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Postpartum Health of Employed Mothers 5 Weeks After Childbirth

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Abstract

Most new mothers return to work soon after childbirth. A need exists to reexamine the definition of postpartum health and evaluate employed women's recovery from childbirth in association with such factors as delivery type and breastfeeding. Using a prospective cohort design, we recruited Minnesota women into the study while they were hospitalized for childbirth in 2001. Telephone interviews were conducted 5 weeks postpartum. Eligible women were 18 years or older, employed, and spoke English. Multivariate models using 2-stage least squares were used to estimate factors associated with physical and mental health and postpartum symptoms. A total of 817 women were enrolled (71% response) in the study; 716 women completed interviews at 5 weeks postpartum. On average, women reported 6 postpartum symptoms, most frequently fatigue (64%), breast discomfort (60%), and decreased desire for sex (52%). Findings showed that cesarean (vs vaginal) deliveries were associated with significantly worse physical function, role limitations, and vitality. Multivariate findings showed that the effect of delivery type on physical health was moderately large (beta = -5.96; P = or <.01), and breastfeeding was associated with an increased frequency of postpartum symptoms (beta = 4.63; P = .01). These mothers experienced several childbirth-related symptoms at 5 weeks postpartum, indicating a need for ongoing rest and recovery. Health concerns were greater for women who were breastfeeding and for those whose babies were delivered by cesarean section, suggesting a need for greater support for these women and a reassessment by the medical community of the progressively growing practice of cesarean deliveries.
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Postpartum Health of Employed Mothers
5 Weeks After Childbirth
ABSTRACT
PURPOSE Most new mothers return to work soon after childbirth. A need exists to
reexamine the defi nition of postpartum health and evaluate employed women’s
recovery from childbirth in association with such factors as delivery type and
breastfeeding.
METHODS Using a prospective cohort design, we recruited Minnesota women
into the study while they were hospitalized for childbirth in 2001. Telephone
interviews were conducted 5 weeks postpartum. Eligible women were 18 years
or older, employed, and spoke English. Multivariate models using 2-stage least
squares were used to estimate factors associated with physical and mental health
and postpartum symptoms.
RESULTS A total of 817 women were enrolled (71% response) in the study; 716
women completed interviews at 5 weeks postpartum. On average, women reported
6 postpartum symptoms, most frequently fatigue (64%), breast discomfort (60%),
and decreased desire for sex (52%). Findings showed that cesarean (vs vaginal)
deliveries were associated with signifi cantly worse physical function, role limitations,
and vitality. Multivariate fi ndings showed that the effect of delivery type on physical
health was moderately large ( = -5.96; P = <.01), and breastfeeding was associ-
ated with an increased frequency of postpartum symptoms ( = 4.63; P = .01).
CONCLUSIONS These mothers experienced several childbirth-related symptoms
at 5 weeks postpartum, indicating a need for ongoing rest and recovery. Health
concerns were greater for women who were breastfeeding and for those whose
babies were delivered by cesarean section, suggesting a need for greater support
for these women and a reassessment by the medical community of the progres-
sively growing practice of cesarean deliveries.
Ann Fam Med 2006;4:159-167. DOI: 10.1370/afm.519.
INTRODUCTION
T
he participation of American women in the labor force during the
last 20 years has changed most dramatically for mothers of infants.
In 2003 their labor force participation rate was at 54%,
1
dipping
slightly from a record high of 58% in 1998, but markedly higher than 31%
in 1966.
2
Many of today’s mothers are established in the marketplace before
starting their families and remain employed during their child’s infancy by
taking a family or medical leave.
3,4
Among fi rst-time mothers employed
during pregnancy and giving birth in the United States between 1991 and
1994, 13% had returned to work by 1 month after childbirth, increasing
to 30% by 2 months, and 41% by 3 months, for a total of 76% returning
within the fi rst year after childbirth.
4
With many new mothers returning to
work soon after childbirth, a need exists to reexamine and broaden the defi -
nition of postpartum health, particularly for employed women.
Traditionally, the medical perspective of the postpartum period refers
to the time after childbirth that is required for the reproductive organs to
return to their nonpregnant state, a process of about 6 weeks.
