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935
Methods
From September of 1996 to July of 1997, a sample of
pregnant women presenting for obstetric services
agreed to complete the Brief Symptom Inventory and
the Short Form-36 in physicians waiting rooms.
Women were recruited consecutively and were excluded if they could not read English or were not in the
third trimester of pregnancy. Five hundred surveys
were printed, which were distributed to physicians
offices by a study coordinator. The women were given a
second, identical survey in a stamped addressed envelope upon discharge after their infants birth. They were
asked to complete the survey and return it by mail
before their first postpartum visit, usually 6 weeks
postpartum. To improve survey return rates, women
were contacted by phone if follow-up surveys were not
completed.
All subjects delivered in the same teaching hospital,
classified as a level II center, with a perinatal mortality
rate between 7.5 and 7.7 per 1000 births per year. At the
center there are approximately 2300 births more than 32
936 Otchet et al
Community sample
Characteristic
Mean
Standard
deviation
Sample
size*
Mean
Standard
deviation
Sample
size
Bodily pain
General health
Mental health
Physical functioning
Social functioning
Vitality
Functional limitations due to
emotional problems
Functional limitations due to
physical health problems
51.86
77.27
74.34
62.91
74.00
47.24
79.78
17.61
16.91
16.00
24.06
22.56
18.29
33.80
391
382
382
370
388
373
389
79.61
74.80
72.45
89.12
84.06
58.04
82.32
20.94
17.24
18.62
18.72
21.66
20.85
31.30
275
275
275
275
275
275
275
18.62
1.83
1.02
14.98
5.75
7.01
0.98
.001
NS
NS
.001
.001
.001
NS
45.00
40.25
385
86.73
27.99
275
14.80
.001
NS not significant.
* Unequal sample sizes reflect missing data.
designed to measure current, point-in-time, psychological symptom status. Subjects are asked to rate how
much they have had symptoms in the past 7 days
including today on five-point Likert scales that range
from not at all to extremely. The inventory is
divided into the following nine symptom dimensions:
somatization, ie, distress arising from perceptions of
bodily dysfunction; obsessive-compulsive thoughts, impulses, and actions that are experienced as unremitting
and irresistible; interpersonal sensitivity, ie, feelings of
personal inadequacy and inferiority; depression, including the representative range of indicators of clinical
depression; anxiety, ie, nervousness, tension, panic attacks, feelings of terror, apprehension, and some somatic correlates of anxiety; hostility, ie, thoughts, feelings, or actions characteristic of anger; phobic anxiety,
ie, fears that are irrational and disproportionate to the
stimulus and lead to avoidance or escape behavior;
paranoid ideation, ie, hostility, suspiciousness, grandiosity, fear of loss of autonomy, and delusions; and
psychoticism from mild interpersonal alienation to dramatic psychosis. The inventory also contains three
global indices of present level of distress. Higher scores
indicate greater distress.
The normative community sample for the Brief
Symptom Inventory, reported in the Brief Symptom
Inventory manual, consisted of 358 women with a mean
age of 46 years. Eleven percent were black, 86% were
white, and 3% were of other races. Twenty-five percent
were single, 60% were married, and 15% had another
marital status.
Results
Three hundred ninety-three women agreed to participate in the study and completed the first part of the
survey. Of those, 253 returned the second part of the
Otchet et al
937
Sample
size*
0.75
0.70
0.55
0.41
0.50
0.59
0.23
0.35
0.23
0.51
1.45
0.63
0.72
0.71
0.61
0.59
0.59
0.44
0.56
0.46
0.49
0.45
388
388
387
388
388
387
387
388
388
388
378
16.74
11.16
384
Mean
Somatization
Obsessive-compulsive
Interpersonal sensitivity
Depression
Anxiety
Hostility
Phobic anxiety
Paranoid ideation
Psychoticism
Global symptom index
Positive symptom
distress index
Positive symptom total
Community sample
Standard
deviation
Standard
deviation
Sample
size
0.35
0.48
0.40
0.36
0.44
0.36
0.22
0.35
0.17
0.35
1.32
0.46
0.54
0.55
0.56
0.54
0.45
0.44
0.49
0.34
0.37
0.43
358
358
358
358
358
358
358
358
358
358
358
10.0
4.7
3.2
1.17
1.45
5.94
0.31
0.00
2.01
5.0
4.0
.001
.001
NS
NS
NS
.001
NS
NS
NS
.001
.001
12.86
9.97
358
4.98
.001
Mean
NS not significant.
* Unequal sample sizes reflect missing data.
community counterparts. Pregnant women had significantly lower scores, indicating a poorer level of function, on the following subscales: bodily pain, physical
functioning, social functioning, vitality, and functional
limitations resulting from physical health problems.
Results of the Brief Symptom Inventory were also
remarkably different compared with the communitybased sample. Pregnant women showed significantly
higher levels of emotional distress (higher scores) on
the following Brief Symptom Inventory global measures: global symptom index, positive symptom distress index, and positive symptom total. Also significantly greater emotional distress was noted on the
somatization, obsessive-compulsive, and hostility subscales compared with the community sample.
Means, standard deviations, sample sizes, t test comparison with the community sample, and significance
values for the Short Form-36 completed during the
puerperium are shown in Table 3. On the Short Form36, significant differences persisted between postpartum women and the community sample for bodily pain,
social functioning, vitality, physical role limitations,
and physical functioning scales. The postpartum sample indicated a poorer level of functioning compared
with community controls. In contrast to the antepartum
findings, scores on the general health scale for women
in the puerperium were significantly greater than scores
in the community controls, indicating improved functioning of women in the puerperium. In marked contrast to the same population in the third trimester, no
significant differences were found between the postpartum sample and the community sample in any of the
mean global scale scores or the means on the individual
subscales of the Brief Symptom Inventory (data not
shown).
