Reliability and validity scores are significantly high. A

pilot group of 40 subjects were given the questionnaire by

Pitt (1968) at 28 weeks and 34 weeks of pregnancy. Test-

retest reliability was indicated by the correlation between

their scores on these two occasions. The correlation co­

efficient, assessed by Pearson Bravai's Product Moment, was

significantly high: + 0.76 (t = 7,2; df * 38; p< 0,001).

In order to test validity, Pitt (19€8) gave 40 subjects the

questionnaire and then interviewed them. The interviewer,

ignorant of their questionnaire score, r.ited them according

to the Hamilton Rating Scale for Depression. Subjects were

then ranked according to their clinical rating and

questionnaire scores. The correlation between their rank

orders on the two assessments was an indication of the

validity of the questionnaire. Spearman's rank correlation

was, in fact, significantly high: + 0,78 (t ■ 7,7; df = 38;

p< 0,001) .

Means and standard deviations wore calculated by Pitt ( 1968)

from the scores of 164 subjects. A moan of 11,89 (SD * 7,7)

was obtained for women tested at 7-10 days postpartum, while

a mean of 11,82 (SD ■ 7,9) was obtained for women tested at

6-8 weeks postpartum.

Pitt's Depression Questionnaire (1968) is v o w e d as one of

the most accurate measures of postpartum depression. It has

109

been successfully used in a number of studies (Brc ;n, 1975).

To date, it remains the only questionnaire designed

specifically to measure postpartum depression.

4 .2.2 Biographical Questionnaire (App< : 4)

A biographical questionnaire, based on that of Chalmers

(1979) was drawn up in order to obtain a detailed sample

description. The questionnaire explored a varying field of

personal information. The areas included nationality,

occupational activities, religious affiliation, marital

history, educational levels, socio-economic status, previous

psychiatric difficulties and treatment, expected abilities to

cope with the baby and the question of whether the baby was

planned or not.

4.2.3 Measurement of S ocial Support (Appenuices 7 and 8)

To date, no measure exists which assesses social support

specifically in the postpartum period. For the purposes of

this study, i special measurement technique was devised. It

was designed to measure both the structure and quality of

social support relationships. Following the majority of

measures in the field, the present scale aimed to assess

suppoit as perceived by the mothers. House (1981) states

that social support is likely to be effective only to the

extent to which it is perceived. This method was considered

110

preferable to unstructured tester rating, which also lends a

subjective bias.

The discussion in Chapter 2.3.1, shows that most

fundamental in the concept of social support is the emotional

aspect. This was the social support quality tapped in the

present scale. According to Kaplan and Blackman (1969) the

most significant support convoys to a mother in the early

postpartum period are, husband, family, doctor and other

hospital staff. To facilitate uniformity and closer control

in the assessment of responses, these four networks were

studied. Paykel et. a K (1980) criticizes many self-rating

social support scales that view only the spouse as a vehicle

of support. The inclusion of 'other patients' as a rating

v a r i a b l e was considered, but subsequently omitted due to the

fact that many patients were in private wards and that the

influx of patients was constantly changing.

The scale was devised to present a complex task in a

simplified form for easy comprehension and self­

administration. Subjects were requested to rate the degree

of perceived emotional support from husband, family, doctor

and hospital staff. Thir< rating was according to a Likert-

type rating scale which included the following levels:

i. No jupport.

ii. A little, but not enough

iii. Adequate, but could have been better

111

iv. Good

v. Very good

v i. Excellent

These levels ensured that a wide range of supportive

responses were assessed. The scores ranged from 0 (no

support) to 5 (excellent) with a possible maximum score of 20

and a minimum of 0.

4.2.4 Measurement o f Locus of Control (Appendices 9 and 10)

To assess each individual's locus of control, Rotter's (1966)

S c a l e to Measure Internal versus External Control was used.

