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He X, Wang X, Li G, Zhu S, Wu Y, Sun X, Wu Y, Hu B, Wu J, Feng L, Li G, Zhang L, Wang N, Li X. Influencing factors of depressive symptoms during pregnancy in Beijing, China. Front Psychiatry 2025; 16:1500034. [PMID: 40027599 PMCID: PMC11868264 DOI: 10.3389/fpsyt.2025.1500034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2024] [Accepted: 01/31/2025] [Indexed: 03/05/2025] Open
Abstract
Objective Prenatal depression is a prevalent mental health challenge encountered during pregnancy and is notably associated with adverse maternal and neonatal outcomes. This study aimed to elucidate the likelihood and determinants of depressive symptoms among pregnant individuals in Beijing, thereby laying a foundational framework for the theoretical underpinning of prenatal screening and preemptive interventions for mental disorders. Methods The study dataset was derived from 4,564 pregnant individuals in Beijing utilizing a cross-sectional survey methodology. Data collection focused primarily on the personal and obstetric information of the participants. The Edinburgh Postnatal Depression Scale (EPDS) was employed as the primary screening tool to identify depressive symptoms. Results The prevalence of depressive symptoms among the included pregnant individuals was 4.1%. The univariate analysis results revealed statistically significant differences in the incidence of depressive symptoms in women with different parities, numbers of births, medication use, numbers of abortions, prepregnancy weights, and body mass indices (BMIs) (the χ2 values were 61.130, 52.008, 23.291, 5.293, and 12.681, respectively; P<0.05). There were statistically significant differences in the incidence of depressive symptoms among women with different occupation types (χ2 = 30.263, P<0.01). The multivariate logistic regression analysis results revealed that a greater number of pregnancies, number of births, and BMI were risk factors for prenatal depression, whereas the commercial and service worker occupation types were protective factors against prenatal depression. Conclusion Future directives should emphasize the enhancement of screening for depressive symptoms among pregnant individuals with greater parity and BMIs, alongside encouraging continued employment and flexible job selection. It is imperative to implement suitable intervention strategies for pregnant individuals exhibiting depressive symptoms to mitigate the incidence of adverse maternal and neonatal outcomes.
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Affiliation(s)
- Xiayue He
- Department of Psychiatry and Mental Health, Beijing HuiLongGuan Hospital, Beijing, China
| | - Xiaoqian Wang
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Guoguang Li
- Department of Psychiatry and Mental Health, Fourth People’s Hospital of Liaocheng, Liaocheng, Shandong, China
| | - Simin Zhu
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yifan Wu
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xiaotong Sun
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuze Wu
- Department of Psychiatry and Mental Health, Beijing HuiLongGuan Hospital, Beijing, China
| | - Bo Hu
- Department of Psychiatry and Mental Health, Beijing HuiLongGuan Hospital, Beijing, China
| | - Jianyin Wu
- Department of Psychiatry and Mental Health, Fourth People’s Hospital of Liaocheng, Liaocheng, Shandong, China
| | - Lina Feng
- Department of Psychiatry and Mental Health, Yanqing District Mental Health Center of Beijing, Beijing, China
| | - Guihong Li
- Department of Psychiatry and Mental Health, Beijing Daxing Xinkang Hospital, Beijing, China
| | - Lei Zhang
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ning Wang
- Department of Psychiatry and Mental Health, Beijing HuiLongGuan Hospital, Beijing, China
| | - Xuehan Li
- Department of Psychiatry and Mental Health, Beijing Daxing Xinkang Hospital, Beijing, China
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Yang CF, Chang SR, Yang YL, Lin WA, Chen SU, Lee CN. Depressive symptoms during pregnancy and postpartum: associations with mode of conception and demographic and obstetric factors. PSYCHOL HEALTH MED 2024; 29:1820-1834. [PMID: 39355977 DOI: 10.1080/13548506.2024.2407442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/15/2024] [Indexed: 10/03/2024]
Abstract
An increasing number of women are conceiving through assisted reproductive technology; however, few studies have investigated their mental health after successful conception. This study investigated the changes in depressive symptoms in women using assisted reproductive technology and the association between the mode of conception and perinatal depressive symptoms. A longitudinal observational study was conducted from 2015 to 2019, 542 pregnant women completed questionnaires on depressive symptoms at eight timepoints during the prepregnancy, pregnancy and first-year postpartum periods. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. A generalized estimating equation regression model was employed for repeated measures. In the assisted reproductive technology group, depressive symptoms were more prevalent during early pregnancy and at 1 month postpartum than before pregnancy, and more prevalent before pregnancy and at 1 month after childbirth than in the spontaneous conception group. No significant association was identified between the mode of conception and depressive symptoms during the antenatal or postnatal period. The lack of full-time employment and prepregnancy depressive symptoms were associated with antenatal depressive symptoms. Primipara status and depressive symptoms during prepregnancy and pregnancy were associated with depressive symptoms during the first-year postpartum. Assisted reproductive technology was not a risk factor for depressive symptoms during the pregnancy and postpartum periods, whereas primipara status, lack of full-time employment and prepregnancy depressive symptoms were negative predictors. Therefore, targeted mental health interventions should address these specific factors to effectively support maternal mental health.
