Postpartum Women

Descriptive statistics (means with standard deviations or frequency distributions) on age, education, work status, and perceived adequacy of income were calculated for each sample and for the combined samples. Comparisons of such demographic variables between the three samples were done using one-way ANOVA for comparing age, the chi-squared test for comparing work status, and Fisher exact test for comparing education and perceived adequacy of income [Table 1].
The internal consistency reliability and the test-retest reliability of the Arabic PSS-10 were assessed using Cronbach's alpha coefficient and Spearman's correlation coefficient (rho) respectively. Internal consistency was evaluated for the combined sample as well as for each of the three women groups (student, pregnant, and postpartum) [Table 2]. The test-retest reliability was performed for the combined group of all women who accepted to do the retest. Subgroup reliability measures were computed for the student group and the combined pregnant and postpartum participants since only 4 pregnant women did the retest.
Exploratory factor analysis was performed using principal components with varimax rotation [Table 3]. Mean PSS-10 and GHQ-12 scores were compared between the three groups using the one-way ANOVA. Post-hoc comparisons were done using Bonferroni's method. Mean EPDS scores were compared between the pregnant women group and the postpartum women group using the independent t-test [Table 4].
Questions about stressful life events were coded from 0 (event did not occur or event occurred and the participant said that it had no impact on her) to 3 (event occurred and participant said it had a severe impact on her) with increasing values indicating increased impact of the event on a person's life. A stressful life event score was computed by adding the scores of all the questions about stressful life events. This event score was compared among the three groups using the Kruskal-Wallis test. Post-hoc comparisons were made using Bonferroni's method. Its correlation with the PSS-10 score was computed using Spearman's correlation coefficient. Finally, a multivariable analysis of covariance (ANCOVA) regression model was fit with PSS-10 score as the response variable and group as the independent variable (using two indicator variables as group is a nominal variable) while adjusting for the following covariates: age, educational level, stressful life event score, work status, and perceived income adequacy.

Our study population includes all women aged 15–49 years who participated in the CLIP trials between September 2013 and May 2018. Samples of pregnant or postpartum women with complete data on where the woman came from to access care, where care was sought, as well as paired data on both self-reported and geographically modelled travel time to care facilities in the three study sites were included in the study. The final participating samples included into the study were 555 women in Mozambique, 517 in India and 159 pregnant women in Pakistan. These women qualified for inclusion to answer the first objective of the study. Of these, 265 women in Mozambique, 293 women in India and all the 159 women in Pakistan qualified to answer the second objective of the study. Figure 2 below shows the inclusion/exclusion sample flow in this analysis.Fig. 2

Study sites with final participating samples per study site

Initial questions were written to correspond directly with the DSM-5 criteria (criterion A, symptoms B-E, onset, duration, and distress) but be specific to childbirth. These initial questions were then reviewed by two groups to check face validity, content validity, and ease of comprehension. First, the questions were reviewed by a group of nine researchers with expertise in perinatal mental health research. These researchers ranged from doctoral to professorial level and were from psychology or mental health nursing. After that, questions were revised and then reviewed by a second group of eight women aged 21–34 who were members of the maternal health Research Advisory Group at the university and whose youngest children were aged between 13 months and 4 years. As a result of review by these groups, changes were made to the instructions of the questionnaire and wording of many items.
This development stage resulted in a questionnaire that comprised 31 questions: 29 questions which map onto DSM-5 diagnostic criteria; and 2 questions from DSM-IV criteria (one for criterion A2; and one on symptoms of emotional numbing). The question on A2 was included on the basis of evidence that it might be important in postpartum PTSD. The question on emotional numbing was included following review by the group of postpartum women who strongly recommended it be retained because of its relevance to them and potential impact on the mother-baby relationship.
The response scale for symptoms asks for frequency of symptoms over the last week and is scored on a scale ranging from 0 (“not at all”) to 3 (“5 or more times”). A higher score indicates greater severity of symptoms of PTSD. Diagnostic criterion A items were scored on a yes/no scale. Distress, disability and potential physical causes were rated as yes/no with a third response category of “maybe” for women who were not sure. The “maybe” category was added after review by postpartum women (as above). A copy of the City Birth Trauma Scale is available as online Supplementary Material.

IVON-IS will be conducted in Lagos State, South West, Nigeria. Specifically, implementation outcomes will be tested in a cluster of six health facilities that have not yet been exposed to training or implementation related to the ongoing IVON trials. The facilities span public (government-owned) and private (individual/organisation-owed) sectors in the state. The cluster will include one tertiary hospital, two secondary hospitals, one comprehensive primary health centre (PHC) in the public sector, and two private hospitals with varied patient bases. The selected facilities will be in proximity and linked to the state’s existing referral process. The cluster will represent a sub-unit of the health system and reflect the points of antenatal and postnatal care for pregnant women. Indeed, in Lagos, public health facilities manage 27% of deliveries in the state, while private health facilities take up about 48% [27 ]. Using projected data from our ongoing IVON clinical trials, we estimate that we will screen about 4000 pregnant and postpartum women per annum and have approximately 400 women eligible for treatment for anaemia.