Effectiveness of Antenatal Emotional Self-Management

Training Program in Prevention of Postnatal Depression in

Chinese Womenppc_331 218..224
Hong-Jing Mao, DR, MD, He-Jiang Li, DR, Helen Chiu, DR, FRCPsych, FHKAM,
Wai-Chi Chan, DR, MRCPsych, FHKAM, and Shu-Ling Chen, DR, PHD
Hong-Jing Mao, DR, MD, is Director, Department of Psychiatry, The Seventh Hospital of HangZhou, HangZhou, ZheJiang, China; He-Jiang Li, DR, is
Director, Department of Obstetrics, Hangzhou First Peoples Hospital, HangZhou, ZheJiang, China; Helen Chiu, DR, FRCPsych, FHKAM, is Professor,
Department of Psychiatry, Chinese University of Hong Kong, Hong Kong; Wai-Chi Chan, DR, MRCPsych, FHKAM, is Chief, Department of Psychiatry,
Shatin Hospital, Hong Kong; and Shu-Ling Chen, DR, PHD, is Professor, Department of Psychiatry, The Seventh Hospital of HangZhou, HangZhou,
ZheJiang, China.
Search terms:
Antenatal intervention, Chinese, postnatal
depression, prevention
Author contact:
Dr. He-jiang Li
hj_006hj@hotmail.com, with a copy to the
Editor: gpearson@uchc.edu
First Received August 22, 2011; Final Revision
received December 27, 2011; Accepted for
publication January 5, 2012.
doi: 10.1111/j.1744-6163.2012.00331.x
PURPOSE: This study aimed to study the effectiveness of an emotional self-
management training program to antenatal women in the prevention of postnatal
depression.
DESIGN AND METHODS: The sample comprised 240 women who were at 32
weeks antenatal. They were randomly assigned into the intervention group and the
control group.
FINDINGS: On completion of the program, the intervention group reported sig-
nicantly lower mean Patient Health Questionnaire-9 and Edinburgh Postnatal
Depression Scale scores than the control group. Fewer participants from the inter-
vention group were diagnosed as having postnatal depression using the Structured
Clinical Interviewfor DSM-IV.
PRACTICE IMPLICATIONS: An antenatal emotional self-management training
that may lower the risk of developing postnatal depressionamong Chinese womenis
recommended.
Background
Postpartumdepression(PPD) has emergedas a major health-
care issue around the world. A meta-analysis of 59 studies
reported that the prevalence of PPD was as high as 13%
(OHara &Swain, 1996). Asimilar trend has been observed in
Chinese societies over the past decade. It was reportedthat the
prevalence of PPDamong Chinese women in Hong Kong was
11.2% (Lee, Yip, Chiu, Leung, & Chung, 2001), whereas 19%
of women in mainland China had PPD (Xie, He, Koszycki,
Walker, &Wen, 2009). While PPD shared a number of symp-
toms with major depression (e.g., depressive mood, frequent
crying, lack of appetite and motivation, fatigue, inability to
cope, suicidal ideation and behavior) (Cho, Kwon, & Lee,
2008), this disorder is associated with unique features of
failure to bond between mother and baby or even thoughts of
hurting the infants. The mother-and-baby interactional rela-
tionship may be compromised, and its inuence is much
greater than the mere exposure of the infant to maternal
depressive symptoms (Murray & Cooper, 1996). In addition,
infants and children of depressed mothers react more nega-
tively to stress, show delayed development of self-regulatory
strategies, exhibit poorer academic performance, fewer social
competencies, lower levels of self-esteem, and higher levels of
behavioral problems (Goodman &Gotlib, 1999).
While the exact etiology of PPD remains unknown, it is
very likely that psychological factors, biological factors
including hormonal changes, and social factors all play a
role. Forty and her colleagues (2006) found that 42% of
women with a family history of PDD experienced depression
following rst delivery but only 15% of those without
did. Women with a previous history of depression are par-
ticularly vulnerable to pregnancy-associated recurrence
(Frank, Kupfer, Jacob, Blumenthal, & Jarrett, 1987). Further-
more, about one half of pregnant depressed women will have
PPD(Graff, Dyck, &Schallow, 1991). The importance of psy-
chosocial and psychological risk factors such as life stress,
marital conict, low maternal self-esteem, and lack of
social support have also beenrecognized(Beck, 2001; Bernaz-
zani, Saucier, David, & Borgeat, 1997; Cooper & Murray,
Perspectives in Psychiatric Care ISSN 0031-5990
218 Perspectives in Psychiatric Care 48 (2012) 218224
2012 Wiley Periodicals, Inc.
1997; OHara, Schlechte, Lewis, & Varner, 1991; OHara &
Swain, 1996).