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Affiliation(s)
- Cheng-Fang Yang
- Second Degree Bachelor of Science, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Yunlin Branch, Yunlin, Taiwan
| | - Shiow-Ru Chang
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ya-Ling Yang
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-An Lin
- Department of Occupational Medicine, Ten-Chan General Hospital, Taoyuang, Taiwan
- Department of Environmental and Occupational Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shee-Uan Chen
- Department of Obstetrics and Gynecology, National Taiwan University, Taipei, Taiwan
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Nan Lee
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
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Kiyak S. The relationship of depression, anxiety, and stress with pregnancy symptoms and coping styles in pregnant women: A multi-group structural equation modeling analysis. Midwifery 2024; 136:104103. [PMID: 38986391 DOI: 10.1016/j.midw.2024.104103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 05/11/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND The changes during pregnancy can increase susceptibility to mental health problems such as depression, anxiety and stress, which is why coping strategies are so important. The aim of this study is to investigate the relationships between depression, anxiety, stress, pregnancy symptoms and coping styles in pregnant women across trimesters, using a multigroup structural equation model. METHODS This cross-sectional and correlational study was conducted with 301 pregnant women who applied to the prenatal clinic of a state university's medical faculty. A hypothetical model was created based on transactional stress and coping theory and literature reviews. Data were collected using a participant information form, the Depression Anxiety Stress Scale, the Pregnancy Symptom Inventory and the Stress Coping Styles Scale. RESULTS Among pregnant women, 40.9 % had symptoms of stress, 52.8 % of anxiety and 37.2 % of depression. Pregnancy symptoms and emotion-focused coping are positively associated with depression, anxiety, and stress (β = 0.468-0.590; β = 0.222-0.373 respectively). Problem-focused coping is negatively associated with depression, anxiety, and stress. (β = -0.255:-0.389). Problem-focused coping is negatively associated with pregnancy symptoms in the whole sample (β = -0.121) and in the third trimester (β = -0.124). The model explained 51 % of the variance in the 1st, 42 % in the 2nd, and 64 % in the 3rd trimesters. CONCLUSION This study showed that problem-focused coping strategies are negatively associated with depression, anxiety and stress and play an important protective role in this context. These findings contribute to understanding the factors affecting mental health during pregnancy and emphasize the importance of developing problem-focused coping skills for pregnant women.
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Affiliation(s)
- Sibel Kiyak
- Necmettin Erbakan University, Seydişehir Kamil Akkanat Faculty of Health Sciences, Department of Obstetrics and Gynecology Nursing, Anabağlar District, Prof. Dr. Necmettin Erbakan Street No:19 /3 postal code: 42370, Seydişehir Konya Turkey
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Ayrout RA, Kookash MH, Kalalib Al Ashabi K, Safiah MH, Latifeh Y. Exploring prenatal depression and postpartum depression: Findings from a prospective cohort study at University Hospital Obstetrics in Damascus. Medicine (Baltimore) 2024; 103:e38170. [PMID: 38758898 PMCID: PMC11098259 DOI: 10.1097/md.0000000000038170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/17/2024] [Indexed: 05/19/2024] Open
Abstract
The perinatal period is crucial for both mother and newborn, and mental health, including prenatal and postpartum depression (PPD), is a significant aspect. Screening for these disorders allows for early treatment and helps prevent risks to both mother and child. This prospective cohort study was carried out at University Hospital Obstetrics in Damascus City. The first phase was during the third trimester of pregnancy and the second phase involved a follow-up assessment after 6 weeks of delivery. The Arabic-validated version of the Edinburgh Postnatal Depression Scale questionnaire (EPDS) was used. A cutoff of 13 or higher was used to determine the presence of probable depression in both assessments. Of 347 pregnant women, 38.6% had prenatal depression (PND). 295 patients have achieved the second assessment, of which 30.2% had PPD. Furthermore, 42.6% who had PND developed PPD on follow-up. Binary logistic regression indicated that PND was predicted by non-Syrian nationality, paternal absence, poor financial status, number of previous pregnancies, and a history of depression independent of pregnancy. PPD was predicted by a history of PPD, and work status. Findings underscore potential value of early screening for depressive symptoms as a predictive measure. It is recommended that women with a history of depression receive heightened attention and care, irrespective of the timing of their depressive episodes.
