of the participants were included in the data analysis.

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Table 1 presents the participants’ demographic, obstetric and related data. There were no significant differences between the two groups in their demographic,

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obstetric and related characteristics (Table 1). There were also no significant

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differences between the two groups in their baseline measures (Table 2). Based on the primary and secondary outcomes in the following, the primary and secondary

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4.1 Primary outcome

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hypotheses of this study were all accepted.

Table 2 shows that the mean scores of the EPDS increased from 2-3 days after delivery to 6 weeks postpartum in the two groups. Although there was no significant difference in the changes between the two groups in this measure, the descriptive data

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showed that the control group had more increase in the mean score of the EPDS than the study group. At 6 weeks postpartum when compared with the control group, the mothers in the study group had less depressive symptoms (t = -2.24, p < 0.001).

4.2 Secondary outcomes Table 2 also shows that the mothers in the control group had significantly more reduction in the mean scores of the PSSS and less increase in the mean scores of the 14

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PSOC-E from 2-3 days after delivery to 6 weeks postpartum when compared with the mothers in the study group. At 6 weeks postpartum the mothers in the study group had a higher level of social support (t = 2.63, p = 0.009) and maternal role competence (t = 3.59, p < 0.001) compared with the control group.

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Pearson’s correlations were conducted to examine the associations amongst the baseline measures. The baseline EPDS scores were significantly negatively correlated

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with the baseline PSSS scores (r = -0.26, p < 0.01) and PSOC-E (r =-0.36, p < 0.01)

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scores. This indicated that participants who had better social support or maternal role competence had fewer depressive symptoms. The baseline PSSS scores were

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positively correlated with the baseline PSOC-E scores (r = 0.22, p < 0.01). This indicated that participants who had higher level of social support had higher level of

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5. Discussion

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maternal role competence.

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This study demonstrated an initiation to apply the principles of IPT into postnatal care in Chinese first-time mothers. The findings of this study indicated that the IPT-oriented postnatal psychoeducation programme was effective in decreasing depressive symptoms and promoting social support and maternal role competence in

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Chinese first-time mothers. This study provided preliminary support for the effectiveness of the IPT-oriented postnatal psychoeducation programme in facilitating Chinese first-time mothers’ transition to motherhood. The perceived social support had decreased from 2-3 days after delivery to 6 weeks postpartum amongst the two groups. This may be due to the social support withdrawn from the health professionals after discharge from the hospital. However,

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when compared with the mothers in the control group, the first-time mothers in the study group had significantly higher level of social support at 6 weeks postpartum. The birth of a baby is a major life changing event, which challenge even the strongest of the relationships (Fraser and Cullen, 2006). The IPT-oriented postnatal programme

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in this study might help first-time mothers to recognize the importance of family and how to keep good relationships with their significant others, such as their husbands

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and mothers-in-law. This might help them to get or perceive higher level of social

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support from family. Moreover, the new mothers in the study group also received social support from the midwife. They got helpful advice and emotional support

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through the telephone follow-up. Thus the women in the study group had higher level of social support than the women in the control group.

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The maternal role competence had increased from 2-3 days after delivery to six weeks postpartum amongst the two groups. However, when compared with the

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control group, the first-time mothers in the study group had significant higher level of maternal role competence at 6 weeks postpartum. The results were consistent with

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Bandura’s self-efficacy theory (1997) in that direct experience with a task or similar tasks is the most potent source of efficacy expectations and social support has a positive effect on maternal role competence. With time past, the first-time mothers in the two groups gradually acquired mater role competence with increasing experience

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of childcare and interactions with their infants at 6 weeks postpartum. More social support has facilitated the first-time mothers in the study group to acquire better maternal role competence. The postpartum depressive symptoms had increased from 2-3 days after delivery to 6 weeks postpartum amongst the two groups. This may be related to the length of the postpartum period under evaluation. The previous studies indicated that longer

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periods in the postpartum period predicted more depressive symptoms in the mothers (O’ Hara and Swain, 1996). However, when compared with the mothers in the control group, the mothers in the study group had less depressive symptoms at 6 weeks postpartum. This may be related to the higher level of social support and maternal role

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competence in the study group. The findings of this present study demonstrated that depressive symptoms were

