Validation of the Postnatal Perceived Stress Inventory in a French Speaking Population of Primiparous Women

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Validation of the Postnatal Perceived Stress Inventory in a French Speaking Population of Primiparous Women Chantal Razurel, Barbara Kaiser, Marc Dupuis, Jean-Philippe Antonietti, Catherine Sellenet, and Manuela Epiney

Correspondence Chantal Razurel, PhD, Department of Midwifery, University of Applied Sciences Western Switzerland, Haute Ecole de Sant´e, 47 Avenue de Champel, 1206 Geneva, Switzerland, [email protected]

ABSTRACT

Keywords perceived stress scale validation postnatal depression anxiety

Results: The exploratory analysis revealed a 19-item structure divided into six factors. This inventory has good internal consistency (Cronbach’s alpha = .815). The predictive validity shows that the PNPSI significantly predicts depression and anxiety at 6 weeks postpartum, and that certain factors are particularly prominent.

Objective: To develop a Postnatal Perceived Stress Inventory (PNPSI) and assess its psychometric properties. Design: Cross-sectional quantitative study. Setting: One nurse-managed labor and delivery unit in a university hospital in a major metropolitan area. Participants: One hundred seventy-nine (179) primiparous French speaking women who gave birth at term. Methods: The PNPSI was validated at 6 weeks postpartum. Its predictive validity for depression and anxiety was assessed at the same time.

Conclusion: The PNPSI’s psychometric properties make it a useful tool for future research to evaluate interventions for perceived stress during the postnatal period. Its predictive power for depression indicates that it is also a promising tool for clinical settings.

JOGNN, 42, 685-696; 2013. DOI: 10.1111/1552-6909.12251 Accepted July 2013

Chantal Razurel, PhD, is a professor of midwifery in the Department of Midwifery, University of Applied Sciences Western Switzerland, Geneva, Switzerland and in the Centre de Recherche en ´ Education de Nantes, University of Nantes, Nantes, France. Barbara Kaiser, PhD, is a professor of midwifery in the Department of Midwifery, University of Applied Sciences Western Switzerland, Geneva, Switzerland.

(Continued)

he experience of childbirth can lead to significant disruption that favors the development of psychological disorders among mothers. It also can cause anxiety, which can be associated with difficulties in adapting to the maternal role (Barnett, Schaafsma, Guzman, & Parker, 1991) with prevalence evaluated between 33% and 59% (Faisal-Cury & Menezes, 2007). Furthermore, it can disturb the development of the mother/infant relationship (Kaitz, Maytal, Devor, Bergman, & Mankuta, 2010; Nicol-Harper, Harvey, & Stein, 2007). The postnatal period also is associated with a risk of depression evaluated between 7% and 12% (Gavin et al., 2005), which can result in a troubled mother/infant relationship and affect the infant’s development (Halligan, Murray, Martins, & Cooper, 2007; McGrath, Records, & Rice, 2008; Murray, Fiori-Cowley, Hooper, & Cooper, 1996; Sinclair & Murray, 1998;).

T

women experience the birth of their first children and showed that it was perceived as a succession of stressful events (Razurel, Bruchon-Schweitzer, Dupanloup, Irion, & Epiney, 2011). The concept of perceived stress does not necessarily refer to an objective fact but is rather the result of an evaluation by the individual. The primary evaluation will allow the individual to characterize the event (“Is this a threat to my peace of mind?”) (Coyne & Lazarus, 1980). The secondary evaluation will allow the individual to consider her resources and the need to change how things work: this is the step that constitutes perceived stress. In this regard, stress can be differentiated from uneasiness (a general and diffuse feeling) and from fear (a negative feeling) (Amiel-Lebigre, 1993). Stress is linked to an event that entails a need to adapt. Lazarus and Folkman (1984) defined stress as an individual perception and a specific relationship with the environment: stress is neither a stimulus nor a response but a dynamic, singular process (a transaction) that is actively developed by an individual facing an aversive situation. This is referred to as perceived stress.

The authors report no conflict of interest or relevant financial relationships.

The way women experience the events linked with childbirth has been correlated with psychological disorders among mothers (Hart & McMahon, 2006). The researchers of one study explored how

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 C 2013 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

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Postnatal stress has an effect on the psychological health of mothers, but the tools currently used to measure stress are not specific to this period.