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Affiliation(s)
- Ramah Abdo Ayrout
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Majd Hatem Kookash
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | | | - Mhd Homam Safiah
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Youssef Latifeh
- Department of Psychiatry, Damascus University, Damascus, Syrian Arab Republic
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Gerges S, Obeid S, Hallit S. Traversing mental health disorders during pregnancy: Lebanese women's experiences of antepartum depression and anxiety. Ir J Med Sci 2023; 192:2949-2959. [PMID: 37081286 PMCID: PMC10117264 DOI: 10.1007/s11845-023-03371-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 04/11/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Over the past few years, Lebanon-a developing country-has faced a plethora of economic and political challenges, with more than half of the general population presenting depressive and anxiety symptoms. However, when it comes to maternal mental health during pregnancy, the last examination in Lebanon dates far back to 2005. Our study's aim was to help delineate the factors associated with Lebanese women's mental health disorders during pregnancy, namely antepartum depression and anxiety. METHODS We launched a cross-sectional study among Lebanese pregnant women (age ≥ 18 years) between June and July 2021, during the COVID-19 lockdown (N = 433). RESULTS In total, 87.8% of the participants experienced depression (mild to severe), where severe depression was observed in 7.9%. In addition, 70.3% had a significant level of anxiety. Increased pregnancy-specific hassles (beta = 0.93), being Muslim compared to Christians (beta = 3.19), being afraid of an existing aggressor (beta = 8.75), urinary tract infections (beta = 2.02), and higher gestational age (beta = 0.07) were significantly associated with higher depression, whereas higher physical activity index (beta = - 0.09) and increased disordered eating attitudes during pregnancy (beta = - 0.27) were significantly associated with less depression, all accounting for 60.4% of the model's variance. Additionally, increased pregnancy-specific hassles (beta = 0.54), being Muslim compared to Christians (beta = 2.42), urinary tract infections (beta = 1.72), and having been emotionally or physically abused (beta = 1.19) were significantly associated with higher levels of anxiety and could predict 49% of the total variance. CONCLUSION Our study has suggested the existence of factors that have additive effects in potentiating the risk for depression and anxiety among Lebanese pregnant women, namely cultural beliefs, pregnancy-related distress, medical complications during pregnancy, and a history of abuse. Therefore, it would be judicious to implement screening programs targeting pregnant women at risk for antepartum depression and anxiety. In addition, high rates of prenatal depression and anxiety were detected among our sample, supporting that recognizing and treating maternal mental health disorders should be prioritized during antenatal care in Lebanon.
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Affiliation(s)
- Sarah Gerges
- School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, P.O. Box 446, Jounieh, Lebanon
| | - Sahar Obeid
- Social and Education Sciences Department, School of Arts and Sciences, Lebanese American University, Jbeil, Lebanon
| | - Souheil Hallit
- School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, P.O. Box 446, Jounieh, Lebanon
- Research Department, Psychiatric Hospital of the Cross, Jal-Eddib, Lebanon
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
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Răchită AIC, Strete GE, Sălcudean A, Ghiga DV, Rădulescu F, Călinescu M, Nan AG, Sasu AB, Suciu LM, Mărginean C. Prevalence and Risk Factors of Depression and Anxiety among Women in the Last Trimester of Pregnancy: A Cross-Sectional Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1009. [PMID: 37374213 DOI: 10.3390/medicina59061009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
Pregnancy represents a psychologically and emotionally vulnerable period, and research indicates that pregnant women have a higher prevalence of symptoms of anxiety and depression, debunking the myth that hormonal changes associated with pregnancy protect the mother. In recent years, several researchers have focused on the study of prenatal anxiety/depression-emotional disorders manifested by mood lability and low interest in activities-with a high prevalence. The main objective of this research was to conduct an antenatal screening in a cohort of pregnant women hospitalized for delivery in order to assess the prevalence of anxiety and depression. The secondary objective was to identify the risk factors associated with depression and anxiety in women in the third trimester of pregnancy. We carried out a prospective study in which we evaluated 215 pregnant women in the third trimester of pregnancy hospitalized for childbirth at the Obstetrics and Gynecology Clinic of the Târgu-Mureș County Clinical Hospital. The research was carried out between December 2019 and December 2021. The results showed that age and the environment of origin are the strongest predictors of mental health during pregnancy (OR = 0.904, 95%CI: 0.826-0.991; p = 0.029). For women from urban areas, there is an increased probability of falling at a higher level on the dependent variable (moderate depression) (OR = 2.454, 95%CI: 1.086-5.545; p = 0.032). In terms of health behaviors, none of the variables were statistically significant predictors of the outcome variable. The study highlights the importance of monitoring mental health during pregnancy and identifying relevant risk factors to provide appropriate care to pregnant women and the need for interventions to support the mental health of pregnant women. Especially in Romania, where there is no antenatal or postnatal screening for depression or other mental health conditions, these results could be used to encourage the implementation of such screening programs and appropriate interventions.