The instrument is designed to measure generalized

expectancies for internal versus external control of

reinforcement. The I-E scale consists of a 29-item, forced

choice questionnaire. Six of these items are fillers adapted

from the 60-item Jones Scale (Lefcourt, 1982). The remaining

23 items offer choices between internal and external belief

statements. The scale is scored by summing the number of

external beliefs endorsed. A high score therefore indicates

a high external locus of control, while a low score indicates

a high internal locus of control.

According to Robinson and Shaver (1970), a Kuder-Richardson

internal consistency analysis of the I-E scale yielded

r = 0,70. Test-retest reliabilities of the I-E scale for

females yielded an increase following a one month time lapse

112

between testing, and a decrease in reliability after a two

month interval. According to Rotter (1966), part of this

decrease was due to differences in administration.

Correlations tor validity with the Marlowe-Crowne Social

Desirability Scale (1964) ranged from - 0,07 to - 0,35.

Several factor analyses reported by Katter (1970) support the

assumption of unidimensionality of the scale, and numerous

laboratory and survey studies give evidence for its construct

validity (Robinson and Shaver, 1970).

After evaluating the critical research on the I-E scale,

Lefcourt (1982) suggests that:

"If one wyre now to summarize the current

status of assessment tools used in the study of

locus of control, it would be possible to

conclude that there is enough evidence to

encourage investigators to both continue in

their use of existing devices and to develop

newer, more criterion-specific measures"

(Lefcourt, 1982, p. 179-180).

In the light of the above conclusion, the Rotter Scale was

considered the tool of choice in determining locus of control

in the new mother. Although the Rotter Scale has not been

standardized for a white, South Atrican postpartum sample, it

has been previously successfully used in two South African

research programmes involving White, pregnant, South African

women (Chalmers, 1979; Friedman, 1979).

In order to assess the obstetric birth risk facing the mother

and baby in the light of the occurrence of any complicating

factors in the maternal medical history, Littman and

Parmalee's (1974) scoring methcd was utilized.

The scoring form lists 41 separate items and is based on the

Prechtl (1968) system of optimal scoring, i.e. each category

is believed to be associated with increased risk of infant

mortality and therefore would be likely to have an effect on

development if the infant survived. Scoring involves

attributing a score of one to each optimal condition (i.e.

non-complication condition) experienced by the mother or baby

during the c o u r s e of the pregnancy or delivery. At the

conclusion of scoring, the optimal responses are summed. For

the purposes of the present study information regarding non-

optimal responses was required. This was obtained by

calculating the difference between the maximum optimal score

and the attaint'd optimal score for each subject. This

procedure rendered no violation of the essential nature of

the complication score of Littman and Parmalee (1974).

Chalmers (1979) conducted an extensive factor analysis of

this measure. Her aim was to examine whether:

4.2.5 Measurement of Neonatal Birth Risk (Appendix 11)

"the 'risk' score was essentially a measure of

degree of disorder in pregnancy or a simple

count of the number of complications occurring

in a pregnancy" 'Chalmers, 1979, p. 238).

114

T

The results of thp analysis showed that the 'risk' score did

not constitute a homogenous unitary scale of pregnancy

disorders, but rather reflected a total score of a number of

possible complications arising in pregnancy and delivery.

The twelv ' factors identified by Chalmers (1979) were;

i. 'Maturity' - including estimated gestational age,

placental weight, weight of the infant and an estimate

of maturity of the child.

ii. 'Stage Three' - including length of stage three and

placental measures, viz. delivery by Modified Brandt-

Andrews, normal and manual methods, as well as other

complications of the placenta or its delivery.

iii. 'Method of Delivery' - including normal delivery,

caesarean section and amount of haemorrhage.

iv. 'Apgar Rating' - including the two Apgar ratings of the

baby's well-being taken at one and five minutes after

birth.

v. 'Stage Two' - including length of stage two of the

delivery, the use of forceps during delivery,

episiotomy and normal delivery.

vi. 'Labour Onset' - including spontaneous onset of labour

and the use of oxytocin for induction or assisted

delivery.