Paired t tests were used to compare responses on the
Community sample
Characteristic
Mean
Standard
deviation
Sample
size*
Mean
Standard
deviation
Sample
size
Bodily pain
General health
Mental health
Physical functioning
Social functioning
Vitality
Functional limitations due to
emotional problems
Functional limitations due to
physical health problems
48.92
80.22
75.52
62.48
68.38
45.10
74.33
21.19
16.51
15.48
25.61
24.65
19.02
37.58
253
252
251
244
251
244
248
79.61
74.80
72.45
89.12
84.06
58.04
82.32
20.94
17.24
18.62
18.72
21.66
20.85
31.30
275
275
275
275
275
275
275
18.49
3.69
1.36
6.96
7.76
7.35
2.65
.001
.001
NS
.001
.001
.001
NS
42.97
40.98
249
86.73
27.99
275
14.35
.001
NS not significant.
* Unequal sample sizes reflect missing data.
938 Otchet et al
Table 4. Paired Comparisons on the Short Form-36 Between the Third Trimester and the Puerperium
Mean value
Standard
deviation of
paired difference
Characteristic
Pregnancy
Puerperium
Sample
size*
Bodily pain
General health
Mental health
Physical functioning
Social functioning
Vitality
Functional limitations due to
emotional problems
Functional limitations due to
physical health problems
52.24
78.30
75.72
63.89
74.50
46.13
81.38
48.92
80.31
75.70
62.19
68.40
44.98
74.22
253
247
244
235
248
238
247
24.38
13.87
15.02
29.43
25.67
15.90
39.28
2.16
2.29
0.02
0.89
3.74
1.12
2.86
NS
NS
NS
NS
.001
NS
.005
44.56
42.84
248
47.93
0.56
NS
NS not significant.
* Unequal sample sizes reflect missing data.
Discussion
This study established a set of norms for the Short
Form-36 and the Brief Symptom Inventory in a large
Table 5. Paired Comparisons on the Brief Symptom Inventory Between the Third Trimester and the Puerperium
Mean value
Symptom
Pregnancy
Puerperium
Sample
size*
Somatization
Obsessive-compulsive
Interpersonal sensitivity
Depression
Anxiety
Hostility
Phobic anxiety
Paranoid ideation
Psychoticism
Global symptom index
Positive symptom distress index
Positive symptom total
0.71
0.71
0.52
0.37
0.48
0.55
0.22
0.32
0.20
0.48
1.43
16.2
0.44
0.63
0.46
0.36
0.41
0.44
0.18
0.28
0.21
0.39
1.34
13.4
248
248
244
248
248
248
248
248
248
248
219
243
Standard
deviation of
paired difference
0.55
0.60
0.54
0.49
0.48
0.43
0.30
0.46
0.41
0.33
0.37
8.38
7.76
2.18
1.84
0.29
2.38
3.98
2.16
1.37
0.30
4.51
3.33
5.13
.001
NS
NS
NS
NS
.001
NS
NS
NS
.001
.002
.001
NS not significant.
* Unequal sample sizes reflect missing data.
Otchet et al
939
successful delivery women have a more positive perception of their overall health status, despite their
reported physical, social, and emotional limitations.
This finding might be founded in the belief that giving
birth is often viewed as evidence of good health. The
significant decrease in social functioning after delivery
and significantly lower scores in the puerperium for
functional limitations resulting from emotional distress
might indicate additional demands that newborn infants place on mothers or couples.
On the Short Form-36, the reduction in the dimensions of health measured might be resulting from the
known physiologic changes in pregnancy and the puerperium, including factors associated with recovering
from the birthing process and care of newborns. Further
support for this conclusion comes from the study by
Hueston et al7 in which repeated assessments using the
Short Form-36 were made in women throughout their
pregnancies. They found that physical health status
(bodily pain, physical functioning, and role limitations
resulting from physical problems) negatively correlated
with gestational age, suggesting that pregnancy was the
cause of the changes. Other studies showed that recovery of physical and social functioning after delivery
requires longer than 6 weeks, which is often presumed
to constitute the puerperium. Tulman et al11,12 and Mike
et al13 found that women still reported considerable
limitations in their abilities to function at work and at
home even up to 6 months postpartum.
Pregnant women reported higher levels of psychological distress compared with controls, including
symptoms of obsessive-compulsive behavior and hostility along with the global symptom indices. The same
sample of women in the puerperium did not differ
significantly from controls on any psychological symptom measures, which was further supported by a significant reduction (less distress) during the puerperium
in the three global scales of the Brief Symptom Inventory and the hostility and somatization subscales.
The normalization of the psychological symptom
scales on the Brief Symptom Inventory in the puerperium suggested that there are psychological changes
associated specifically with pregnancy. The results on
the somatization scale might be confounded by symptoms commonly experienced during pregnancy. The
somatization scale asks questions about nausea, faintness, shortness of breath, numbness, tingling, hot or
cold spells, and pains in the heart or chest. It is more
difficult to explain the increase in hostility and obsessive-compulsive symptoms. Changes on the Brief
Symptom Inventory did not persist into the puerperium, unlike the other physical and social adaptations
addressed by the Short Form-36. We were surprised
that women in our sample displayed significantly more
940 Otchet et al
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