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Affiliation(s)
- Anca Ioana Cristea Răchită
- Doctoral School, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Târgu Mureș, 540139 Târgu Mureș, Romania
| | - Gabriela Elena Strete
- Department of Psychiatry, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Târgu Mureș, 540136 Târgu Mureș, Romania
- Mental Health Center, Mureș County Clinical Hospital, 540072 Târgu Mureș, Romania
| | - Andreea Sălcudean
- Department of Ethics and Social Sciences, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Târgu Mureș, 540136 Târgu Mureș, Romania
| | - Dana Valentina Ghiga
- Department of Medical Scientific Research Methodology, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Târgu Mureș, 540136 Târgu Mureș, Romania
| | - Flavia Rădulescu
- Department of Endocrinology, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Târgu Mureș, 540136 Târgu Mureș, Romania
| | - Mihai Călinescu
- Graduate of Cluj School of Public Health, Babes-Bolyai University Cluj Napoca, 400347 Cluj-Napoca, Romania
| | - Andreea Georgiana Nan
- First Department of Psychiatry, Clinical County Hospital, 540139 Târgu Mureș, Romania
| | - Andreea Bianca Sasu
- First Department of Psychiatry, Clinical County Hospital, 540139 Târgu Mureș, Romania
| | - Laura Mihaela Suciu
- Department of Obstetrics and Gynecology Clinic II, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Târgu Mureș, 540136 Târgu Mureș, Romania
| | - Claudiu Mărginean
- Department of Obstetrics and Gynecology Clinic II, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Târgu Mureș, 540136 Târgu Mureș, Romania
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Kovacheva K, Rodríguez-Muñoz MF, Gómez-Baya D, Domínguez-Salas S, Motrico E. The socio-demographic profile associated with perinatal depression during the COVID-19 era. BMC Public Health 2023; 23:786. [PMID: 37118763 PMCID: PMC10141819 DOI: 10.1186/s12889-023-15665-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 04/13/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has caused an increase in perinatal depression. The aim of this research was to identify which sociodemographic variables are related to the increase in perinatal depression due to the pandemic. In addition to estimating to what extent they predict perinatal depression, differentiating the prenatal and postnatal periods. METHODS The sample consisted of 3,356 subjects, 1,402 in the prenatal period and 1,954 in the postnatal period. The Edinburgh Postnatal Depression Scale was used to assess depressive symptomatology. A subset of 14 questions was included to collect demographic data. Items from the Spanish version of the Coronavirus Perinatal Experiences Survey were also included. RESULTS Experiencing the change of environment due to COVID-19 as negative and having a history of mental health predict perinatal depression, otherwise having higher education decreases the risk. In the prenatal stage having symptoms compatible with COVID-19 is a predictor of perinatal depression and having more than 3 years living together with the partner and being a housewife decreases the risk. In the postnatal stage being unemployed is a predictor of prenatal depression and being a first-time mother decreases the risk. CONCLUSIONS This study highlights the relevance of sociodemographic status. It is essential to be aware of the risk factors of perinatal depression, to make adequate prevention, and to create health policies to alleviate the consequences of the pandemic.
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Affiliation(s)
- Katina Kovacheva
- Department of Personality, Assessment, and Psychological Treatment, Faculty of Psychology, Universidad Nacional de Educación a Distancia Madrid, Madrid, Spain
| | - María F Rodríguez-Muñoz
- Department of Personality, Assessment, and Psychological Treatment, Faculty of Psychology, Universidad Nacional de Educación a Distancia Madrid, Madrid, Spain.
| | - Diego Gómez-Baya
- Department of Social, Developmental and Educational Psychology, Universidad de Huelva, Huelva, Spain
| | - Sara Domínguez-Salas
- Department of Psychology, Universidad Loyola Andalucía, Dos Hermanas, Seville, Spain
| | - Emma Motrico
- Department of Psychology, Universidad Loyola Andalucía, Dos Hermanas, Seville, Spain
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Artieta-Pinedo I, Paz-Pascual C, Espinosa M, García-Alvarez A, Group TEQ, Bully P. Coping strategies during pregnancy and their relationship with anxiety and depression. Women Health 2023; 63:296-307. [PMID: 36941108 DOI: 10.1080/03630242.2023.2188097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
How individuals perceive and cope with stressful situations may determine their level of anxiety or depression. The identification of coping strategies (CS) in pregnancy could help prevent depression and anxiety (D&A), and their consequent effects on the health of the mother and the baby. A cross-sectional descriptive correlational study was conducted to identify the CS most commonly used by pregnant women in a Spanish population and to evaluate the association of these CS with D&A. A consecutive sample of 282 pregnant women over 18 years of age were recruited when attended midwife consultations and through snowball sampling between December 2019 and January 2021 in the Basque public health system. CS were measured using the RevisedPrenatal Coping Inventory (NuPCI) questionnaire, assigning the score to an avoidant, preparatory or spiritual scale. Cutoff points were established to categorize anxiety and depressive symptomatology, using the STAI-S and EPDS scales. Multivariate logistic regression models were constructed to analyze the association between CS and D&A. The results show that the higher the score on the avoidance subscale, the higher the likelihood of having an anxiety disorder (OR: 8.88 (95 percent Confidence Interval [CI] 4.26-20.1), and depressive symptoms (OR: 8.29 (95 percent CI 4.24-17.4). Multiparous women are more likely to have anxiety (OR: 3.41 (95 percent CI 1.58-7.5) or depressive symptomatology (OR: 4.1 (95 percent CI 2.04-8.53) during pregnancy. These results highlight the need to consider the evaluation of CS used during pregnancy to tailor the care provided, but further studies on the implementation and effectiveness of interventions are needed.