5
For physi-
cians this time is often perceived as one that requires little assistance other
Pat McGovern, PhD
1
Bryan Dowd, PhD
1
Dwenda Gjerdingen, MD
2
Cynthia R. Gross, PhD
3
Sally Kenney, PhD
4
Laurie Ukestad, MS
1
David McCaffrey
1
Ulf Lundberg, PhD
5
1
School of Public Health, University of
Minnesota, Minneapolis, Minn
2
Medical School, University of Minnesota,
Minneapolis, Minn
3
College of Pharmacy and School of Nursing,
University of Minnesota, Minneapolis, Minn
4
Hubert H. Humphrey Institute of Public
Affairs, University of Minnesota, Minneapolis,
Minn
5
Department of Psychology, Stockholm
University, Stockholm, Sweden
Confl icts of interest: none reported
CORRESPONDING AUTHOR
Pat McGovern, PhD, MPH
School of Public Health
University of Minnesota
Mayo Mail Code 807
420 Delaware St SE
Minneapolis, MN 55455
pmcg@umn.edu
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POSTPARTUM HEALTH OF EMPLOYED MOTHERS
than the single postpartum visit recommended at 4 to
6 weeks after delivery. Yet fi ndings from longitudinal
studies suggest that recovery from childbirth involves
more than the healing of reproductive organs. Most
women contend with several minor to moderate dis-
comforts for weeks (eg, fatigue, breast soreness, cesar-
ean section or episiotomy discomfort, constipation,
hemorrhoids, and sexual concerns),
5-10
and some face
serious problems, such as depression,
11-14
that may limit
daily activities for months.
15
Although postpartum recovery is likely affected by
such common factors as cesarean delivery or breast-
feeding, few studies have examined the association of
these variables with postpartum health.
Cesarean deliveries reached a record high of 26% of
all US births in 2002, increasing from 21% in 1996.
16
The rise in the cesarean section delivery rate is primar-
ily a result of an increase in primary cesarean sections
16
and a steep decline in vaginal births after a previous
cesarean delivery.
17
Whereas cesarean deliveries pro-
duce higher rates of postpartum infections,
18,19
vaginal
deliveries are associated with increased discomfort with
sexual intercourse,
5,7,20
fecal incontinence,
21
hemor-
rhoids,
5,7
and urinary stress incontinence.
7,22
There is
little information, however, comparing general mental
and physical health and function in women by delivery
type beyond the immediate postpartum period.
Although Healthy People 2010 initiatives promote
a goal of 75% breastfeeding initiation through the
early postpartum period,
23
national estimates show that
68% of children were breastfed to any extent at 7 days,
declining to 52% at 3 months.
24
Benefi ts of breastfeed-
ing include enhanced infant nutrition and immunity,
more rapid uterine involution, easier loss of pregnancy
weight, and reduced risks of breast cancer and osteopo-
rosis.
25,26
Breastfeeding, however, may also cause prob-
lems, including plugged milk ducts, nipple soreness or
cracking, and mastitis,
27,28
which may affect maternal
vitality on a daily basis. Fewer women who return to
work full-time initiate and continue breastfeeding com-
pared with those who return part-time.
29,30
With many new mothers returning to work soon
after childbirth, a need exists to investigate factors
that may affect their well-being. This article extends
previous research by examining the effect of delivery
type and breastfeeding on women’s health at 5 weeks
postpartum in a sample of employed women, some of
whom have already returned to work.
METHODS
Theory
The theory underlying this analysis is a hybrid model
of health and workforce participation adapted from
Becker
31
and Grossman.
32
The theoretical model
assumes that health is determined by genetic endow-
ment, other “predetermined” factors, and personal
choices. For example, women’s postpartum health is
explained not only by demographics, preconception
health status, and childbirth experience, but also by
choices. Mothers’ choices (eg, timing of return to work,
whether to breastfeed, or use of health care services)
are conceptualized in the model as contributing to the
production of women’s health. The application of this
theoretical model to the research question has implica-
tions for the study design and estimation methods.
For our purposes, women’s postpartum health was
modeled as a function of (1) predetermined variables
that include personal, perinatal or employment factors;
and (2) choice variables that include hours of work,
health services used, and breastfeeding status. The
inclusion of choice variables among our explanatory
variables required special attention when the model
was estimated.
Study Design
Using a prospective cohort study design, we selected 3
community hospitals from Minneapolis-St Paul, Minn.
Given the ethnic diversity and urban/suburban loca-
tions of these hospitals, the demographics of their birth
mothers were anticipated to be comparable to those
of women giving birth at 41 other hospitals in the
7-county area. Two hospitals were from a private, non-
profi t St Paul health care system: 1 urban, tertiary care
hospital with 258 licensed beds and 1,000 annual deliv-
eries; the other a suburban, tertiary care hospital with
184 licensed beds and 2,700 annual deliveries. The
third site, located in an ethnically diverse working-class
Minneapolis suburb, was a private, nonprofi t 546-bed
teaching hospital with 3,000 annual deliveries.
