ANTENATAL PSYCHOSOCIAL RISK-FACTORS ASSOCIATED WITH ADVERSE POSTPARTUM FAMILY OUTCOMES

Objective: To determine the strength of the association between antena tal psychosocial risk factors and adverse postpartum outcomes in the f amily, such as assault of women by their partner, child abuse, postpar tum depression, marital dysfunction and physical illness. Data sources : MEDLINE, Cinahl, Famli, Psych Abstracts and the Oxford Database of P erinatal Trials were searched for relevant articles published from Jan . 1, 1980, to Dec. 31, 1993, with the use of MeSH terms ''depression, involutional,'' ''child abuse,'' ''child neglect,'' ''domestic violenc e,'' ''family, ''marital adjustment,'' ''family health, ''newborn heal th,'' ''child health, ''physical illness,'' ''social support,'' ''psyc hosocial risk,'' ''prediction,'' ''risk factors,'' ''obstetrics'' and ''prenatal care.'' Further articles. were identified from bibliographi es. Study selection: Of the 370 articles identified through the search , 118 were included for review. Studies were included if they examined the association between psychosocial risk factors and the outcomes of interest. Articles were excluded if they were reviews of poor quality or they had one or more of the following features: insufficient descr iption of the sample, a high attrition rate, a lack of standardized ou t come measures, outcomes other than the ones of interest or results t hat had already been reported in a previous study. Data extraction: Th e strength of evidence of each study was evaluated. On the:basis of th e evidence, each risk factor was assigned a rating of the strength of its association with each of the postpartum outcomes. The ratings were class A (good evidence of association), class B (fair evidence) and c lass C (no clear evidence). Of the 129 antenatal psychosocial risk fac tors studied, 15 were found to have a class A association with at leas t one of the postpartum outcomes. Data synthesis: Child abuse and abus e of the mother by her partner were most strongly correlated (class A evidence) with a history of lack of social support, recent life stress ors, psychiatric disturbance in the mother and an unwanted pregnancy. Child abuse was also strongly associated with a history of childhood v iolence in the mother or her partner, previous child abuse by the moth er's partner, a poor relationship between the mother and her parents, low self-esteem in the mother and lack of attendance at prenatal class es. Postpartum abuse of the mother was also associated with a history of abuse of the mother, prenatal care not started until the third trim ester and alcohol or drug abuse by the mother or her partner (class A evidence). Child abuse had a fair (class B) association with poor mari tal adjustment or satisfaction, current or past abuse of the mother an d alcohol or drug abuse by the mother or her partner. There was class B evidence supporting an association between abuse of the mother and p oor marital adjustment, traditional sex-role expectations, a history o f childhood violence in the mother or her partner and low self-esteem in the mother. Postpartum depression was most strongly associated with poor marital adjustment, recent life stressors, antepartum depression (class A evidence), but was also associated with lack of social suppo rt, abuse of the mother and a history of psychiatric disorder in the m other (class B evidence). Marital dysfunction was associated with poor marital adjustment before the birth and-traditional sex-role expectat ions (class A evidence), and physical illness was correlated with rece nt life stressors (class,B evidence). Conclusions: Psychosocial risk f actors during the antenatal period may herald postpartum morbidity. Re search is required to determine whether detection of these risk factor s may lead to interventions that improve postpartum family outcomes.