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Affiliation(s)
- Isabel Artieta-Pinedo
- Primary Care Midwife OSI Barakaldo-Sestao Osakidetza Basque Health Service, Bizkaia, Spain
- Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
- School of Nursing, University of the Basque Country, Bizkaia, Spain
| | - Carmen Paz-Pascual
- Primary Care Midwife OSI Barakaldo-Sestao Osakidetza Basque Health Service, Bizkaia, Spain
- Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
- Midwifery Training Unit of Basque Country, Bilbao, Spain
| | - Maite Espinosa
- Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
- Osakidetza Basque Health Service-OSI General Management, Bizkaia, Spain
| | - Arturo García-Alvarez
- Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
- Osakidetza Basque Health Service-OSI General Management, Bizkaia, Spain
| | - The Ema-Q Group
- The ema-Q Group: Multidisciplinary Group of Midwives, Medical Professionals, Psychologists and Researchers of Osakidetza Basque Health Service and University of Basque Country, Bizkaia, Spain
| | - Paola Bully
- Methodological and Statistical Consulting, Bizkaia, Spain
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ERGUT N, KESER E. Testing the efficacy of the Virtual Body Project in a sample of Turkish female university students using a Randomized Controlled Trial. KLINIK PSIKOLOJI DERGISI 2022. [DOI: 10.57127/kpd.26024438m000103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The current study aimed to test the effectiveness of the Virtual Body Project (vBP) on self-esteem, disordered eating attitudes, and psychological symptoms in young females. A pretest posttest control group design was used in the study. The intervention (vBP, N = 40) and placebo (Expressive Writing, N=33) groups were determined using random assignment. The Body Mass Index (BMI), Brief Symptom Inventory (BSI), Eating Disorder Examination Questionnaire (EDE-Q), Body Image Quality of Life (BIQLI), and Rosenberg Self-Esteem Scale (RSES) were administered. The groups did not differ in terms of pretest scores. However, the intervention group had significantly lower EDE-Q, BIQLI, BSI scores, and higher RSES scores than the placebo group in the post-test assessment. Within-subjects comparisons showed that the placebo group’s pretest and post-test scores were not significantly different. However, the EDE-Q, BIQLI, and BSI posttest scores were found to be significantly lower than the pretest scores in the intervention group. In addition, the RSES post-test scores were significantly higher than the RSES pretest scores in the intervention group. The current study indicated that the Virtual Body Project was found to be an effective intervention on eating disorder risk factors, psychological symptoms, and self-esteem in young females. It is thought that the Virtual Body Project, which is applied to groups online, makes an extremely important contribution to preventive mental health studies.
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Matthey S. Is Validating the Cutoff Score on Perinatal Mental Health Mood Screening Instruments, for Women and Men from Different Cultures or Languages, Really Necessary? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074011. [PMID: 35409694 PMCID: PMC8998276 DOI: 10.3390/ijerph19074011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
Background: The most commonly used mood screening instrument in perinatal health is the Edinburgh Depression Scale. The screen-positive cut-off score on this scale, as for others, has been determined, via validation techniques, for over 20 languages/cultures, and for both women and men. While such validation appears to be considered essential, there are studies that could be interpreted to suggest that this is not an important consideration. Methods: Selective studies have been chosen to indicate these opposing points of view. Results: Examples of studies that support the notion of validating cut-off scores are described, as are examples of studies that appear not to support this point of view. Conclusions: (i) Clinical services and researchers need to be mindful of these opposing points of view, and openly discuss them when using screening cut-off scores for their respective populations. (ii) Researchers and Journals need to be more rigorous in ensuring this issue is correctly reported in studies, and/or openly discussed when relevant.
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Affiliation(s)
- Stephen Matthey
- Department of Clinical and Experimental Sciences, Faculty of Medicine and Surgery, Università degli Studi di Brescia, 25123 Brescia, Italy
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Korukcu O, Ozkaya M, Boran OF, Bakacak M. Factors associated with antenatal depression during the COVID-19 (SARS-CoV2) pandemic: A cross-sectional study in a cohort of Turkish pregnant women. Perspect Psychiatr Care 2022; 58:61-70. [PMID: 33772802 PMCID: PMC8251216 DOI: 10.1111/ppc.12778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine the effect of the COVID-19 pandemic on antenatal depression in Turkish pregnant women. DESIGN AND METHODS In this cross-sectional study, data were collected from 497 pregnant women between May and July 2020 using the Edinburgh Depression Scale (EDS) to determine the effect of obstetrics history, fear of hospitalization, concerns about the pandemic, birth, and the health of both mother and infant, on antenatal depression during the COVID-19 outbreak in Turkey. FINDINGS The general EDS mean score of the total group was determined as mean 13.70 ± 6.22, which was higher than the critical cutoff point of 13. According to the multiple linear regression model applied in the study, the best predictive variables for the mean EDS score were determined to be concerned about completing a healthy pregnancy (r = -0.45), social media and news programs related to COVID-19 increasing levels of concern (r = -0.31), fear of hospitalization as the birth approaches (r = -0.45), having bad dreams during the COVID-19 pandemic (r = -0.41), the request for an elective cesarean delivery because of fear of catching COVID-19 (r = -0.40), fear of breastfeeding the infant (r = -0.45), and concerns that their own health would be negatively affected because of the pandemic (r = - 0.39), and these variables affected the mean EDS score negatively (total variance 40.5%, R = 0.642). PRACTICAL IMPLICATIONS The COVID-19 pandemic has created an urgent need to implement specific antenatal programs to promote the psychological health of pregnant women and reduce antenatal depression during this or similar crises.
