EPIDEMIOLOGICAL ASPECTS OF FEMALE USERS FROM A CENTRE OF PSYCHOSOCIAL ATTENTION IN RECIFE CITY , NORTHEAST BRAZIL , THAT SUFFERED POSTPARTUM PSYCHIATRIC PROBLEMS

Objective: to contribute to the early identification of risk factors, treatment, and/or support for female users of a Psychosocial Attention Center (CAPS), in Recife city. Method: this is a descriptive, exploratory, retrospective study of quantitative approach. Data were systematically collected from 350 questionnaires completed, resulting in a sample of 34 women, from 2002 to 2005, who showed symptoms of developing some type of psychological change over the postpartum period. Results: they showed that being pregnant for the first time, the presence of a family history of mental problems, and lack of support from the father were significantly present in women that showed some type of postpartum psychological problem, which could be addressed during prenatal consultations, facilitating the early identification of atrisk women and the realization of adequate treatment. Contrary to the literature, this study showed that the majority of afflicted users had family support and no personal history of mental problems. Conclusion: in summary, we believe that making health professionals aware to the investigation and identification of risk factors to the development of postpartum psychosis in prenatal appointments could prevent and/or alleviate the damage resulting from this problem, both for mother and baby, through early intervention. Descriptors: mental problems; psychosis; postpartum, risk factors.

In the life cycle of a woman, pregnancy constitutes one of the critical transformation periods in the development of personality, characterized by complex metabolic and temporary changes in equilibrium, due to some alterations in the aspects of social function, the need to adapt to these changes, interpersonal and intrapsycological readjustments, and a changing of identity. 1ring pregnancy, women live a period of transformation, which is part of the normal process of her development, presenting remarkable changes in behavior that are neatly observed in the three successive trimesters and correspond to the attempt to adapt to the transitory disturbances of this period. 2However, this critical period does not conclude at childbirth, as a large part of the maturational changes occur postnatal, and, therefore, must be considered as a continuation of the transformational situation, resulting in new physiological and psychosocial changes.
The transformations that begin postpartum with the goal of re-establishing the woman's body to its pre-pregnancy state occur not only in endocrine and genital aspects, but in her as a whole.The woman, at this time, and as at other times, must be seen as one entire being, not exclusively her psychological component. 3uroendocrinological changes and changes in family dynamics and the questioning of deidealization of the newborn are important factors after birth, which, through association and interaction, can initiate the appearance of intercurrent psychopathological problems. 2ccording to Kaplan and Sadock, 4 between 20 and 40% of women relate some emotional disturbance of cognitive dysfunction during postpartum.Moreno  According to Moreno and Soares, 5 postpartum psychiatric changes are classified as: postpartum blues, postpartum depression, and postpartum psychosis.They pointed out that there is the possibility of overlapping symptoms in different levels of severity, though there were no indications that they constituted the three distinct clinical entities.However, with the purpose of applying the most common approach to the topic, we characterized the three categories separately as postpartum blues, postpartum depression, and postpartum psychosis.This article draw an epidemiological profile of women assisted by a CAPS in the city of Recife, from 2002 to 2005, who suffered postpartum psychiatric problems, with the following objectives: to contribute to the early identification of risk factors, treatment, and/or support of women using this service; to look at the organization of a body to assist professionals that give women prenatal assistance through the systematic investigation of factors, which could put the mental health of women at risk during and after gestation.
Finally, it is essential further knowledge about the aspects involved in postpartum mental problems, so that, through early intervention, it is possible to avoid them and/or reduce their harm, thereby protecting both mother and child from their consequences, by means of a holistic approach to the woman by health professionals during the gestation and postpartum cycles.This is an explorative, descriptive, retrospective study of quantitative nature.The population consisted on 350 completed questionnaires of women who used a CAPS in Recife (PE), a city in the northeast of Brazil, since the inauguration of the program until the beginning of the study, a period between 2002 and 2005, and that showed symptoms of some type of postnatal mental illness, resulting in a sample size of 34 women.
Data were systematically collected with the filling in a pre-establishment form by the researchers, with questions regarding socioeconomic status (age, ethnicity, education, family income, marriage status, occupation), gynecological history, obstetrics, the newborn (conception date, position of child in the family, planning of pregnancy, intercurrent illnesses during gestation, abortions, sex of the newborn, length of gestational period), support of family and child's father, and family and personal history of mental illness.
Regarding support from family members, it is considered that the preferred assistance to the mother is from parents (in particular,

METHOD INTRODUCTION
the newborn's maternal grandmother), friends or neighbors, and support may be economic, affective, and/or by doing tasks related to the care of the well-being of both the family and the newborn.The support of the partner involved: to accept and want the pregnancy, a stable relationship with the woman, and to provide financial and emotional support.Only first-degree parents were considered in the family history item.
The following inclusion criteria were established in this study: to be a women that used CAPS, since its inauguration until the present, from 2002 to 2005; and to have registered in the questionnaire the experience of some type of postpartum psychological transformation.The exclusion criteria were: to have undergone some type of postpartum mental transformation after abortion, or cases in which newborns were deformed or stillborn, as these occurrences could represent situations of risk of transformation with different characteristics in the studied cases.
Data were tabulated and presented in absolute numbers and percentages, with an explanation table and       Questionnaires of all the women who used CAPS in Pernambuco, from 2002 to 2005, were analyzed, resulting in 350 women.From these, approximately 10% (34) of the women revealed to have undergone some type of psychological suffering during their postpartum period.