The investigators of some studies have suggested that perceived stress has an effect on the course of pregnancy (Dunkel-Schetter & Glynn, 2010; Dunkel-Schetter & Lobel, 2012) and on the psychological well-being of mothers (Razurel, Kaiser, Sellenet, & Epiney, 2013). Corwin, Brownstead, Barton, Heckard, and Morin (2005) and Leung, Martinson, and Arthur (2005) suggested that postnatal stress is associated with postnatal depression, whereas researchers of other studies suggested that postnatal perceived stress is associated with postnatal depression (Gao, Chan, & Mao, 2009; Leigh & Milgrom, 2008; Wang & Chen, 2006). However, perceived stress is evaluated in a general way without linking birth events to stress and most often using the Perceived Stress Scale (PSS) (Cohen, Kamarck, & Mermelstein, 1983). The investigators of some studies have suggested that specific stress is a much better predictor, especially during pregnancy (Alderdice, Lynn, & Lobel, 2012; Di Pietro, Hilton, Hawkins, Costigan, & Pressman, 2002; Lobel et al., 2008). Marc Dupuis, MSc, is a psychologist in the Forensic Psychiatry Institute, University Hospital of Lausanne, Lausanne, Switzerland. Jean-Philippe Antonietti, PhD, is a senior lecturer of statistics in the Institute of Psychology, University of Lausanne, Lausanne, Switzerland. Catherine Sellenet, PhD, is a professor of educational sciences in the Centre de ´ Recherche en Education de Nantes, University of Nantes, Nantes, France. Manuela Epiney, MD, is a senior registrar in the Department of Obstetrics and Gynecology, University of Geneva Hospitals, Geneva, Switzerland.

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Researchers also have suggested that the nature of events during the postnatal period could have an influence on the perception of stress (Honey, Bennett, & Morgan, 2003; Leigh & Milgrom, 2008; McGrath, Records, & Rice, 2008; Razurel et al., 2011). For example, McGrath et al. suggested that the stress caused specifically by caring for the infant does not increase the risk of depression, whereas Razurel et al. (2011) suggested that stress caused by breastfeeding can result in a negative mood. However, no specific inventory seems appropriate for the postnatal period. Only the researchers of one study (Leigh & Milgrom) used a specific perceived stress inventory, the Parenting Stress Index (PSI) (Loyd & Abidin, 1985); however, they did not link the different particular postpartum events to perceived stress. In fact, it was built using tools that measured the mother/infant relationship, dysfunctions of the mother/infant dyad, and the emotional reactions of the infant (Abidin, 1986).

suggested that a previous birth could strongly influence subsequent experiences (Olde, Van der Hart, Kleber, & Van Son, 2006; Soet, Gregory, Brack, & Dilorio, 2003) and that premature delivery, which is associated with particular stress, may be accompanied by difficulties in the mother/infant relationship (Muller-Nix et al., 2004). For these reasons, we did not include multiparous mothers and those who had preterm deliveries. The aim of this study was to validate a new perceived stress inventory at 6 weeks postpartum because no tool has yet been proposed to investigate stress related to events specific to this period for primiparous mothers who gave birth at full term.

Methods Developing the Inventory In a previous study, we developed the Postnatal Perceived Stress Inventory (PNPSI) based on the content analysis of 60 interviews carried out on primiparous mothers who gave birth at term in Geneva Maternity Hospital (Razurel et al., 2011). Because the interviews were semistructured, the themes broached by the women were not limited. Interview content was then analyzed using a category tree based on the concept of perceived stress (Flick, 2006). Events were characterized as stressful if the mothers cited that the events affected them (i.e., made them feel like they had used up all their resources and threatened their well-being) as defined by Lazarus and Folkman (1984). Expressions, such as “that worried me and that stressed me out” were identified as significant. Another researcher performed a second coding. A comparison of these codings was carried out and followed up by discussion where there was disagreement. A third coding was carried out by an expert in the field. Content analysis was performed using qualitative data analysis software (Nud∗ Ist. version QSR N6) that generated a list of 27 items of perceived stress in the postpartum period and provided information on the intensity of the perceptions of stress according to each item. Factor structure and PNPSI validation was performed using the list of 27 items produced by the qualitative analysis (Table 1).