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Affiliation(s)
- Oznur Korukcu
- Department of Obstetrics and Gynecological Nursing, Faculty of Nursing, Akdeniz University, Antalya, Turkey
| | - Meltem Ozkaya
- Department of Obstetrics and Gynecological Nursing, Faculty of Nursing, Akdeniz University, Antalya, Turkey
| | - Omer Faruk Boran
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
| | - Murat Bakacak
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
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Míguez MC, Vázquez MB. Risk factors for antenatal depression: A review. World J Psychiatry 2021; 11:325-336. [PMID: 34327125 PMCID: PMC8311510 DOI: 10.5498/wjp.v11.i7.325] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/20/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
Depression is the most prevalent mental disorder in pregnancy, and yet it is less studied than postpartum depression despite the consequences it may have on both the pregnant woman and her offspring. Therefore, it would be important to know which risk factors may favour the appearance of antenatal depression in order to carry out appropriate prevention interventions. The aim of the present review was to identify the main risk factors of antenatal depression. We searched in databases PubMed and PsycINFO for articles published about the factors associated with antenatal depression from January 2010 through December 2020. The literature review identified three main groups of antenatal depression risk factors: sociodemographic, obstetric, and psychological. First, among the sociodemographic variables, the low level of studies and the economic income clearly stood out from the rest. Then, not having planned the pregnancy was the main obstetric variable, and finally, the main psychological risk factors were having a history of psychological disorders and/or depression as well as presenting anxiety, stress, and/or low social support during pregnancy. This review shows that the antenatal depression is affected by multiple factors. Most can be identified at the beginning of the pregnancy, and some are risk factors potentially modifiable through appropriate interventions, such as psychological factors. For this reason, it is important to carry out a good screening for depression during pregnancy and consequently, be able to prevent its appearance or treat it if necessary.
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Affiliation(s)
- M Carmen Míguez
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Santiago de Compostela, Santiago de Compostela 15782, Spain
| | - M Belén Vázquez
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Santiago de Compostela, Santiago de Compostela 15782, Spain
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Míguez MC, Vázquez MB. Prevalence of Depression during Pregnancy in Spanish Women: Trajectory and Risk Factors in Each Trimester. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:6789. [PMID: 34202666 PMCID: PMC8297098 DOI: 10.3390/ijerph18136789] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 01/14/2023]
Abstract
The aims of this research were to determine the trajectories of probable depression and major depression during pregnancy and to identify the associated and predictor variables (sociodemographic, pregnancy-related, and psychological) for both conditions in each trimester of pregnancy. A longitudinal study was carried out with 569 pregnant Spanish women who were assessed in the first, second, and third trimesters of pregnancy. Depression was assessed using the Edinburgh Postnatal Depression Scale and a clinical interview. Measures of anxiety and stress were also included. The prevalence of probable depression in the first, second, and third trimesters was 23.4%, 17.0%, and 21.4%, respectively, and that of major depression was 5.1%, 4.0%, and 4.7%. Thus, the prevalence of both conditions was the highest in the first and third trimesters. The trajectories of probable depression and major depression followed the same pattern throughout pregnancy. All of the psychological variables studied were associated with both conditions in all three trimesters, with perceived stress being a predictor at all times. The association between the other variables and both conditions of depression was similar. Two exceptions stand out: having had previous miscarriages, which was only associated with probable depression and was also a predictor, in the first trimester; and complications during pregnancy, which was only associated with probable and major depression in the third trimester. These findings should be taken into account in routine pregnancy follow-ups, and necessary interventions should be started in the first trimester.
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Affiliation(s)
- M. Carmen Míguez
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain;
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Fukita S, Kawasaki H, Yamasaki S. Comprehensive analysis of depression-related factors among middle-aged residents in Japan, an Eastern culture: A cross-sectional study. Medicine (Baltimore) 2021; 100:e25735. [PMID: 34106600 PMCID: PMC8133093 DOI: 10.1097/md.0000000000025735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/06/2021] [Indexed: 11/26/2022] Open
Abstract
There is a need to comprehensively identify depression-related factors, including individual and socioeconomic factors, in each country or cultural area, to consider effective measures to address depression within communities. However, there are not enough studies on middle-aged residents in Japan or other Eastern countries to currently achieve this. Thus, the aim of this study was to comprehensively identify factors related to depression in middle-aged residents in Japan, an Eastern country.The study design was cross-sectional. A questionnaire survey was conducted among all community residents aged 40 to 59 in a rural municipality in Western Japan. The questionnaire contained items on demographic characteristics, psychological factors, health-related behaviors, and socioeconomic factors. A Chi-Squared test or Fisher exact test was used to analyze the relationships between depression and each assessed factor. Next, a logistic regression analysis was performed to identify comprehensive relationships between depression and its related factors.Data from 362 participants were analyzed. The average age was 51.5 years; 148 were male. A Chi-Squared test or Fisher exact test demonstrated that many psychological factors, health-related behaviors, and socioeconomic factors ware significantly related to depression. A logistic regression analysis showed that depression was significantly associated with male gender, low sense of coherence, high cognitive stress levels, low help-seeking behavior, poor quality sleep, and a lack of hobbies. Nagelkerke R2 was 51%.This study revealed through multivariate analysis that depression was primarily associated with personal behavioral and psychological factors in Japan, an Eastern country with a holistic cultural background. This result is consistent with findings from Western countries. This study can contribute the promotion and evaluation of preventive measures for depression in Eastern culture that focus on individual behavioral and psychological factors.