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correlated negatively with social support and maternal role competence and social

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support was correlated positively with maternal role competence in Chinese first-time mothers. This result was consistent with previous study in Western countries (Silver et

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al., 2006; Warren et al., 2012). With higher level of social support and better maternal role competence, the first-time mothers in the study group demonstrated less

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depressive symptoms. This finding was congruent with previous studies that women who had a higher level of social support or maternal role competence were less

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susceptible to depression (Gao et al., 2012; Haslam et al., 2006). Though the study group had less depressive symptoms at 6 weeks postpartum

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when compared with the control group, there was no significant difference in the changes of scores between the two groups. It could be related to that all the participants in this study were first-time mothers with a single full-term health baby, and without a past or family psychiatric history. The effect of this study might be

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larger if the participants were having a diagnosis of depression. Further study which targeted women who have a depression may give more conclusive understanding of the intervention. This study was built on an IPT framework (Klerman et al., 1984; Stuart and Franzcp, 2003). The intervention was well-received by the participants, as indicated by the high adherence to the intervention protocol. This study’s positive results

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indicated that the application of IPT in the postnatal care was appropriate. IPT may hold intuitive appeal for postpartum women with its focus on current personal relationships and networks. The findings of the current study along with our earlier report (Gao et al., 2010a; 2012) demonstrated that the IPT framework was acceptable

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by Chinese women. It may be due to that IPT is consistent with Chinese culture. In Chinese society, interdependent interpersonal family relationships are strongly

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encouraged, which are regarded as a way toward happiness (Chan et al., 2002; Gao et

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al., 2012).

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4.1 Study limitation and future research

This study has some limitations. First, because blinding of participants and

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caregivers was not possible the Hawthorne effect (McCarney et al., 2007) might exist. It could be argued that the increased interaction between the nurse and the new

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mothers in the study group might have contributed to the positive effects. Further, the participants were limited to first-time mothers who have given birth with single

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full-term health baby, and without a past or family psychiatric history. Caution is thus needed when generalising the findings of the present study. In addition, this study only recruited new mothers, and the family was not involved. Future studies could explore the effects of the intervention for multiparas and with husbands involved in

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the programme. This study did not take into account of the cost of the intervention. Future study could conduct a cost-effective analysis of the IPT oriented postnatal psychoeducation programme.

4.2 Conclusions

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Nurses have responsibilities to facilitate women’s transition to motherhood. The early postpartum period during the hospital provides an opportunity for nurse to initiate nursing interventions. This study provides preliminary empirical support for the effectiveness and feasibility of incorporating the principles of IPT into postnatal

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care for Chinese first-time mothers. The IPT-oriented postnatal programme is simple and easy to deliver. The programme has the potential benefits of promoting maternal

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role competence and decreasing depressive symptoms. A larger trial is required to test

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for therapist effects and whether the intervention is acceptable to staff and feasible to

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use in current practice.

Acknowledgements

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This study was supported by Department of Health of Guangdong Province, China. The authors would like to thank the women who participated in our study and

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Funding

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pay tribute to the experts and hospitals for supporting this project.

Medical Scientific Research Foundation of Guangdong Province, China supported this research and governed the progress and review of this study. (No. A2012164)

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Competing interests None declared.

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depression. American Journal of Psychiatry 163, 1443-1445.

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*Contribution of the paper

Contribution of the paper

What is already known about the topic? Social support has a positive impact on new mothers’ transition to motherhood.

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Facilitating new mothers’ transition to motherhood is an important concern for

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and help them to get social support from their family as well.

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nurses and midwives. Nurses and midwives could offer social support to the mothers

What this paper adds?

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This study found an interpersonal-psychotherapy-oriented postnatal psychoeducation programme was effective in enhancing social support, maternal role

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competence and reducing depressive symptoms at six weeks postpartum as compared with those who received only routine postnatal care.

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This study found that Chinese mothers appeared to accept the interpersonal-psychotherapy-oriented postnatal psychoeducation programme as

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indicated by the high adherence to the intervention protocol. The programme is brief and could be conducted by trained midwives. The programme has the potential to be

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incorporated into the routine postnatal care.