Sample and Procedure

Furthermore, the 6 weeks after delivery appear to be a pivotal period during which a number of events linked to childbirth require major adaptations (Razurel et al., 2011). Researchers have

The perceived stress inventory was administered to 179 French speaking primiparous women who gave birth at full term in Geneva University Hospital. Participation in the study was proposed to all mothers who met the inclusion criteria during their postnatal hospital stays. Informed consent

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Table 1: Items Related to Postnatal Perceived Stress I am or was more or less stressed by the following 1 = not at all; 2 = a little; 3 = moderately; 4 = very; 5 = extremely 1. Episiotomy scars and lesions associated with childbirth (I did not recognize my body) 2. Painful scar (episiotomy or cesarean) 3. Baby’s health 4. Not knowing if my baby was eating (or is eating) enough (not being able to control the quantity of milk when breastfeeding) 5. Baby’s routine (e.g., baby crying, being demanding) 6. The risk of stillbirth 7. Caring for the baby (e.g., bath, umbilical cord care, changing) 8. My fatigue, my lack of sleep 9. Being overwhelmed and having little time for myself 10. Organizational issues at home (baby care, shopping, laundry, etc.) 11. Pain of breastfeeding 12. Difference between how I imagined it would be and my actual experience of: breastfeeding, the baby’s routine, organization at home (underline whichever applies to you) 13. Baby blues, wanting to cry, dark thoughts 14. Contradictory advice from caregivers 15. Father’s role with the baby 16. My relationship with my partner 17. Recovering sexual intimacy 18. Housing issues (e.g., moving in, moving out) 19. My smoking (or alcohol intake) 20. Not being able to do what I was doing before (e.g., going out, travelling) 21. My relationship with the baby 22. The impression of not being able to look after my baby 23. Changes in my body 24. Care of the child when I go back to work 25. Going back to work (or back to my other activities) 26. My relationship with those close to me (family, friends) (all the advice they gave me or the judgments I felt) 27. My relationship with caregivers

forms were signed by all mothers who agreed to participate in the study. Of the 220 mothers who agreed to participate in the study, 179 actually completed the questionnaires. The questionnaires were filled in at 6 weeks postpartum by the mothers and returned to the principal researcher who anonymized the data and recorded them in a database. The list of stress items comprised 27 elements. With a sample of 179 women, we were able to validate our ques-

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tionnaire. We met the recommendation made by Kline (2005) and Kraemer and Thiemann (1990), which indicated that to establish the structure of a questionnaire, the number of individuals interviewed should be at least five times the number of items included in the questionnaire. This project was reviewed and approved by the ethics committee of Geneva University Hospitals. The characteristics of the study sample are presented in Table 2.

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Table 2: Characteristics of the Study Population (N = 179) Variable

n (%)

Mean ± SD (min-max) 31.5 ± 3.9 (21–43)

Age Lifestyle Single In a relationship Living with parents

3 (1.7) 171 (95.7) 5 (2.6)

Marital status Single

67 (37.3)

Married

106 (59.2)

Divorced

5 (3.1)

Separated

1 (0.4)

Socioprofessional status Employee or middle manager

102 (57)

Senior executive or self-employed

36 (20)

Unskilled workers or employees

32 (18)

Unemployed

9 (5)

Nationality Swiss national

95 (53)

European

65 (36.2)

North American

2 (0.9)

African

7 (3.9)

Latin American

9 (5.6)

Asian

1 (0.4)

Smokers Alcohol consumers Antenatal class

25 (13.8) 9 (4.8) 150 (83.8)

Type of delivery Spontaneous vaginal delivery

98 (55)

Instrumented vaginal delivery

46 (25.9)

Cesarean delivery

35 (19.1)

Episiotomy

45 (25)

Perineal tear

77 (43)

Epidural

161 (90)

Breastfeeding

170 (95)

STAI-T score

39.03 ± 7.04 (27–67)

STAI-S score

35.7 ± 10.9 (20–69)

EPDS score

8.06 ± 3.7 (2–20)

Note. EPDS = Edinburgh Postnatal Depression Scale, SD = standard deviation, STAI-S = State Trait Anxiety Inventory-anxiety state, STAI-T = State Trait Anxiety Inventory-anxiety trait.