Participants were recruited from the population of
women aged 18 years and older who were admitted to
the hospital for childbirth between April 9, 2001, and
November 19, 2001. Sample selection criteria included
residing in the 7-county area, giving birth to a single
infant without serious complications, speaking English,
and being employed before childbirth, and intending
to return to work after childbirth.
Data Collection
A structured questionnaire was developed using mea-
sures with established reliability and validity wherever
possible. Perinatal nurses conducted study enrollment
in person. University research staff subsequently con-
ducted a telephone interview using a 4-week window
for conducting the interview (ie, 4 to 8 weeks postpar-
tum). The full interview required 45 minutes, whereas,
to assess for response bias, a 10-minute mini interview
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was available for women who had quit employment or
had time constraints.
All staff was extensively trained in nonbiased inter-
viewing techniques. After receiving approval from the
relevant institutional review boards, nurses reviewed
women’s medical charts relative to primary selection
criteria and interviewed potentially eligible women
regarding employment criteria and informed consent.
Measures of Dependent and
Independent Variables
The dependent variables included (1) a physical com-
ponent summary (PCS) score, (2) a mental component
summary (MCS) score, and (3) a postpartum symptom
score. The PCS and MCS were taken from the SF-12
(Version 2), a 12-item measure of general health that
is internationally recognized for its validity, reliability,
and the availability of population norms.
33
The general
population norms for the SF-12v2 were estimated from
responses to the 1998 National Survey of Functional
Health Status, which includes 550,000 households rep-
resentative of the US population.
Questionnaire items addressed physical func-
tion, role limitations from physical and emotional
health, bodily pain, general health, social function,
mental health, and vitality, which are summarized
into physical and mental component scores. Because
the SF-12 is standardized and norm-based, all scores
above and below 50 are above and below the average,
respectively, in the general US population.
33
Ware et
al reported that effects in the PCS and MCS can be
interpreted as very large (10 points or more), moderate
to large (5 to 10 points), or small to moderate (2 to
5 points).
33
The 28-item postpartum symptom score was
adapted from a 76-item symptoms checklist used in
a previous postpartum study.
5
Items were selected for
this study based on their increased prevalence after
childbirth (as noted in the earlier study)
5
or potential
association with childbirth.
The independent variables included measures of
personal, perinatal, postpartum, and employment fac-
tors (Table 1).
34-43
Statistical Analyses
Some of our explanatory variables were chosen by the
subject (eg, hours of work). In the case of these endog-
enous explanatory variables, there may be unobserved
variables that infl uence both the value of the choice
variable and the subsequent maternal health outcomes,
resulting in omitted variables bias (sometimes referred
to as confounding bias). This potential problem was
addressed through the use of instrumental variables
estimation methods (in this case, 2-stage least squares
or 2SLS).
44
The estimated regression coeffi cient for
any variable shows the effect of a 1-unit change in the
explanatory variable on the dependent variable. For
example, when the PCS score is regressed on “delivery
type” and other explanatory variables, the regression
coeffi cient for delivery type is -5.96. Thus, the PCS
score for women having a cesarean section (coded 1) vs
a vaginal delivery (coded 0) declines approximately 6
points, a moderate to large effect.
RESULTS
Generalizability
The generalizability of the study population can be
evaluated in relation to national data. The Minnesota
study population was restricted to mothers 18 years
of age and older, on average 29 years. The Minnesota
mothers were less likely to be married (77%) than new
mothers aged 25 to 29 years nationwide (83%)
2
and
were less likely to give birth by cesarean section (17%
vs 24 %, respectively).
45
The Minnesota mothers were
more likely to have completed high school (94%) when
compared with national data on new mothers aged 25
to 34 years (84% to 90%).
46
The proportion of white
and Native American mothers in the study population
was comparable to that found in the national data (78%
and 1%, respectively), but the study population had
relatively fewer African American mothers (9% vs 15%)
and more Asian mothers (11% vs 5%).
46
Descriptive Statistics
Among 2,736 women giving birth at the study hospitals
for the 8-month study enrollment period, 1,157 met eli-
gibility criteria (42% of births). Among 1,579 ineligible
women, 581 (37%) were ineligible because of demo-
graphic or health characteristics, and 998 women (63%)
were ineligible because of employment-related criteria.