115

vii. 'Admissions' - including premature labour, infection or

other complications requiring hospital admission prior

to delivery.

viii. 'Stage One' - including length of the first stage of

labour and artificial rupture of membranes.

ix. 'Metabolic Imbalance' - including ketones and albumin,

both measured by urine tests.

x. 'Membranes' - including only the presence of complete

membranes at delivery.

xi. 'Toxaemia' - including hypertension and oedema.

xii. 'Blood Incompatibility' - including only blood

incompatibility occurring in the pregnancy. Only one

of the variables, 'normal delivery', loaded

significantly on more than one of the 12 factors

(Factors 3 and 5) indicating the presence of a fairly

clear factor structure (Chalmers, 1979).

The choice of Littman and Parmalee's (1974) scoring method

was based largely on its' existance as one of the most

comprehensive, yot least conplox of th<’ frw measures designed

for this purpose, and that it was effectively employed in a

previous South African research programme involving White

mothers (Chalmers, 1979).

116

4.2.6 Measurement of Obstetric Interventions (Appendix

13)

No instrument exists within the field of psychology or

obstetrics to assess women's perceptions of obstetric

procedures.

Three major limitations are apparent in obstetrical research.

The first is that only a few specific procedures have been

assessed with regards to their impact on women. Oakley and

Chamberlain (1981), in assessing affective states and medical

procedures at birth, merely asked women whether instruments

and/or epidural anaelgesia had been utilized. This research

also highlights the second major problem of measurement, i.e.

that generalized statements regarding the effects of

obstetrical procedures are often made on the basis of only a

few interventions under study. Tne third problem, is that

studies have researched obstetric procedures in a global

manner, attributing the same importance to both major and

minor procedures (Grossman et a l . , 1980). To date, no

studies have scientifically measured the varying effects of

different interventions and the degree of stress or ease with

which women respond to them.

In order to allow more accurate comparisons and predictions

to be made as to the effects of obstetric interventions on

postpartum depression, a specific check-list was devised.

The aim of the check-list was to obtain objective mean

ratings as to the stressfulness of each intervention. These

responses could then be summed, to yield a total score of

mothers' attitudes to obstetric interventions. Such a

scientific objective measure would facilitate statistical

calculation as to the contribution of obstetric procedures to

the development of postpartum depression.

To obta in <t stress r a ting to r c ach obstetric technique used,

a separate research programme was conducted. On-' hundred

early postpartum mothers were selected according to the same

criteria as those of the major sample. All were patients at

the Johannesburg General Hospital. These women were asked to

rate n number of interventions on a constructed check-list,

(Appendix 12, Obstetric Interventions Checklist 1) according

to their own experience of the ease, difficulty, stress,

intrusiveness or relief associated with each. The rating

choice ranged from 0 to 10, where 0 indicated no negative

associations, and 10 indicated maximal stress and difficulty

associated with the intervention. In the list given to

mothers, complex technical terminology was simplified.

The check-list comprised antenatal, natal and postnatal

obstetric procedures (Appendix 12). The it«*ms were devised

by consulting hospital records, obstetricians and obstetric

textbooks (Chamberlain, 1980; Llewellyn-Jones, 1971). The

list indexed all possible procedures, both rare and common,

118

which are practiced at birth. The followinq sections were

delineated:

A. Antenatal Interventions

B. First Stage Intervertions

C. Second Stage Interventions

- Maternal

- Foetal

D. Third Stage Interventions

- Placenta

_ Cord

E. Postnatal Interventions

- Infant

- Maternal

F. Other

All ratings from the women were summed, and mean ratings for

each procedure on the check-list were obtained. Table 3

in Chapter 5.2 indicates the objective mean rating weights

and standard deviations obtained for each obstetrical

procedure.

These rating weights represent objective values for each

obstetric intervention. The rating weights obtained from

these subjects could therefore be used as objective measures

for the second group of subjects included in the major

research programme. Holmes and Rahe (1967) argue that this

method is more reliable and valid than obtaining subjects'own

subjectively perceived ratings.