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Instruments The PSS was developed by Cohen et al. (1983) to assess how stress is perceived globally. It is a self-administered questionnaire that consists of items measured on a 5-point Likert-type scale. This scale has good psychometric properties, with Cronbach’s alpha coefficients ranging from .84 to .86 and a test–retest reliability of .85 based on analyses made on three different samples. The items are neither too general, nor too specific (e.g., “Were you disturbed by this unexpected event?: and “Did you feel nervous or stressed?”), so this tool can be used in various contexts. Furthermore, it is widely used in studies that measure stress in the perinatal period (Razurel et al., 2013). The Cronbach’s alpha coefficient for this study was .86. Form Y of the State Trait Anxiety Inventory (STAI) is a self-administered questionnaire developed by Spielberger (1983) that measures the levels of anxiety trait (STAI-T) and anxiety state (STAI-S). Anxiety trait corresponds to a behavioral disposition acquired in the course of one’s personal history and is considered to be stable throughout one’s life. Anxiety state corresponds to a temporary emotional state, which exists at any given moment and at a level of intensity particular to specific events. Each scale comprises 20 questions. This tool is very widely used in research, including research on the perinatal period (Razurel et al., 2013). Internal consistency reliability (Cronbach’s alpha) of the STAI-S was 0.94 and the test–retest reliability was 0.89. In general, a cutoff score greater than 40 was used to determine a high-anxiety state (Grant, McMahon, & Austin, 2008) and a cutoff score greater than 41 was used to determine a high anxiety trait (Denollet, 1991; Spielberger, 1985). Cronbach’s alpha for this study was .95. The Edinburgh Postnatal Depression Scale (EPDS) (Cox, Halden, & Sagovsky, 1987) is a self-administered questionnaire that evaluates the risk of depression. This scale has very good psychometric properties and has been validated at 6 weeks postpartum (Chabrol & Teissedre, 2004). Cox et al. reported a standardized alpha coefficient of .88 for the EPDS in a sample of 84 postpartum women. High test–retest reliability was found in the short-term (r = .98) (Guedenay & Fermanian, 1998). It includes 10 questions (e.g., “I could laugh and look on the bright side,” “I felt so unhappy that I cried”). This tool is the most widely used instrument in the scientific literature for assessing symptoms of postpartum depression (Henshaw & Elliot, 2005; Razurel et al., 2013). A cutoff score greater

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We developed and validated a stress inventory specific to the postnatal period (6 weeks after delivery).

than 11 is recommended to determine the risk of postpartum depression (Chabrol & Teissedre 2004; Gibson, McKenzie-McHarg, Shakespeare, Price, & Gray, 2009). The Cronbach’s alpha score for this study was .72.

Statistical Analysis The analyses were performed using the Statistical Package for the Social Sciences (SPSS; version 13). The level of statistical significance was set at 0.05. Exploratory factor analysis using principal component analysis (PCA) was performed on the perceived stress inventory 6 weeks postpartum to identify factors and was refined by Cattell’s scree test (1966). Construct validity was tested with Cronbach’s alpha, which calculates uniformity based on the correlation between the items and provides information on the reliability of the questionnaire and the relevance of the construct (Tavakol & Dennick, 2011). The construct validity is satisfactory if the score is greater than .70. To evaluate concurrent validity, which measures the same dimensions with a different valid instrument (Bouvard & Cottraux, 1996), we carried out a correlation analysis between the PNPSI and the PSS (Cohen et al., 1983). To evaluate convergent validity (i.e., distinct but close concepts), we carried out a correlation analysis between the PNPSI and the EPDS (Cox et al., 1987) and STAI-S (Spielberger, 1983). Intergroup comparisons were made with ANOVA to assess the effect of independent variables on perceived stress as measured with the PNPSI, such as the type of delivery, breastfeeding, followup by a midwife at home, participation in prenatal classes and STAI-T (Spielberger, 1983). Finally, predictive validity was assessed through multiple regression analysis between the different stress factors and depression (EPDS) and STAI-S.