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Affiliation(s)
- Susumu Fukita
- Faculty of Nursing & Medical Care, Keio University, Kanagawa
- Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiromi Kawasaki
- Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Satoko Yamasaki
- Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Kazemi A, Ghaedrahmati M, Kheirabadi G. Partner's emotional reaction to pregnancy mediates the relationship between pregnancy planning and prenatal mental health. BMC Pregnancy Childbirth 2021; 21:168. [PMID: 33639876 PMCID: PMC7913387 DOI: 10.1186/s12884-021-03644-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 02/16/2021] [Indexed: 12/13/2022] Open
Abstract
Background An unplanned pregnancy may be followed by increased depression and anxiety. The aim of the present study was to evaluate the mediating role of partner’s emotional reaction to pregnancy (PERP) on the relationship between pregnancy planning and prenatal mental health. Methods This cross-sectional study was conducted on 303 healthy Iranian pregnant women during their third trimester. The levels of depression and anxiety were measured using the Edinburgh Postnatal Depression Scale and the State-Trait Anxiety Inventory. The PERP score was also measured using a researcher-made questionnaire. The data were analyzed using the plug-in application PROCESS macro. Results The results showed that PERP score was reversely related to pregnancy planning and prenatal depression and anxiety. The direct effect of the pregnancy planning on depression (c = −.05) and anxiety levels (c = −.02) were not significant; but the indirect effect of pregnancy planning on depression (Point Estimate = −.379, CI: −.523 to −.250) and anxiety levels (Point Estimate = −.560, CI: −.741 to −.385) with the mediating role of PERP were significant. Conclusions The results indicated that the effect of pregnancy planning on prenatal mental health is mediated by PERP, and in unplanned pregnancy women need to receive positive reaction of their partners toward pregnancy so that they can preserve their mental health.
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Affiliation(s)
- Ashraf Kazemi
- Reproductive Health Department, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Hezarjerib Av., Isfahan, Iran.
| | - Maryam Ghaedrahmati
- Reproductive Health Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gholamreza Kheirabadi
- Behavioral Sciences Research center, Department of psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Romero-Gonzalez B, Martin CR, Caparros-Gonzalez RA, Quesada-Soto JM, Peralta-Ramirez MI. Spanish validation and factor structure of the Prenatal Distress Questionnaire Revised (NuPDQ). J Reprod Infant Psychol 2020; 40:242-253. [PMID: 33327777 DOI: 10.1080/02646838.2020.1861227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Due to an absence of maternal stress being measured in routine prenatal care by clinicians, prenatal stress has become a serious problem which is associated with poorer obstetric outcomes, as well as worse maternal and infant health. For that reason, the aim of this study was the translation, validation and adaptation of Prenatal Distress Questionnaire Revised (NuPDQ) in a Spanish sample.Methods: Three-hundred and seventy-one pregnant women were assessed using the NuPDQ, the Prenatal Distress Questionnaire, Perceived Stress Scale and the Connor-Davidson Resilience Scale. The NuPDQ was translated into Spanish by the backtranslation method and administered to participants.Results: A confirmatory factor analysis revealed the established unidimensional structure to be a poor fit to data with the Spanish version. An exploratory factor analysis suggested a five-factor structure with 14 items. The instrument had good reliability, convergent and discriminant validity psychometric properties.Conclusions: The five-factor 14-item NuPDQ is useful to assess pregnancy-specific stress in Spanish pregnant women. It may be appropriate to use this instrument in order to identify pregnant women with high pregnancy-specific stress to try to prevent negative consequences derived from those high levels.
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Affiliation(s)
- Borja Romero-Gonzalez
- Department of Personality, Assessment and Psychological Treatment, University of Granada, Granada, Spain.,Brain, Mind and Behavior Research Center (CIMCYC), Faculty of Psychology, University of Granada, Granada, Spain
| | - Colin R Martin
- Faculty of Health Sciences, University of Hull, Hull, UK
| | | | - Juan M Quesada-Soto
- Brain, Mind and Behavior Research Center (CIMCYC), Faculty of Psychology, University of Granada, Granada, Spain
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Comorbid Anxiety and Depression among Pregnant Pakistani Women: Higher Rates, Different Vulnerability Characteristics, and the Role of Perceived Stress. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197295. [PMID: 33036215 PMCID: PMC7579342 DOI: 10.3390/ijerph17197295] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/27/2022]
Abstract
Anxiety and depression commonly co-occur during pregnancy and may increase risk of poor birth outcomes including preterm birth and low birth weight. Our understanding of rates, patterns, and predictors of comorbid anxiety and depression is hindered given the dearth of literature, particularly in low- and middle-income (LMI) countries. The aim of this study is (1) to explore the prevalence and patterns of comorbid antenatal anxiety and depressive symptoms in the mild-to-severe and moderate-to-severe categories among women in a LMI country like Pakistan and (2) to understand the risk factors for comorbid anxiety and depressive symptoms. Using a prospective cohort design, a diverse sample of 300 pregnant women from four centers of Aga Khan Hospital for Women and Children in Pakistan were enrolled in the study. Comorbid anxiety and depression during pregnancy were high and numerous factors predicted increased likelihood of comorbidity, including: (1) High level of perceived stress at any time point, (2) having 3 or more previous children, and (3) having one or more adverse childhood experiences. These risks were increased if the husband was employed in the private sector. Early identification and treatment of mental health comorbidities may contribute to decreased adverse birth outcomes in LMI countries.