In order to assess the effects of obstetric interventions on

postpartum depression, the author recorded which medical

interventions wore experienced by women (Appendix 13). The

information was obtained from hospital records and nursing

staff and, where necessary, obstetricians and the women

themselves (for example, details of shaving and placement of

the infant, which were not included in records). The lists

were then scored according to the mean rating weights

previously obtained. The scores for each intervention were

then summed and a single total value was acquired. These

final values indicated measures of mothers' attitudes to the

obstetric interventions they experienced.

4.3 Procedure

The names of all primiparous women who were maternity

patients at the Johannesburg General Hospital were located

from hospital files over a period of five months. The tester

briefly interviewed these women in order to assess their

120

suitability for the study according to the criteria discussed

in Chapter 4.1.1, i.e. primiparous, married, no congenital

anomalies in the baby, and no psychiatric history in

pregnancy. The hospital is exclusively for White patients,

therefore this control was already established.

Appropriate subjects w.>re selected and invited to participate

in the study. The language preference (English or Afrikaans)

of each woman was established. All further communications

and questionnaires wore administered according to the stated

preference of each individual. Subjects were told that

research was being carried out by the School of Psychology of

the University of the Witwatersrand, in order to assess how

women felt in the first week after giving birth to their

first oaby. Assuran:e as to the confidentiality of answers

was given. Ail women who agreed to participate in the study,

signed consent forms (Appendices 1 and 2). To prevent the

calculation of expected responses by the subjects, specific

details regarding the aims of the study, i.e. the

assessment of postpartum depression and its relation to the

independent variables, were not explained.

Testing was conducted over a period of five months. All

subjects were tested between the third and seventh day after

birth (32% on the third day; 30% on the fourth; 25% on the

fifth; 11% on the sixth; and 2% on the seventh). In order

to ascertain whether the day of interview influenced

121

me as urement of depression, an analys is of variance procedure

was performed. The results showed no correlat ion oetween the

day of testing and the incidence of post par tuin depression

(F = 1,08; df = 2; p> 0,05).

Subjects were tested in hospital. The tester distributed the

Biographical, Social Support, Locus of Control and Depression

Questionnaires to each subject for self-administration.

Distribution, completion and collection of questionnaires was

carried out on the sam-> day for each woman. Subjects were

asked not to obtain help with the completion of

questionnaires. Separate instructions for the different

measures were given in the respective questionnaires.

The Birth Risk and Obstetric Interventions Checklists were

filled out by the tester. The required information was

obtained from hospital records, staff, and where necessary,

the patients themselves. These lists were completed by the

tester while mothers completed the four self-administered

questionnaires. This ensured that the tester was unaware of

depression scores, rendering a 'blind' rating of risk and

obstetr ics.

Finally, all questionnaires and check-1ists were collated and

scored according to the methods outlined in Section Chapter

CHAPTER FIVE

RESULTS

5.1 Aims of the Data Analysis

The aims of the present, study were stated in Chapter 3 as:

i. To assess the possible contribution of neonatal birth

risk, locus of control, social support and obstetric

interventions to postpartum depression.

ii. To assess the relative importance of these factors in

contributing to postpartum depression.

The aims of the data analysis were therefore to measure the

explanatory and predictive efficacy of neonatal birth risk,

locus of control, social support and obstetric interventions

on the dependent variable of postpartum depression. To

fulfill this aim, a Forward Selection Regression Procedure

was performed.

A further aim of the data analysis was to obtain stress

ratings for each obstetric technique listed in tne

Obstetrics Interventions Checklist 1 used in the preliminary

study. Mean scores and standard deviations were calculated

in order to fulfill this aim.

123

5.2 Mean Scores and Standard Deviations for the Obstetric

Interventions Checklist 1

Table 3 shows the mean scores and standard deviations

obtained for procedures included in the Obstetric

Interventions Checklist 1.

From Table 3 it is evident that the highest mean ratings

obtained were for a "caesarean section under general

anaesthetic" (M = 6,70; SD * 2,95), and for "operative

removal of the placenta" (M = 6,70; SD = 2,60).