Results Factor Analysis The analysis revealed a Kaiser-Meyer-Olkin (KMO) index of 0.839 and a significant Bartlett’s test result (p < 0.05), which provided favorable conditions for factor analysis (Kline, 1998; Snedecor & Cochran, 1989). Initial exploratory

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factor by PCA was performed on the early PNPSI, followed by orthogonal rotation (varimax) and revealed eight factors. Cattell’s (1966) scree test suggested a six-factor model, which explained 58.6% of the cumulative variance. Eight items were excluded from the PCA because they either had a weight less than 0.4 or because the difference in factorial weight was less than 0.1 between different factors (Tabachnick & Fidel, 2001). Therefore, the proposed model is composed of 19 items divided into six factors with a consistent distribution of factorial weight. Only Item 22, “The impression of not being able to look after my baby,” was distributed differently. Indeed, this item should be in Factor 1, Fatigue and Organization at Home (according to its factorial weight), but it seems more logical to place it in Factor 2, Relationship with Baby. Table 3 shows the distribution of each item with their corresponding factorial weight.

cated that the concepts of perceived stress and depression and anxiety were well differentiated (Cohen, 1992).

Discriminant Validity To evaluate whether independent factors influenced the PNPSI, we performed intergroup comparisons using ANOVA (Table 6). A significant difference was noted in the level of perceived stress in terms of trait anxiety, F(1, 149) = 22.9, p < 0.05, and follow-up of preparation for birth, F(1, 163) = 4.539, p < 0.05. Mothers with a STAI-T score greater than 41 had higher mean perceived stress (group 0: Mean = 2.04, Standard Deviation [SD] = .56] versus group 1: Mean = 2.5, SD = .51]). Mothers who participated in antenatal classes had higher mean perceived stress than mothers who did not (group 0: Mean = 1.93, SD = .47, versus group 1: Mean = 2.23, SD = .59).

Predictive Validity Construct Validity The Cronbach’s alpha was 0.82 for the PNPSI, which indicated a good internal consistency and good consistency between the items (Nunnally, 1978). We found that all of the factors correlated significantly or positively to the others, except for Factor 2, Relationship to Baby, which did not correlate significantly with Factor 6, Relationship with Partner. However, the coefficients of correlation for these factors were less than 0.5, which indicated that the factors were well differentiated and that there was no overlap between them (Cohen, 1992) (Table 4).

Convergent and Concomitant Validity The results obtained with the PNPSI were compared with those obtained with the PSS (Cohen et al., 1983) to assess concomitant validity. We found that the total perceived stress score measured with the PNPSI significantly correlated with that obtained with the PSS (r = .642, p < 0.01) with a strong correlation index (Cohen, 1992). This indicates that the PNPSI provides an accurate measurement of perceived stress.

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Finally, to evaluate whether certain stress factors in the PNPSI predicted depression and anxiety, we performed a multiple regression analysis (Table 7). We found that Factor 1, Fatigue and Organization at Home, and Factor 6, Relationship with Partner, had a significant predictive value on postpartum depression (β = .321 and β = .299, p < 0.05) and postnatal anxiety (β = .229 and β = .296, p < 0.05). Factor 2, Relationship with Baby, also had a significant predictive value on postpartum depression (β = .151, p < 0.05) and tended to have a significant predictive value on postnatal anxiety (β = .149, p = .054). Conversely, Factor 3, Relationship with Body; Factor 4, Feeding the Baby; and Factor 5, Future Plans had no significant predictive value on depression and anxiety when they were in competition with the other factors.

Discussion Structure of the Inventory

To evaluate convergent validity, a correlation analysis was carried out between the PNPSI, the EPDS (Cox et al., 1987), and STAI-S (Spielberger, 1983). The results suggested that the PNPSI significantly correlated with the STAI-S and the EPDS (r = .477 and r = .527, respectively; p < 0.05) (Table 5). However, the correlation coefficients were less than 0.5, which indi-

The objective of this study was to assess the factorial structure of perceived stress at 6 weeks postpartum in a population of primiparous women. The results of the factorial analysis showed that the 19item version divided into six factors was the most appropriate. The six factors identified were Factor 1, Fatigue and Organization at Home; Factor 2, Relationship with Baby; Factor 3,Relationship with Body; Factor 4,Feeding the Baby; Factor 5, Future Plans; and Factor 6, Relationship with Partner. This inventory demonstrated good internal consistency.