The study enrolled 817 women (response rate: 71%
of eligible women). Women who refused participation
stated a lack of interest or time. No signifi cant differ-
ences between participants and refusals were found for
infant birth weight, gestation, maternal age, marital
status, or employment duration.
At 5 weeks postpartum (mean 4.8 weeks, SD 1
week), 716 participants (87.5% of enrollees) completed
a full interview, 30 women (3.5%) completed a mini
interview, and 71 (9%) could not be reached. Com-
parisons showed that women completing the full inter-
view were slightly older, more likely to be white and
married, and more likely to report higher household
incomes relative to others (Table 2). Women complet-
ing the full and mini interviews, however, did not dif-
fer signifi cantly (by t test) on their mental or physical
health scores at 5 weeks postpartum.
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Characteristics of women completing the full inter-
view are displayed in Table 3. Mothers scored slightly
worse than women nationally on physical health
(mean 51.4 vs 52.7; SD 7.2, 9.13; z = -3.9; P <.001)
and slightly better than women nationally on mental
health (mean 49.6 vs 47.2; SD 7.9, 12.1; z = 4.9;
P <.001) for women aged 25 to 34 years. When
women were compared by delivery type, women with
Table 1. Measures of Independent Variables
Independent Variables (Coding) Item Description, Reference, and Data Source
Personal Factors
Age (years) Abstracted from the medical chart
Race (1 = white, 0 = non-white) Adapted from Census 2000
34
*
College educated (1 = yes; 0 = no) Adapted from National Health Interview Survey
35
*
Marital status (1 = married; 0 = no) Adapted from National Health Interview Survey
35
*
Primiparous (1 = yes; 0 = else) Adapted from National Health Interview Survey
35
*
Annual household income ($) Adapted from National Health Interview Survey
35
*
Prenatal smoking (1 = yes; 0 = no) Item assessed smoking during pregnancy
36
*
Perceived control (1 = none/very little,
2 = some, 3 = a lot, 4 = complete)
“Before this pregnancy how much control did you have over the time and effort spent caring
for family, doing home chores or paid work?”
37
*
Social support
(5-item scale with summary score: 5 = none
of the time to 25 = all of the time)
“How often are the following kinds of support available to you, if needed: someone to: (1)
confi de in or talk about your problems, (2) get together with for relaxation, (3) help with
daily chores if you are sick, (4) turn to for suggestions about how to handle personal prob-
lems, and (5) someone to love and make you feel wanted”
38
*
Perinatal Factors
Chronic health problems
(1 = some problems; 0 = none)
Presence/absence of hypertension, diabetes, cardiac disease, renal disease, asthma; abstracted
from medical records
Preconception health
(1 = poor/fair, 2 = good,
3 = very good, 4 = excellent)
“How would you rate your health in general before this pregnancy?” item adapted from
SF-12
33
*
Prenatal mood disturbances
(1 = yes; 0 = no)
“During this pregnancy did you ever have a problem with your mood, such as feeling
depressed or anxious?”
11
*
Labor and delivery complications
(1 = some problems; 0 = none)
Presence/absence of anesthetic complications, excessive bleeding, lacerations, seizures,
eclampsia, abruptio placenta or infections; abstracted from medical chart
Cesarean delivery (1= yes, 0 = no) Abstracted from medical chart
Infant girl (1= yes, 0 = no) Abstracted from medical chart
Colicky baby (1 = yes, 0 = no) Item developed and validated by investigators
6
: “Has your baby had fussy, irritable behavior
that lasts for at least 2 days or had colic?”
Postpartum Factors
Breastfeeding (1 = yes, 0 = no) Item developed and validated by investigators,
6
“Which of the following are you feeding your
baby: breast milk, formula, milk (cow or soy), other? “ (Multiple response options allowed)
Health services used ($) Measure of price-weighted volume of health care services used after hospital discharge from
childbirth through 5-wk interview. Services included emergency department visits, number
of hospital days, outpatient surgeries/procedures, doctor offi ce/urgent care visits, mental
health visits; the number of encounters was multiplied by the unit price/encounter using
claims data for women of reproductive years from Blue Cross Blue Shield Minnesota, 2001.
All costs were summed for a price-weighted volume of services used
39
Time elapsed since childbirth (days) Computed from infant birth date and interview date
Employment characteristics
Employment status (1 = working,
0 = on leave from work)
Item adapted from Cantor et al
40
*
Occupational classifi cation
(blue collar/service = 1; else = 0; clerical = 1;
else = 0; professional = reference)
Taken from US Census
41
Prenatal hours worked/week (hr) Average work hours past 12 mo*
Prenatal job stress
(2-item summary score of 2 = almost
never to 10 almost always)
Items taken from Mardburg et al
37
and validated
6
; “How often do you have too much to do?