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Figure(s) Click here to download Figure(s): Figures.doc

Assessed for eligibility (n = 368)

Excluded (n = 188)  Did not meet the criteria (n = 120)  Refused to participate (n = 68) (Reasons: no interest = 50; may not return the hospital for routine checkup = 18) Baseline measure: Demographic questionnaires, PSSS, PSOC-E, EPDS

Allocation

 Completed (n = 85)  Loss to follow-up (n = 5) Reasons: - Did not go back the hospital to have the routine examination (n=5)

Follow-up at 6-weeks postpartum

Allocated to the control group (n = 90)

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Allocated to the study group (n = 90) (Routine postnatal care and a one-hour postnatal session with one telephone follow-up within 2 weeks after discharge)  Completed the postnatal session (n = 90)  Received the telephone follow-up (n = 86)

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Randomised (n = 180)

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ed

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Routine postnatal care

 Included in analysis (n = 90)

An intention to treat analysis

 Completed (n = 81)  Loss to follow-up (n = 9) Reasons: - Did not go back the hospital to have the routine examination (n= 6) - Refuse to receive the measurement (n = 3)

 Included in analysis (n = 90)

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Figure 1. Participants’ recruitment, intervention and assessment.

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Table(s)

Table 1 Demographic, obstetric and related data of the participants (n = 180) Study group

Control group

(n = 90)

(n = 90)

f Age (yrs)(M±SD)

%

f

28.49±2.73

t/2

P

t=-0.42

0.673

0.18

0.672

%

28.67±2.91

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Characteristics

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Education 12

13.3%

14

15.6%

College or above

78

86.7%

76

84.4%

Professional

33

36.7%

36

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High school or below

Semi-professional

35

38.9%

33

36.7%

Skilled

20

22.2%

20

22.2%

Unskilled

2

M 2.2%

1

ed

35.6%

30

33.3%

58

64.4%

60

66.7%

Mode of delivery

Spontaneous vaginal

42

46.7%

38

42.2%

Forceps or vacuum delivery

3

3.3%

3

3.3%

Caesarean

45

50.0%

49

54.4%

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0.10

0.875

0.46

0.888

0.36

0.654

1.33

0.515

1.1%

32

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≥ ¥6000

0.931

40.0%

Monthly household income < ¥6000

0.62

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Occupation

Newborn’s gender Male

46

51.1%

50

55.6%

Female

44

48.9%

40

44.4%

Type of feeding Breastfeeding

29

32.2%

30

33.3%

Bottle-feeding

11

12.2%

16

17.8%

Mixed

50

55.6%

44

48.9%

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Table 2 Comparison of EPDS, PSSS and PSOC-E at baseline, post-test and changes in these three measures between the study group and the control group (n = 180) The control group

(n = 90)

(n = 90)

Mean (SD)

Mean (SD)

Baseline T1

7.38 (3.76)

7.69 (3.31)

Post-test T2

7.61 (3.43)

8.96 (4.55)

Changes in EPDS

0.23 (3.27)

1.27 (4.21)

Baseline T1

66.01 (7.17)

66.56 (8.35)

Post-test T2

65.44 (8.43)

Changes in PSSS

-0.57 (6.05)

t

P

EPDS

0.556

-1.35 to 0.73

-2.24

0.026*

-2.53 to -0.16

-1.84

0.067

-2.14 to 0.08

-0.47

0.639

-2.83 to 1.74

61.82 (9.99)

2.63

0.009*

0.90 to 6.34

-4.73 (8.26)

-3.86

0.000*

-6.30 to -2.04

30.90 (3.87)

-0.88

0.379

-1.76 to 0.68

Post-test T2

35.87 (4.41)

32.79 (6.86)

3.59

0.000*

1.39 to 4.78

5.52 (4.19)

1.88 (6.07)

-4.67

0.000*

-5.17 to -2.10

Changes in PSOC-E

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ed

30.36 (4.40)

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Baseline T1

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-0.59

PSSS

PSOC-E

95% CI

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The study group

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Time measured

Note. EPDS: Edinburgh Postnatal Depression Scale; PSSS: Perceived Social Support Scale; PSOC:

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Parenting Sense of Competence Scale-Efficacy subscale. * p < 0.05.

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