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Table 3: Factorial Weight of Items with an Extraction Method by Principal Component Analysis (PCA) After Varimax Rotation With Kaiser Normalization Items

F1

F2

F3

F4

F5

F6

.789

.196

.015

.069

.077

.211

.770

−.031

.242

.071

−.119

−.037

Item 8, My fatigue, my lack of sleep

.714

.176

−.092

.107

.103

.230

Item 5. Baby’s routine (baby crying, being

.627

.150

.131

.172

.303

.209

.410

.308

−.102

−.292

.006

−.105

Item 3. Baby’s health

.034

.744

.147

.104

.049

−.020

Item 6. The risk of stillbirth

.121

.750

−.025

.081

.032

−.042

Item 7. Caring for the baby (bath, umbilical cord

.193

.598

.065

−.038

.114

.120

.192

.163

.868

−.026

.070

.030

.176

−.031

.746

.133

.135

.317

−.183

.077

.730

.052

.159

.171

.086

−.097

.006

.779

.005

.067

−.044

.407

.103

.686

.073

.083

.569

−.018

−.056

.621

.084

−.169

.359

.347

.150

.489

.037

−.097

Item 24. Care of the child when I go back to work

.082

.069

.192

−.012

.893

.145

Item 25. Going back to work (or back to my other

.076

.118

.106

.094

.886

.069

Factor 1: Fatigue and Organization at Home Item 9. Being overwhelmed and having little time for myself Item 20. Not being able to do what I used to do before (e.g., going out, travelling)

demanding) Factor 2: Relationship with Baby Item 22. The impression of not being able to look after my baby

care, changing) Factor 3: Relationship with Body Item1. Episiotomy scars and lesions associated with childbirth (I did not recognize my body) Item 17. Recovering sexual intimacy Item 2. Painful scar (episiotomy or cesarean) Factor 4: Feeding the baby Item 11. Pain of breastfeeding Item 4. Not knowing if my baby was eating (or is eating) enough (not being able to control the quantity of milk when breastfeeding) Item 12. Difference between how I imagined it would be and my actual experience of: breastfeeding, the baby’s routine, organization at home (underline whichever applies to you) Item 14. Contradictory advice from caregivers Factor 5: Future Plans

activities) Factor 6: Relationship with Partner Item 16. My relationship with my partner

.098

.021

.208

.022

.114

.898

Item 15. Father’s role with the baby

.195

.202

.000

.010

.114

.892

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Table 4: Interfactor Correlations (n = 179) F1PNPSI F1PNPSI

Pearson’s correlation coefficient

F2PNPSI

Pearson’s correlation coefficient

F3PNPSI

Pearson’s correlation coefficient

F4PNPSI

Pearson’s correlation coefficient

F5PNPSI

Pearson’s correlation coefficient

F6PNPSI

Pearson’s correlation coefficient

F2 PNPSI

F3 PNPSI

∗∗

1

.407

.290

1

F4 PNPSI

∗∗

.475

∗∗

F5 PNPSI .272

∗∗

F6 PNPSI .397∗∗

.163∗

.308∗∗

.185∗

.123

1

.266∗∗

.274∗∗

.365∗∗

1

.160∗

.207∗∗

1

.234∗∗ 1

Note. F = factor, PNPSI = postnatal perceived stress inventory. ∗∗ P < 0.01 (bilateral) ∗ P < 0.05 (bilateral) PNPSI = postnatal perceived stress inventory, STAI-S = State Trait Anxiety Inventory-anxiety state F1PNPSI: Factor 1 (Fatigue and Organization at Home) of the PNPSI (Postnatal Perceived Stress Inventory) F2PNPSI: Factor 2 (Relationship with Baby) of the PNPSI F3PNPSI: Factor 3 (Relationship with Body) of the PNPSI F4PNPSI: Factor 4 (Feeding the Baby) of the PNPSI F5PNPSI: Factor 5 (Future Plans) of the PNPSI F6PNPSI: Factor 6 (Relationship with Partner) of the PNPSI

PNPSI and Psychological Health Issues Concomitant validity results revealed that the PNPSI correlated with depression and anxiety. Factor 1, Fatigue and Organization at Home, was linked to all the other factors and predicted postpartum depression. This factor included items, such as being overwhelmed and having little time to oneself, lack of sleep, difficulty doing certain activities and maintaining the infant’s routine. Corwin et al. (2005) previously suggested that postpartum fatigue strongly correlated with postpartum depression. The researchers of other studies showed that fatigue and lack of sleep were very disruptive and brought mothers close to exhaustion (Razurel et al., 2011). Dennis and Ross (2005) also suggested that when mothers could not adjust to the lack of sleep, the risk of postpartum depression increased significantly.