How often do you experience stress from your job?”
*
Prenatal job satisfaction
(1 = very to somewhat satisfi ed;
0 = very to somewhat dissatisfi ed)
Global job satisfaction item taken from Quinn and Staines
42
*
Prenatal supervisor support
(1 = strongly disagree, 2 = disagree,
3 = agree, 4 = strongly agree)
Item adapted from Bond et al
43
and validated
6
;
assesses maternal perception of supervisor’s
helpfulness during pregnancy
* Data collected in person at enrollment in the hospital.
† Data collected by telephone at the 5-week interview.
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cesarean sections reported signifi cantly worse physical
function, role limitations, vitality, and pain. Signifi cant
differences in mean scores on SF-12 subscales by deliv-
ery type (using analysis of variance), in which a higher
score refl ects better health, were found for physical
function (54.5 for vaginal vs 48.9 for cesarean section,
P <.001); physical role limitations (50.5 for vaginal vs
44.4 for cesarean section, P <.001); vitality (48.0 for
vaginal vs 45.19 for cesarean section, P = .001); and
bodily pain (49.8 for vaginal vs 43.3 for cesarean sec-
tion, P <.001).
On average, women reported 6.2 symptoms over-
all (SD 3.5), and 4.9 symptoms (SD 3.1) when breast
symptoms were excluded. The most frequent symptom
was fatigue at 63.8% (Table 4). On average, women
reported 6.4 hours of sleep, being awakened 2.6 times
per night, and 50% reported never or rarely feeling
refreshed after waking in the morning.
Multivariate Results
Women’s Physical Health
Results from 2SLS that revealed factors signifi cantly
associated with better postpartum physical health
included better preconception health, increased per-
ceived control, a vaginal (vs cesarean section) delivery,
and more time since childbirth (Table 5). The effect of
delivery type on physical health was moderate to large
(approximately 6 points), whereas the effects of other
variables were small.
Women’s Mental Health
Factors signifi cantly associated with better postpartum
mental health included better preconception health,
an absence of prenatal mood problems, having a baby
girl, and more available social support (Table 5). These
effects were small to moderate. The effects of delivery
type and breastfeeding on mental health were not sta-
tistically signifi cant.
Women’s Postpartum Symptoms
Women’s breast symptoms were excluded from the
summary score because they were considered to be
a consequence of breastfeeding. Fewer symptoms
were signifi cantly associated with better preconcep-
tion health, an absence of prenatal moods, not having
a colicky baby, and not breastfeeding (Table 5). The
effect of not breastfeeding on symptoms was moderate,
whereas the effects of preconception health, prenatal
moods, and a colicky baby were small. Delivery type
was not associated with symptoms.
Breastfeeding at 5 weeks postpartum was associ-
ated with more symptoms than not breastfeeding (6.6
vs 5.1 for all symptoms, and 5.2 vs 4.5 for symptoms
other than breast-related). Breastfeeding mothers expe-
rienced signifi cantly more fatigue, breast symptoms,
back and neck pain, more constipation and hemor-
rhoids, sweating, and hot fl ashes and less desire for sex
than women not breastfeeding, based on exploratory
analyses conducted with
2
tests (Table 6). There were
Table 2. Important Differences Between Women by 5-Week Interview Status
Variables
Mean No. (SD)
Signifi cance of F Test
Using ANOVA or t Test*
P Value
Full Interview
n = 716
Mini Interview
n = 30
No Interview
n = 71
Continuous
Maternal age, y 29.9 (5.30) 27.2 (5.8) 27.9 (6.1) .001
Annual household income, $ 71,741 (38,018) 51,930 (27,122) 66,262 (39,902) .012
Days from childbirth until
5-wk interview
33.42 (6.32) 42.73 (11.3) N/A <.001
Physical health (PCS) score 51.4 (7.2) 49.4 (11.3) N/A Not signifi cant*
Mental health (MCS) score 49.6 (7.9) 49.4 (7.6) N/A Not signifi cant*
No. (%) Signifi cance of
2
Discrete
White 615 (86) 13 (43) 53 (75) <.001
Married 531 (74) 14 (47) 38 (54) <.001
College educated 331 (46) 7 (23) 16 (23) <.001
One or more chronic health
problems
116 (16) 10 (33) 15 (21) .040
PCS = physical component summary of the SF-12
33
; MCS = mental component summary of the SF-12
33
; N/A denotes that information is missing for enrolled subjects
given their interview status at 5 weeks postpartum.