In view of its high prevalence and potentially signicant
consequences, there have been growing interests in identify-
ing interventions that effectively prevent PPD. Of these, psy-
chosocial and psychological interventions have attracted
much attention from the researchers. This may be because
mothers often have concerns about breast milk transmission
and side effects of pharmacological interventions. However,
results of the studies about the effectiveness of psychosocial
and psychological interventions have been inconsistent. A
number of studies have shown that interventions such as
public assistance for pregnant women, antenatal cognitive
behavioral therapy, and interpersonal psychotherapy-
oriented childbirth education program could reduce the
occurrence of PPD (Cho et al., 2008; Gao, Chan, Li, Chen, &
Hao, 2010; Zlotnick, Miller, Pearlstein, Howard, & Sweeney,
2006). But Dennis (2005), who reviewed 15 randomized con-
trolled trials, reported that psychosocial or psychological
interventions did not signicantly reduce the number of
women who develop PPD.
Assumptions about the nature of postnatal experience
and effectiveness of interventions among Chinese women
based on data from Western countries may not be appropri-
ate. A number of cultural factors connected with childbirth
have been reported in China, for example, negative reaction
of family members toward the birth of a female baby, doing-
the-month (zuoyuezi, Chinese postnatal custom of conne-
ment and support of the mother by female relatives), and
the practice of caring for newborns by the mother-in-law. In
the province where the study took place, the standard
maternity care is almost the same. These cultural factors
may have signicant effect on the mental well-being of
mothers. For example, there was over a 2-fold increased risk
in developing PPD among women who carried a female
fetus than in those with a male one (Xie et al., 2009). Mean-
while, Wan et al. (2009) reported that those who had their
mothers-in-law as caregivers or who perceived zuoyuezi as
unhelpful had twice the odds of PPD. Chan, Williamson,
and McCutcheon (2009) also pointed out that Hong Kong
Chinese women attributed their PPD to their mothers-in-
law and husbands and expressed much anger. It was very
different from their Australian counterparts who attributed
their depression to not being able to live up to the ideal
mother image and felt guilty. Therefore, one should take
into consideration the cultural values when formulating
preventive strategies for PPD.
In the current study, we designed an emotional self-
management group training (ESMGT) program, which was
based on the basic tenet of cognitive-behavioral treatment
(CBT) withelements of Chinese culture of delivery. We aimed
to investigate the effectiveness of ESMGT in preventing PPD
among Chinese women.
Method
Design
It was a randomized controlled trial. ESMGTwas provided to
the intervention group while the control group received stan-
dard antenatal care. Outcomes were measured at three points:
before and after the intervention and 6 weeks after delivery.
The study was conducted in accordance with Good Clinical
Practice and the Declaration of Helsinki. The protocol and
statement of informed consent were approved by the institu-
tional ethics board of the Hangzhou First Peoples Hospital.
Sample
Participants were primiparous women presented to the
Department of Obstetrics of The First Hospital of Hangzhou,
Zhejiang, China, from January to December 2009. Other
inclusion criteria included single birth, cephalic presentation,
normal pelvic external measurement, and absence of physical
illness. Exclusion criteria included puerpera of old age, com-
plications of pregnancy, and personal and family history of
psychiatric disorder. Of the 532 participants, 240 individuals,
according to the inclusion and exclusion criteria, were
selected by the second author (Figure 1). The baseline data
were collected by three trained maternity nurses. They were
randomized into the intervention group (n = 120) and the
control group (n = 120) according to a computer-generated
randomization list kept by a third party.
Intervention
The control group received standard antenatal education at
the study venue, whichconsisted of four 90-minsessions con-
ducted by obstetrics nurses. The content of the program
focused on childbirth education.
The intervention group received ESMGT program, which
was composed of four weekly group sessions and one indi-
vidual counseling session. Participants were divided into 12
groups, and each group comprised 10 couples (their hus-
bands were as a secondary participation, e.g., play-role,
support, and supervision). The group training was called
Happy Mother 4 plus 1 Emotion Self-management Group
Training Program. Each group session lasted for 90 min.
Themes of the group sessions included Understanding
self-management and Chinese delivery culture, Effective
problem solving and positive communication, Relaxation
exercise and cognitive restructuring, and Improving self-
condence. There were some homework after every session
for participants to practice learned skills. The group sessions
were run by an obstetrician (the second author) who had
received intensive training of the intervention program. On
completion of the group training, one individual counseling
Effectiveness of Antenatal Emotional Self-Management Training Program in Prevention of Postnatal Depression in Chinese Women
219 Perspectives in Psychiatric Care 48 (2012) 218224
2012 Wiley Periodicals, Inc.
session was arranged to tackle further personal problems.