Postpartum depression has been suggested to be a corollary of fatigue in several studies. For some authors, this is one of the first signs of depression (Bozoky & Corwin, 2002; Righetti-Veltema, ConnePerreard, Bousquet, & Manzano, 1998); for others, ´ fatigue is a triggering factor (Doering Runquist, Morin, & Stetzer, 2009). Therefore, taking fatigue into account is a fundamental aspect of postpartum care. Moreover, mothers do not always have an available network (family or friends) to help them with household chores and their spouses often are absent during the day because of work. Thus, mothers find themselves alone when facing different events and feel overwhelmed and tired (Razurel et al., 2011). However, health systems barely take this aspect into account: household assistance is not part of a systematic intervention and is not covered by health insurance.

Table 5: Correlation Between Postnatal Perceived Stress Inventory (PNPSI), Edinburgh Postnatal Depression Scale (EPDS), and State Trait Anxiety Inventory-Anxiety State (STAI-S)

Score STAI-S

Score EPDS

F1

F2

F3

F4

F5

F6

Overall score

PNPSI

PNPSI

PNPSI

PNPSI

PNPSI

PNPSI

PNPSI

Pearson’s correlation coefficient

.404∗∗

.284∗∗

.245∗∗

.167∗

.293∗∗

.406∗∗

.477∗∗

n

158

158

156

152

158

158

150

Pearson’s correlation coefficient n

∗∗

∗∗

∗∗

∗∗

∗∗

∗∗

.506

.335

.231

.245

.279

.445

177

177

173

171

177

176

.527∗∗ 167

Note. ∗ p < 0.05 (bilateral) ∗∗ p < 0.01 (bilateral)

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Razurel, C. et al.

Table 6: Analysis of Variance (ANOVA) Sum of

Intergroups (age)

Mean of

squares

Degrees of freedom

squares

F

Significance

.193

1

.193

.553

.458

Intergroups (marital status)

1.026

2

.513

1.473

.232

Intergroups (SPC)

1.229

3

.410

1.109

.348

Intergroups (tobacco)

.066

1

.066

.178

.673

Intergroups (alcohol)

.426

1

.426

1.223

.270

Intergroups (breastfeeding)

.982

1

.982

2.734

.100

6.865

1

6,865

22.965

.000

.352

3

.117

.313

.816

1.554

1

1.554

4.539

.035

.442

1

.442

1.226

.270

Intergroups (anxiety trait) Intergroups (type of delivery) Intergroups (antenatal classes) Intergroups (follow-up with midwife)

Note. SPC = socioprofessional categories. For age, because the median and mode were both equal to 31, we differentiated two groups: group 1: age ≤ 31 years and group 2: age > 31 years. For marital status we differentiated three groups: (a) married, (b) in a relationship, and (c) single (separated or divorced) Socioprofessional categories: employee or middle manager; senior executive or self-employed; blue collar or employees; unemployed Trait anxiety is part of the character traits that make up the individual and remains stable in any situation. Researchers agree on a cut-off score of 41 for State Trait Anxiety Inventory-anxiety trait (STAI-T) (Denollet, 1991; Spielberger, 1985). Therefore, we differentiated two groups in our sample: 1) STAI-T ≤ 41 and 2) STAI-T > 41 For the type of delivery, we differentiated 4 groups: (a) spontaneous vaginal delivery, (b) instrumented vaginal delivery, (c) planned cesarean section, and (d) emergency cesarean section. Follow-up with a midwife consisted of home visits during the 10 days postpartum

Factor 6, Relationship with Partner, also had an effect on anxiety and depression. The relationship with the partner plays a prominent role in the mother’s well-being, not only in terms of support, but also in the new balance of the couple: the relationship is no longer about two people because the child is now at the heart of this relationship. Although mothers consider that their partner has an essential role, their expectations are not always met because the father, who also is experiencing profound changes that relate to his new role, cannot always provide the support the mother needs (Razurel et al., 2011). The desire to assist their partners in spite of the stress they are themselves experiencing, can lead to inept support that does not meet the partner’s expectations. This can lead to significant stress, as identified in several studies (Demontigny & Lacharite, ´ 2002; Gremigni, Mariani, Marracino, Tranquilli, & Turi, 2011; Wandersman, Wandersman, & Kahm, 2006;). Factor 2, Relationship with Baby, also had an effect on anxiety and tended to have an effect on depression. Leung et al. (2005) and Honey et al. (2003) also reported that stress caused by the behavior of the infant had an effect on the risk of depression, whereas McGrath et al. (2008) showed that stress caused specifically by caring for the infant was