"Amniocentesis" followed closely, with a mean rating of 6,67

(M = 6,67; SD = 2,43). The lowest ratings were those of

"childbirth preparation classes" (M = 1,67; SD = 1,24),

and "covering of the infant" (M = 1,61; SD = 1,08).

Further low ratings were located for "natural urinary bladder

emptying" (M = 1,95; SD » 1,07), and "cleaning of the

infant" M = 1,97; SD = 1,03).

124

Mean stress ratings and standard deviations for

Obstetric Interventions Checklist 1.

n = 100

Intervent ion Mean

(Range 0-10)

Standard

Deviation

A. Antenatal

Examination - clinical 2,02 1,47

Examination - laboratory 2,44 1,99

Non-stress test 3,20 3,03

Oxytocin challenge test 5,27 2,84

Sonar 2,11 2,05

X-rays 2,60 1,76

External cephallic version 5,78 2,87

Amn iocentesis 6,67 2,43

Medicat ion 4,76 2,83

Childbirth preparation classes 1 ,67 1,24

B. First Stage

Shaving - pubic 3,07 2,57

- perineal 3,09 2,81

- umbilicus to pubis 3,52 2,82

Bowel preparation

- suppositories 4,05 2,53

- fleet enema 4,52 2,65

Analgaes ic

- Pethidine/Atarax 3,59 2,76

- Gas 4,21 2,38

Table 3 (continued)

Intervent ion Mean

(Range 0-10)

Standard

Deviation

B. First Stage (continued)

Urinary bladder emptying

- natural 1,95 1,07

- catheterization 5,11 3,04

Drip (Dextrose water) 4,98 3,13

Surgical induction of labour 4,86 2,84

(A.R.O.M.)

Pharmacologica1 induction of

labour - oxytocin/syntocinon 5,23 3,15

- intravaginal prosta­

glandins (E2/F2) 4,82 2,79

C. Second Stage

Materna1

Position- supine 4,57 3,08

- lithotomy 5,61 2,94

Epis iotomy 5,41 3,21

Forceps - Andersons 6,18 2,63

- Wriggleys 5,95 2,62

- Keillands 6,05 2,66

Vacuum Extraction 6,02 2,62

Caesarian Section

- with local anaesthetic 6,50 2,88

- with general anaesthetic 6,70 2, 95

Breech - delivery 5,82 2,70

- extraction 6,00 2,61

- Pinnard's manoeuvre 6,05 2,61

- Loveset's manoeuvre 5,89 2,50

- other manoeuvres 5,64 2,55

Cervical manipulation 6,45 2,50

126

Table 3 (continued)

Intervent ion Mean

(Range 0-10)

C. Second Stage (cont inued)

Analgesic injections

- Pethidine/Aterax

Local anaesthetics

- local infiltration

- pudendal block

- epidural

- spinal

Other drugs - Syntometrine

- Ergometrine

Antimicrobial agents

- one

- more than one

4,25

4.68

4,93

5,80

5.68

4.45

4.45

3,02

3,61

Standard

Deviat ion

2,75

2, 59

2 , 68

2,83

2,88

3.19

3.19

2,41

2,81

Foeta1

Foetal heart monitor

External pressure monitorinq

Intrauterine pressure monitoring

Third Stage

3,23

3,18

5, 30

2,93

2,76

2,87

Piacenta

Delivery- natural 2,73

- modified Brandt Andrews 3,68

(with cord traction)

- complicated - manual 5,68

- operative 6,70

2,04

2,00

2,47

2,60

Cord

Clamped and cut immediately

Manually slipped over head

Palpation of pulsation of cord

2,43

3,70

3,73

2,28

2,73

2,77

127

Table 3 (continued)

Intervention Mean

(Range 0-10)