Contents of the group sessions are detailed in Table 1.
Instruments
The PHQ-9 is the nine-itemdepression module of the Patient
Health Questionnaire (Kroenke, Spitzer, &Williams, 2001). It
consists of nine symptoms of the DSM-IV Criterion A for
major depressive episode. Each item is scored on a 4-point
scale (from 0 to 3), making a total score from 0 to 27. It is a
criterion-based instrument originally developed for depres-
sion screening in primary care. The Chinese version of the
PHQ-9 is available with satisfactory validity and reliability
(Yeung et al., 2008). Participants were requested to rate their
depressive symptoms inthe past 2 weeks. Ascore of 10 indi-
cates depression. In this study, participants were scored twice
to compare their depressive symptoms before and after the
training.
Assessment PHQ-9 Assessment PHQ-9
Assessment EPDS
Completed (n=113)
Reasons for dropout::
Moved to another province
(n=3)
Refused to continue (n=2)
Not traceable (n=2)
Assessment EPDS
Completed (n=108)
Reasons for dropout::
Moved to another province
(n=6)
Refused to continue (n=5)
Not traceable (n=1)
Follow-up
at 6-weeks
postnatal
EDPS 11(n=18) EDPS 11(n=21)
PPD (n=3)
SCID
After training
SCID
PPD (n=10)
Assessed for eligibility (n=532)
Excluded (n=292)
Did not meet the criteria (n=167)
Refused to participate (n=125)
Baseline measure: Demographic questionnaires, PHQ-9
Randomised (n=240)
Interventing group (n=120)
Emotional self-management
group training program
All participants completed the
program
Control group (n=120)
Standard antenatal education
Figure 1. Participants recruitment,
intervention, and assessment. EPDS,
Edinburgh Postnatal Depression Scale;
PHQ-9, Patient Health Questionnaire-9;
PPD, postpartum depression; SCID,
Structured Clinical Interview for DSM-IV
Effectiveness of Antenatal Emotional Self-Management Training Program in Prevention of Postnatal Depression in Chinese Women
220 Perspectives in Psychiatric Care 48 (2012) 218224
2012 Wiley Periodicals, Inc.
The Edinburgh Postnatal Depression Scale (EPDS) (Cox,
Holden, &Sagovsky, 1987) is a 10-itemscale most extensively
used in research and clinical settings to assess PPD. Each item
is scored on a 4-point scale (from 0 to 3), with the minimum
and maximumtotal EPDS scores being 0 and 30, respectively.
The Chinese version of the EPDS has been validated among
Chinese women and its psychometric performance is compa-
rable with the original scale (Lee et al., 1998). A study indi-
cated that the 10/11 cut-off point is most appropriate for
identifying the PPD (Lai, Tang, Lee, Yip, & Chung, 2010). We
used EDPS scores to select participants who needed further
Structured Clinical Interviewfor DSM-IV(SCID).
The SCID-TR Axis I Disorders (SCID-I/P) (First, Spitzer,
Gibbon, &Williams, 2002) was adopted in this study to estab-
lish psychiatric diagnosis of clinical depression according to
the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR) criteria and cat-
egories for depressive disorder among antenatal women at
stage III. It was the gold standard for dening clinical depres-
sion among postnatal women across countries and cultures
(Gorman et al., 2004).
Data Collection
Two hundred forty participants were requested to ll in the
demographic data and PHQ-9 before they were randomized
to the intervention and control groups by a table of random
numbers. There were 120 participants assigned to the inter-
vention group, whereas another 120 were assigned to the
control group. Participants were reassessed with PHQ-9 on
completionof training (i.e., at 36 weeks antenatal). At 6 weeks
postnatal, they lled in the obstetric questionnaire and EPDS.
The obstetrician would inform the psychiatrist if EPDS score
was 11 or above, provided consent from participants were
available. These participants were then interviewed by the
rst author who was blind to their group with SCID.
Data Analysis
Data analysis was by intention to treat, using the Statistical
Package for Social Sciences for Windows version 13.0 (SPSS
Inc., Chicago, IL, USA). Descriptive statistics were used to
summarize the data. Chi-square analysis and independent
t-tests were used to detect any signicant differences between
the two groups on the baseline variables. Independent-
samples t-test was used to compare the differences between
the two groups in the posttest outcome measures and paired-
samples t-test was used to evaluate the changes in outcome
measures over the study period.