Note: Variables not signifi cantly different between groups included the proportion of women who smoked while pregnant, were primiparous; experienced prenatal mood
problems, labor and delivery complications, cesarean deliveries; and reported prenatal prenatal job satisfaction. There were no differences between groups on the mean
levels of perceived control and preconception overall health and prenatal job stress. The proportion of women on leave vs returned to work at 5 weeks did not vary between
women completing the full interview and those completing the mini interview because of time constraints.
* t Test used to evaluate the differences in mean PCS and MCS scores between women completing the full interview and those completing the mini interview.
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POSTPARTUM HEALTH OF EMPLOYED MOTHERS
no signifi cant differences in time since childbirth to the
interview between women who breastfed (33 days) and
those who did not (34 days). Breastfeeding was more
common among women on leave from work than those
working, however (69% vs 37%,
2
= 22, P <.001).
DISCUSSION
Women whose infants were delivered by cesarean sec-
tion had signifi cantly worse physical health than women
who gave birth vaginally. Amidst the growing trend
toward cesarean sections, parents and clinicians need
to acknowledge the risks of operative deliveries. In this
study, even in the absence of major surgical complica-
tions, women who had undergone cesarean sections
were not completely recovered after 5 weeks, which
is just less than the 6-week period usually allotted for
recovery from major surgery (eg, laparotomy for chole-
cystectomy). This fi nding is likely because these moth-
ers were recovering from both childbirth and surgery
and also had infant care responsibilities. These fi ndings
stress the importance of physicians educating women
about the expected symptoms, duration of disability, and
length of leave from work associated with delivery type.
Breastfeeding was associated with signifi cantly
more symptoms. While the physiological basis of these
problems is not completely understood, it is likely that
some symptoms, such as breast discomfort, relate to
the physical process of breastfeeding. Increased fatigue
may be due to the caloric expenditure of lactation,
and excessive sweating and hot fl ashes may result from
persistent hormonal changes.
5
Constipation and hemor-
rhoids may relate to the women’s hydration in associa-
tion with breastfeeding. The decreased desire for sex
among breastfeeding mothers is consistent with others’
ndings
20
and may be based on hormonal changes or
Table 4. Frequency of Specifi c Postpartum
Symptoms (n = 716)
Symptoms No. (%)
Fatigue 457 (63.8)
Breast discomfort 432 (60.3)
Decreased desire for sex 375 (52.4)
Nipple irritation or soreness 358 (50.0)
Headaches 355 (49.6)
Back or neck pain 310 (43.3)
Decreased appetite 224 (31.3)
Constipation 196 (27.4)
Runny or stuffy nose 189 (26.4)
Hemorrhoids 169 (23.6)
Excessive sweating 165 (23.0)
Sore throat, cough, or cold 164 (22.9)
Abdominal pain including indigestion
(heartburn and cramps)
149 (20.8)
Acne 129 (18.0)
Dizziness 104 (14.5)
Numbness or tingling of hands 102 (14.2)
Hot fl ashes 85 (11.9)
Sinus trouble 84 (11.7)
Diarrhea or stomach fl u 54 (7.5)
Rash 53 (7.4)
Fever >100°F 51 (7.1)
Breast infection/mastitis treated with antibiotics 45 (6.3)
Asthma 41 (5.7)
Hair loss 34 (5.0)
Uterine infection treated with antibiotics 19 (2.7)
Irregular heartbeats 15 (2.1)
High blood pressure treated by a physician 13 (1.8)
Bronchitis or pneumonia treated by a physician 4 (0.6)
Table 3. Characteristics of Women Completing
the Full 5-Week Interview (n = 716)
Variables
Value
Mean No. (SD)
Continuous
Maternal age, y 29.9 (5.30)
Annual household income, $ 71,741 (38,018)
Prenatal perceived control (1 = little control
to 4 = complete control)
3.04 (0.72)
Available social support (summary score
5 = none of the time to 25 = all of
the time)
20.7 (3.68)
Preconception health (1 = poor/fair to
4 = excellent)
3.09 (0.79)
Health services used, $ 191 (1,119)
Days elapsed from childbirth until 5-wk
interview, No.