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González-Mesa E, Kabukcuoglu K, Blasco M, Körükcü O, Ibrahim N, González-Cazorla A, Cazorla O. Comorbid anxiety and depression (CAD) at early stages of the pregnancy. A multicultural cross-sectional study. J Affect Disord 2020; 270:85-89. [PMID: 32275225 DOI: 10.1016/j.jad.2020.03.086] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/23/2020] [Accepted: 03/25/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION When anxiety and depression are comorbid (CAD), symptoms are more severe and the response to treatments is worse. Given the links between mood disorders and poor perinatal outcomes, CAD and its correlates deserve special clinical attention during pregnancy. The main objective of this study was to learn about the prevalence of comorbid anxiety and depression (CAD) in early stages of the pregnancy analyzing the relationship between CAD and cultural and sociodemographic factors. METHODS We have studied a multicultural sample of 514 Turkish and Spanish pregnant women (264 in Málaga, 102 in Istambul and 148 in Antalya) recruited at the moment of their first pregnancy medical check-up between 10 and 12 weeks of pregnancy. These women completed a questionnaire that included the Turkish or Spanish validated versions of the Edinburg postnatal depression scale (EDS), the state and trait anxiety scale (STAI) and a series of questions related to health status, general mood, and sociodemographic variables. RESULTS We found a CAD prevalence rate of 26.9% and a significant higher prevalence rate among Turkish women (47.6%) when compared to Spanish participants (9.5%) (p<0.001). The multivariate analysis showed that the lack of someone who provided emotional support was the variable that best predicted CAD symptoms. CONCLUSION The CAD prevalence rate was high and significant differences were found depending on the geographic and cultural context.
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Affiliation(s)
| | | | - Marta Blasco
- Hospital Regional Universitario de Málaga, Spain
| | - Oznur Körükcü
- Akdeniz University Nursing Faculty Campus, 07058 Antalya, Turkey
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González-Mesa E, Kabukcuoglu K, Körükcü O, Blasco M, Ibrahim N, Cazorla-Granados O, Kavas T. Correlates for state and trait anxiety in a multicultural sample of Turkish and Spanish women at first trimester of pregnancy. J Affect Disord 2019; 249:1-7. [PMID: 30739036 DOI: 10.1016/j.jad.2019.01.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/25/2018] [Accepted: 01/17/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The main objective of this research was to assess the potential influence of cultural factors on the anxiety levels of a multicultural sample of Spanish and Turkish pregnant women at the beginning of the pregnancy. METHODS Between October and December 2017 a total of 250 Turkish and 264 Spanish pregnant women attending their first pregnancy medical check-up between 10 and 12 weeks of pregnancy in three different cities, Istanbul, Antalya and Malaga, were recruited for study. These women completed a questionnaire that included the Turkish or Spanish validated of the state-trait anxiety Inventory, and a series of questions related to health status, general mood, and sociodemographic variables. RESULTS The mean value for State Anxiety was 47.1 [16-56] (SD 4.2), and mild, moderate and severe State Anxiety was observed in 56.8%, 14.7% and 20.5% of participants, respectively. Mean value for trait anxiety was 46.9 [34-89] (SD 4.6) and 31.4%, 19.7% and 20.2% of participants scored for mild, moderate and severe anxiety respectively. Anxiety scores were significantly higher among Turkish women. In the whole sample, religion, working status, pregnancy planning and perceived partner´s support predicted anxiety at first trimester of pregnancy. Social support and educational level were the most important predictive variables in the Spanish subgroup, while religion, the number of living children and the lack of husband´s support were among Turkish pregnant women. CONCLUSION Our results confirm the existence of a high prevalence of women´s anxiety at the beginning of the pregnancy and some differences between Turkish and Spanish pregnant women have been observed. We have confirmed that some cultural features like family structure (having more children and cohabitants), the Islamic religion or the lack of perceived partner´s support became the most important vulnerability elements.
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Affiliation(s)
| | | | - Oznur Körükcü
- Akdeniz university Nursing Faculty Campus, 07058 Antalya, Turkey
| | - Marta Blasco
- Hospital Regional Universitario de Málaga, Spain
| | | | | | - Türker Kavas
- Obstetrics and Gynaecology Clinic, Sisli, Istanbul
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