JOGNN 2013; Vol. 42, Issue 6

The psychometric analysis of the PNPSI shows excellent psychometric indices and very strong predictive validity for postnatal depression.

not associated with depression. However, in our study, this factor referred as much to care (caring for the infant, e.g., bath, umbilical cord care, and changing) as to the parental role (the impression of not being able to look after my infant) and the infant’s health. In addition, Leigh and Milgrom (2008) showed that parental stress (i.e., stress linked to parental duties) predicted postnatal depression. This is a major factor during the postpartum period, and the role of parent clearly requires adaptations that could create significant stress. This finding could give rise to practical applications, particularly in developing educational resources centered on the care and development of the child, as suggested by Leigh and Milgrom. We also noted that maternal breastfeeding at this postpartum stage (i.e., 6 weeks after giving birth) was not associated with depression. This is probably because most of the problems and

693

RESEARCH

Postnatal Perceived Stress Inventory

Table 7: Multiple Regression Analysis Assessing the Predictive Value of Postnatal Perceived Stress Inventory (PNPSI) and the Different Factors on Depression and Anxiety Model

Beta

Standard Error

p

F1PNPSI/EPDS

.321

.395

.000

F2PNPSI/EPDS

.151

.287

.033

F3PNPSI/EPDS

−.024

.302

.732

F4PNPSI/EPDS

−.022

.344

.767

F5PNPSI/EPDS

.082

.229

.227

F6PNPSI/EPDS

.299

.301

.000

F1PNPSI/STAI-S

.229

1.246

.010

F2PNPSI/STAI-S

.149

.853

.054

F3PNPSI/STAI-S

.048

.921

.542

F4PNPSI/STAI-S

−.057

1.071

.473

F5PNPSI/STAI-S

.084

.715

.279

F6PNPSI/STAI-S

.296

.942

.000

Note. EPDS = Edinburgh Postnatal Depression Scale, F = factor, PNPSI = postnatal perceived stress inventory, STAI-S = State Trait Anxiety Inventory-anxiety state. F1PNPSI: Factor 1 (Fatigue and Organization at Home) of the PNPSI (Postnatal Perceived Stress Inventory) F2PNPSI: Factor 2 (Relationship with Baby) of the PNPSI F3PNPSI: Factor 3 (Relationship with Body) of the PNPSI F4PNPSI: Factor 4 (Feeding the Baby) of the PNPSI F5PNPSI: Factor 5 (Future Plans) of the PNPSI F6PNPSI: Factor 6 (Relationship with Partner) of the PNPSI

adjustments were resolved during the first month postpartum. In addition, Factor 5, Future Plans, did not play a prominent role in depression and anxiety either, perhaps because mothers are still on maternity leave and, therefore, are not yet faced with being separated from their children.

Variation and Generalization of the Inventory We found that trait anxiety and antenatal classes influenced the level of perceived stress measured by our inventory. Mothers who participated in antenatal classes had greater mean perceived stress. There are several potential explanations for this surprising result. We can presume that women who are particularly stressed are more likely to enroll in antenatal classes, but it also is conceivable that antenatal classes caused stress by communicating particularly high standards; as such, current monitoring systems could cause more stress for mothers than they alleviate. These hypotheses should be explored in further studies.

ther validation should thus be performed in culturally diverse populations and among multiparous mothers to confirm that the use of this scale can be generalized.

Conclusions The psychometric properties of the PNPSI indicate that it meets the validity criteria expected of this type of instrument and is a valid inventory for the measurement of postnatal perceived stress. Furthermore, its correlation to the depression and anxiety scales makes it a suitable tool for clinical application. This inventory can be used in a general population without restriction of specific factors and may lead to a better understanding of the effects of perceived stress on the psychological health of mothers, particularly regarding each individual factor. Therefore, interventions using PNSPSI should be considered to improve the care of mothers during the postpartum period, and particularly those based on the evidence regarding perception of stress (e.g., through postnatal interviews) and the management of stress.

Limitations

694

Scale validation was conducted among primiparous mothers living in Geneva, Switzerland ,who gave birth at the public University Hospital. Fur-

Abidin, R. R. (1986). Parenting Stress Index manual 2nd edition. Char-

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http://jognn.awhonn.org

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