33.42 (6.32)
Prenatal time worked, h/wk 38.1 (8.50)
Prenatal job stress (1= never to 8 = always) 4.35 (1.73)
Prenatal supervisor support (1 = strongly
disagree to 4 = strongly agree)
0.89 (0.31)
No. (%)
Discrete
White 615 (86)
Married 531 (74)
College educated 331 (46)
Primiparous 333 (47)
Smoking during pregnancy 97 (14)
Experienced prenatal mood disturbances 333 (47)
One or more labor and delivery complications 103 (14)
One or more chronic health problems 116 (16)
Cesarean delivery 123 (17)
Infant girl 350 (49)
Colicky baby 109 (15)
Some breastfeeding at 5-wk postpartum 480 (67)
Very or somewhat satisfi ed with prenatal job 637 (89)
Occupational classifi cation
Service/blue collar
Clerical
Professional
103 (14)
281 (39)
158 (47)
Employment status (back to work at
5-wk postpartum)
51 (07)
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fatigue. The measure of breastfeeding used was rela-
tively simplistic, and future studies are needed to vali-
date these fi ndings. If valid, fi ndings suggest a role for
physicians in counseling breastfeeding mothers about
what to expect and how to manage symptoms.
Consistent with other studies, these mothers contin-
ued to experience several childbirth-related symptoms at
5 weeks postpartum, indicating a need for ongoing rest
and recovery.
5,7,8
Fatigue was the most frequent symptom,
and 50% reported never or rarely feeling refreshed after
waking in the morning. Although fatigue often results
from reduced sleep and increased childcare responsibili-
ties, it may also be related to low levels of hemoglobin.
9
Some mothers may adapt better to their return to
work by using an intermittent rather than straight-time
family and medical leave. Intermittent leave under the
federal Family and Medical Leave Act (FMLA) allows
return to work on a gradual, part-time basis for a lon-
ger period of time. Women who struggle with fatigue
or postpartum symptoms that limit daily role function
may fi nd intermittent leave helpful. Physicians, how-
ever, must certify intermittent leave as necessary for
the mother’s serious health condition (as defi ned in the
FMLA regulations)
47
related to childbirth and distinct
from time for infant bonding.
While study fi ndings are internally valid, they can
Table 5. Selected Results from Estimations of Maternal Postpartum Health Equations
With 2-Stage Least Squares (n = 716)
Independent Variables
2SLS Coeffi cients (P Value)
Physical Health*
1
Mental Health
Symptoms
Preconception overall health (scaled 1 to 4) 2.35 (<.001)
0.79 (.04)
-0.69 (<.001)
Prenatal moods (1 = yes) 0.10 (.86) -3.67 (<.001)
1.19 (<.001)
Cesarean delivery (1 = yes) -5.96 (<.001)
0.60 (.45) -0.19 (.59)
Infant sex (1 = female) -0.24 (.64) -2.27 (<.001)
-.03 (.91)
Perceived control (scaled 1 to 4) 0.83 (.03)
0.84 (.06)
-0.23 (.27)
Social support (scaled 5 to 25) 0.06 (.42) 0.49 (<.001)
-0.03 (.42)
Breastfeeding (1 = yes) -1.32 (.67) -1.49 (.68) 4.63 (.00)
Infant colic (1 = yes) 0.69 (.39) -1.25 (.17) 0.89 (.04)
Time elapsed since childbirth, d 0.14 (.03)
.02 (.77) -.02 (.44)
2SLS = 2-stage least squares.
* Physical health was measured with the PCS (physical component summary of the SF-12) score.
† Mental health was measured with the MCS (mental component summary of the SF-12) score.
‡ Statistically signifi cant t test on the estimated 2SLS regression coeffi cient.
Table 6. Signifi cant Differences in Postpartum Symptoms by Women’s Breastfeeding Status
Postpartum Symptoms
Breastfeeding
No. (%)
(n = 480)
Not Breastfeeding
No. (%)
(n = 236)
P Value of
t Test or
2
Continuous variables*
Mean number of total symptoms 6.6 5.1 <.001
Mean number of nonbreastfeeding symptoms 5.2 4.5 .003
Discrete variables
One or more breast symptoms (discomfort,
nipple soreness, infection)
377 (78.0) 115 (48.7) <.001
Fatigue 323 (67.3) 134 (56.8) .006
Decreased desire for sex 284 (59.2) 91 (38.6) <.001
Back or neck pain 223 (46.5) 87 (36.9) .015
Constipation 152 (31.7) 44 (18.6) <.001
Hemorrhoids 134 (27.9) 35 (14.8) <.001
Excessive sweating 126 (26.3) 39 (16.5) .004
Hot fl ashes 67 (14.0) 18 (7.6) .008
Decreased appetite 136 (28.3) 88 (37.3) .020
Runny/stuffy nose 115 (24.0) 74 (31.4) .040
* The mean difference in total symptoms and nonbreastfeeding symptoms (ie, all symptoms except breast discomfort, nipple soreness, and breast infection) by breastfeed-
ing status was evaluated by t test.