Results
Participant Description
The intervention group and control group were comparable
withrespect todemographic andbaseline obstetric character-
istics (Table 2). The mean age of participants receiving the
ESMGT program and standard antenatal care were 28.5 and
28.8 years, respectively. Around two thirds of participants in
each group had more than 12 years of education. In addition,
12.3% of the intervention group and 11.4% of the control
grouphadahistoryof miscarriages. Noneof thesecharacteris-
tics were statistically different betweenthe twostudy groups.
Effectiveness
All participants completed the 4-week ESMGT program or
standard antenatal education, and nished the assessment at
36 weeks antenatal. Seven women dropped out from the
intervention group before 6 weeks postnatal. Three of them
moved to another province, two refused further contact by
the research team, and the two others were not traceable. At 6
weeks postnatal, 12 participants dropped out from the
control group. Six of them moved out of the province, ve
refused, and the other could not be contacted.
Table 1. Outline of the Happy Mother 4 Plus 1 Emotion
Self-Management Group Training Objectives and Content
Objectives Content
Session 1 (gestational age over 32
weeks)
Understanding self-management
and Chinese delivery culture
Self-introduction
Objectives of the program
Establish group contract
Role play to cope with delivery
culture
Skills to cope with baby gender
Skills to cope with postpartum
rituals
Making out homework
Session 2 (gestational age over 33
weeks)
Effective problem solving and
positive communication
Feedback
Brainstorm
Role-play, experience
relationship with husband and
mother-in-law
Skills to establish social support
system
Skills to communicate
Making out homework
Session 3 (gestational age over 34
weeks)
Relaxation exercise and cognitive
restructuring
Feedback
Skills to abdominal breathing
Understanding negative
cognitive and mood
Challenging negative cognitive
Making out homework
Session 4 (gestational age over 35
weeks)
Improving self-condence
Feedback
Antenatal education
Sharing experience with
postnatal women
Visiting the delivery room
Effectiveness of Antenatal Emotional Self-Management Training Program in Prevention of Postnatal Depression in Chinese Women
221 Perspectives in Psychiatric Care 48 (2012) 218224
2012 Wiley Periodicals, Inc.
The mean baseline scores and changes from baseline at 36
weeks antenatal and 6 weeks postnatal are depicted inTable 3.
At baseline (i.e., 32 weeks antenatal), the mean PHQ-9 scores
for interventionandcontrol groups were 8.20 2.84 and8.35
2.96, respectively (t = 1.15, p > .05), which was comparable
between the two groups. On completion of ESMGT/standard
care at 36 weeks antenatal, the mean score of PHQ-9 of
intervention group decreased to 5.45 2.42, which was
signicantly lower than the control group (7.23 3.52)
(t = 3.34, p < .01). In addition, the mean score of EPDS at
6 weeks postnatal was also signicantly lower in the inter-
vention group (6.45 1.09) than in the control group (9.23
2.91) (t = 1.95 p < .05) (Table 4). Using SCID, the presence
of depression was ascertained at 6 weeks postnatal. Only 3 out
of 113 (2.7%) in the intervention group was diagnosed as
having PPDwhereas 10 among 108 (9.3%) participants in the
control grouphadPPD(c
2
=4.35, p <.05) (Table 5). The odds
ratio of PPD for women who attended the ESMGT program,
as compared with those who did not attend the program, was
0.29 (95%CI 0.21 to 1.01).
Discussion
The transition to motherhood involves enormous physical,
emotional, social, and relational changes that may culminate
ina state of crisis (Gruen, 1993). Some mothers may appear to
harbor negative thoughts anddoubt if they canadjust to these
intense physiological and social changes. A small but signi-
cant proportion of them even develop PPD. Through learn-
ing the knowledge and skill to manage depressive emotion,
mothers are better equipped to adjust to the postnatal period.
Our study found that the ESMGT intervention resulted in a
signicant improvement in depressive symptoms compared
with the control group as exemplied by PHQ-9 and EPDS
scores.