Standa rd

Deviat ion

E. Postnatal

Infant

Resusci tat ion

- airways cleared 3,34 2,01

- oxygen mask 4,02 2,96

- manual positive pressure 4 , 34 2,85

vent ilat ion

- intubation 5,20 3,05

- cardiovascular drugs 5,32 3,23

- cardiovascular massage 4,77 3,23

Eyedrops (silver nitrate) 2,80 2,57

Vitamin Kl injection 2,61 2,33

I ncubator 4, 30 2,32

Cleaning of infant 1,97 1,03

Covering of infant 1,61 1,08

Placement of infant

- mothers stomach 1,86 1,04

- table 3,55 2,77

- cot 3,45 2,17

Materna1

Clinical obstetric examination

- by medical team 3,16 2,38

Laboratory examination

- blood, urine tests 2,98 2,37

Suturing of episiotomy or tear 5,34 2,96

Curettage 6, 34 2,45

Examination of placenta 2,20 1,73

Examination of cord 2,02 0,88

128

5.3 Mean Scores and Standard Deviations for the Dependent

and Independent Variables

Mean scores and standard deviations were calculated for the

dependent variable of postpartum depression, and the

independent variables of social support, obstetric

interventions, locus of control and birth risk. The results

are shown in Table 4.

Table 4

Mean scores and standard

independent variables.

deviations for the

n = 87

dependent and

Variable Mean

Standard

Deviat ion

Postpartum Depression 19, 59 11,74

Social Support 14,66 4,76

Obstetric Interventions 117,12 19,93

Locus of Control 10,5 4,2

L

r

5.4 The Forward Selection Regression Analysis

The explanatory and predictive efficacy of the independent

variables of social suoport, obstetric interventions, locus

of control and birth risk on the criterion of postpartum

depression, was assessed within the framework of a Forward

Selection Regression Procedure. Table 5 is a summary of the

results of this analysis.

Table 5

The determinants of postpartum depression: summary of the

Forward Selection Regression Analysis.

n - 87

Independent Vari­

able entering

equat ion

Step Multiple R

2 F* in final

R Change equation

(Step 4)

Social Support

Obstetr ic

Intervent ions

Locus of

Cont rol

Birth

Risk

Var iables

Comb i ned

2

3

0,192

0,223

0,229

0,235

0, 235

2

0,037

0,013

0,003

0,004

0,004

15 .07**

3,51

0,72

0,61

6, 30**

*F tests the null hypothesis R

1 1

df /4 - k - 1,

** p < 0,0002.

130

* 0 with

/87 - 4 - 1 / 8 2 .

From Table 5, it is evident that social support was the only

independent variable which made a significant contribution to

postpartum depression (F = 15,07; p < 0,0002). Obstetric

interventions, locus of control and birth risk made no

significant independent contribution to the variance of

postpartum depression. Social support remained a significant

predictor when the effects of obstetric interventions, locus

of control and birth risk had been partialled out, and

appeared therefore to be the best predictor variable.

At the final step of the analysis an optimal linear

combination of the four independent variables accounted for a

significant proportion of the variance of the dependent

variable (F = 6,30; p < 0,0002). Social support, obstetric

interventions, locus of control and birth risk explained 5,7%

of the variance of postpartum depression (Cumulative

CHAPTER SIX

DISCUSSION

The aim of the study was to identify factors at the time of

birth that are predictive of maternal adaptation problems in

the postpartum period. The following discussion integrates

the previously mentioned results and explores the

implications of these findings. The independent variables,

viz., social support, locus of control, obstetric

interventions and birth risk were assessed individually and

in combination against the criterion of depression. In

addition, the mean stress ratings and standard deviations

obtained for items included in the Obstetric Interventions

Checklist 1 are discussed.

6.1 Social Support

Social support was the only variable to make a significant,

independent contribution to the variance of postpartum

depression (F = 15,07; p < 0,0002). Although this result is

significant within the statistically accepted level of 0,05,

it must be interpreted conservatively, since the proportion

of variance explained by social support is in fact, only

3,7% .

132

Author Cooke W L Name of thesis Some determining factors of postpartum depression 1985

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