† The difference in the frequency of women reporting any symptom by breastfeeding status was evaluated by
2
test.
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be generalized only to employed women of comparable
demographic and income levels. Longitudinal studies
are needed to examine which factors may affect wom-
en’s health throughout the fi rst postpartum year.
These mothers continued to experience several
childbirth-related symptoms 5 weeks after delivery, indi-
cating a need for rest and recovery beyond the tradi-
tional postpartum period. Physicians evaluating women
during pregnancy and the postpartum may want to dis-
cuss strategies to promote health, expected symptoms,
and duration of disability in relation to delivery type to
promote maternal well-being. Postpartum evaluations
should include an assessment of fatigue, the most com-
mon postpartum symptom, as well as other physical and
mental symptoms, including those related to breastfeed-
ing. Physicians should also discuss with mothers their
plans to return to work and possible need for medical
certifi cation for FMLA, including intermittent leave.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/4/2/159.
Submitted July 12, 2005; submitted revised October 14, 2005; accepted
November 9, 2005.
Key words: Postpartum period; postnatal care; maternal welfare; wom-
en’s health; occupational health
Parts of this study were previously presented in the following formats: “The
Health of Employed Women at 6 Weeks after Childbirth,” P. McGovern,
with B. Dowd, D. Gjerdingen, S. Kenney, L. Ukestad, D. McCaffrey, U. Lun-
dberg, a poster presentation at the Academy Health Annual Research Meet-
ing, 2005, Hynes Convention Center, Boston, Mass, June 27-28, 2005.
“Preliminary Findings from the Minnesota Postpartum Health Study:
Women’s Health 6 Weeks after Childbirth,” P. McGovern with B. Dowd,
D. Gjerdingen, T. Rockwood, C. Gross, S. Kenney, L. Ukestad, D. McCaf-
frey, U. Lundberg, After Birth: Policies for Healthy Women, Families, and
Workplaces. A Signature Study and Conference of the Humphrey Institute
of Public Affairs conducted in collaboration with the School of Public
Health and Consortium on Law and Values in Health, Environment, and
the Life Sciences Colloquia Program, Humphrey Institute of Public Affairs,
University of Minnesota, Minneapolis, October 1, 2004.
“The Health of Employed Women at 6 Weeks after Childbirth: Preliminary
Findings,” P. McGovern with B. Dowd, D. Gjerdingen, T. Rockwood, C.
Gross, S. Kenney, L. Ukestad, D. McCaffrey, U. Lundberg, at the Women’s
Health Research Conference, National Center for Excellence in Women’s
Health, University of Minnesota, Minneapolis, September 13, 2004.
“The Health of Employed Women at 6 Weeks after Childbirth: Preliminary
Findings, “ P. McGovern with B. Dowd, D. Gjerdingen, T. Rockwood, C.
Gross, S. Kenney, L. Ukestad, D. McCaffrey, U. Lundberg, at the National
Occupational Research Agenda (NORA) Symposium: Health and Safety
Priorities for the 21st Century, Midwest Center for Occupational Health
and Safety, University of Minnesota, Minneapolis, May 27, 2004.
“The Minnesota Women’s Postpartum Health Study: Design, Implementa-
tion and Preliminary Findings,” P. McGovern with B. Dowd, D. Gjerdingen,
T. Rockwood, C. Gross, L. Ukestad, D. McCaffrey, U. Lundberg, at the
School of Social Work, Wayne State University, Detroit, Mich, June 9, 2004.
Funding support: This publication was supported by grant # 5 R18
OH003605-05 from the National Institute for Occupational Safety and
Health (NIOSH).
Disclaimer: The contents of this study are solely the responsibility of the
authors and do not necessarily represent the offi cial views of NIOSH.
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... It would suggest that women who had vaginal delivery will only experience labour and women are naturally built to adapt to it and have rapid involution within 3-6 weeks following birth. 12 More so, women who had caesarean delivery will experience the effect of anesthetic agents which are expected to wear off in 3-4 weeks and the primary healing of the surgical scar occurs also occur within 6 weeks. 13,14 Furthermore, the protocol of care and support for women who undergo caesarean delivery may have played an additional role in their rapid HRQoL recovery. ...
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