We also found that the intervention effectively decreased
the risk to develop PPDat 6 weeks postnatal. This nding was
not consistent with previous studies that failed to demon-
strate any benecial effects of psychosocial interventions
(Brugha et al., 2000; Hayes, Muller, & Bradley, 2001). A more
structured training program based on CBT and cultural con-
sideration may partly account for the more successful
outcome in our study. Several studies had similar results:
Antenatal CBT intervention can be an effective preventive
treatment for PPD (Cho et al., 2008). Interpersonal psycho-
therapy intervention couples therapy for PPD may be useful
withcouples struggling inthe postpartumperiod to negotiate
conicts at a time of great adjustment and role shifts (Carter,
Grigoriadis, & Ross, 2010). The ESMGT intervention
embraced the basic tenet of CBT and focused on Chinese
culture about delivery that may lead to depressive emotion
(e.g., the postnatal rituals, baby gender, and conicts between
women and their mothers-in-law). Increased risk of PPD in
Chinese women who give birth to a female infant is caused by
lack of social support after childbirth (Xie et al., 2009). In
addition, participation of fathers-to-be in training sessions
of effective problem solving and communication skills also
contributes to the success of the program. Fathers also
Table 2. Demographic Characteristics of the
Sample
Variables
Intervention
Group (n = 120)
Control Group
(n = 120) t/c
2
n (%) n (%)
Age (years) (MSD) 28.5 2.4 28.8 2.5 0.53
Education 0.12
9 years educational (%) 7 (5.8) 8 (6.9)
9~12 years educational (%) 30 (25.4) 32 (26.7)
More than 12 years (%) 83 (68.8) 80 (66.4)
Obstetric miscarriage 0.15
1 time (%) 14 (11.7) 13 (10.8)
2 times (%) 5 (0.4) 4 (0.3)
More than 2 2 (0.2%) 2 (0.3)
Household income (per person per month) 0.34
<3,000 (%) 49 (40.8) 52 (43.3)
3,000 (%) 71 (59.2) 68 (56.7)
Table 3. Patient Health Questionnaire-9 Scores
Before and After Training
Group Case
Assessment Point
Before Training (32 Weeks) After Training (36 Weeks)
Intervention 120 8.20 2.84 5.45 2.42*
Control 120 8.35 2.96 7.23 3.52
*p < .01.
Effectiveness of Antenatal Emotional Self-Management Training Program in Prevention of Postnatal Depression in Chinese Women
222 Perspectives in Psychiatric Care 48 (2012) 218224
2012 Wiley Periodicals, Inc.
experienced some depressive symptoms. The most common
barriers for fathers were lack of information regarding PPD
resources and difculty seeking support (Letourneau,
Duffett-Leger, Dennis, Stewart, & Tryphonopoulos, 2011).
Through role-plays and simulation of the difculties encoun-
tered in the postnatal period, the couple brainstormed the
method to solve the problems together, discussed issues like
equality of genders and roles of paternal grandma and mater-
nal grandma, and had an understanding of the science of
delivery. This positive thinking process was reinforced
through completing homework assignments. We also col-
laborated with the maternity department. Mothers attending
the maternity department who gave birth naturally the day
before were invited to share with the participants their expe-
rience. Knowing what would happen could enhance their
self-condence toward childbirth and alleviate their anxiety.
Structured group training is considered an appropriate
intervention for participants because they shared a common
goal, and could listen to and offer support, encouragement,
trust, and supervision to one another. They managed to
master the skill of emotion self-management in an under-
standing and free environment. Another strength of the
current study was the involvement of fathers-to-be, whichwas
pivotal to the success of the self-management program. The
individual counseling session offered an opportunity for par-
ticipants to solve more personal difculties like sexual rela-
tionship and problems with trust between husband and wife.
Limitations
This study has a number of limitations. Firstly, there is selec-
tion bias, with the sample selected from only one hospital
where patients come from, mostly Zhejiang province. Sec-
ondly, the study did not target womenwho were vulnerable to
antenatal depression. All of the participants were primipa-
rous with a single, normal pregnancy, and without a past or
family history of mental health problems. The effect of the
studied intervention toward this high-risk group remains
unclear. Thirdly, the study did not incorporate biological
markers as part of the assessment. Further studies should
include these in the evaluation as evidence suggested a bio-
logical mechanism underlying PPD, especially among those
with a past or family history of depression. Lastly, the current
study assessed the effect at 6 weeks postnatal. Therefore, we
could not conrmthe long-termeffect of the intervention.
Implications for Nursing Practice
Participants can benet from acquiring the knowledge and
skills in self-management of depressive emotion through
ESMGTduring the antenatal period. It does not only improve
the well-being of mothers, but also brings positive impacts on
infant development. The content of ESMGT was designed
according to the psychiatric and obstetric needs of pregnant
women. Adoption of the group training format is considered
economical and particularly suits countries where healthcare
resources are less abundant. Furthermore, the standardized
programmakes it easy for healthcare workers in different set-
tings to adopt.
Acknowledgments
The authors acknowledge all of the participants of this study
and thank the nurses of the Department of Obstetrics of The
First Hospital of Hangzhou, Zhejiang, China. The study was
supported by Zhejiang Provincial Natural Science Founda-
tion of China (Y207858).
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