RESULTS
According to Kaplan and Sadock, 4 between 50 and 80% of new mothers showed some tendency to mood swings after childbirth, or postpartum blues, with symptoms that do not begin to compromise their daily routine and generally regress spontaneously within approximately seven days and, for this reason, they do not begin to seek mental health services for treatment and support.Owing to the absence of major symptoms, the new mother and her family associated the moodiness with the changing of routine and overburdening of housework and care of the baby. 6

DISCUSSION
Based on these results, we can infer that the prevalence found in this research includes only new mothers who showed major symptoms of postpartum depression or psychosis, which could indicate between 10 to 15% and 0.1 to 0.2%, respectively.Ninety seven point one percent of participants in the study (34) were in the 14 to 34 age bracket (with a median age of 20.2 years) and only 2.9% were older than 35 yearsold (1); 50% ofwomen were ethnically white (17), the others were evenly distributed between black (10) and mixed (7).In terms of education, 61.7% had neither started nor finished elementary education (13) (presenting a low level of education); and only 2.9% had reached university (1), which shows the need to appropriately approach them with understanding, while still considering the sociobehavioral factors that make up the foundation of an effective therapeutic relationship between the participant, interdisciplinary team, family, and community.
Concerning women that lived with the father in the pregnancy-postpartum period and showed some type of mental illness, 67.6% of them (23) were either married or in a stable relationship.
Forty-seven per cent-family income of the studied women were less than the minimum salary; 50% of the families had the following range established: one to five minimum salaries, and just one of the participants (3%) had family income above five minimum salaries.
Among the present risk factors, with the most frequent in women that showed some type of postpartum psychological problem indicated by literature and by the socioeconomic research data, we found concordance with regards to: age of the women, being younger than 40 years-old; financial instability, we identified the majority were unemployed (64.7%) with 47% of those (16) having a household income lower than the minimum wage. 4,5,[7][8] Rlts related to the civil status variable showed disagreement with previous literature, it was seen that the majority (14) of women from the research (41.1%) were married or lived in a stable relationship (09) with the father of the child (26.4%).However, it is worth highlighting that these data do not include the support of the father to the woman during the pregnancy-postpartum period.We did not find in the literary references to the relationship of either the race or education of the woman as major risks to suffering postpartum psychosis.
In relation to obstetric data and to the newborn, the first pregnancy represented an important factor, since 58% of women showed some type of mental illness with the birth of their first child, and literature cites the first pregnancy as one of the main factors that predispose an outbreak of mental illness.With regards to sex of the newborn, 58% of them were male.However, the literature did not refer to these data as risk factors for developing postpartum mental illnesses. 4-5,7- 8,11 Maldonado 9 states that the birth of a child is a family experience, seeing as the entire family undergoes a significant change.Emotional and family support for the woman during the pregnancy-postpartum cycle constitutes a protecting factor from the development of postpartum psychosis. 4owever, in the present study, 68% of the women were receiving some type of family support i during the pregnancy-postpartum cycle and still developed some type of psychological affliction in the period.
In contrast, lack of support for the mother from the father of the child during the pregnancy-postpartum cycle showed a number that represented an important factor (71% of the women did not receive support from the father), when related to the development of postpartum mental problems.According to Maldonado, 9 the father's attitude has a direct influence on the way in which the mother would view the changes that occur in her life during and after pregnancy.A cutting-edge transversal study with 70 new mothers attending two units of the Family Health Program in the city of São Paulo, Brazil, recently undertaken by Cruz (2005) concluded that "the more social support ii from the husband, the less prevalence of postpartum depression."One revised study, of realized literature by Zinga, 13 points out the possibility of there being a genetic or family component related to the occurrence of postpartum mental problems, considering that the prevalence is much greater with women who have a history of first degree mental illness in their immediate family.This study agrees with Kaplan and Sadock, 4 who found that women i It is considered that the assistance to the mother is from relatives (in particular, the maternal grandmother of the newborn), friends or neighbors, and support may be economic, affective and/or in doing tasks related to the care of the well being of both the family and the newborn.
ii Assistance and emotional support to the mother in her domestic tasks and in the care for her and for the baby.
with a family history of mood changes are at bigger risk than the general population to be committed for this illness.This study confirms that risk increases, as 70% of women (23) that showed postpartum psychosis had a family history of first degree mental illness.
A personal history of mental illness is also shown in the literature as a very relevant risk factor for developing postpartum psychosis. 2,4,6,9,11However, we obtained data that, when compared to the literature, contradicted this in the present research as more than half of the women (61%) did not register in their questionnaires that they had suffered episodes of mental problems, before experiencing them in postpartum.
According to the results of this research, we realize the possibility and importance of previous identification of risk factors that initiate the suffering of postpartum psychosis in pregnant women, especially during prenatal assistance, seeing as the growing attention health during this period softens the negative influence of psychosociological factors predisposed to postpartum mood changes.
The stages of pregnancy, delivery, and postpartum are generally treated by health professionals in a predominantly physiological manner, with emphasis to pathology, with assistance being upset through interventional actions.Consequently, the woman is seen in a fragmented way through weaknesses in the interaction among the health team.
We highlight the importance of the good sense of health professionals to provide humanistic and individualized care for pregnant women, and the need to understand each woman's needs, by educating her in the process of adapting to the transformations that take place when giving birth to a child.
With this in mind, we propose the creation of a device that aids in the approach to women during prenatal assistance, through the systematic investigation of factors that pose a risk to their mental health during and after pregnancy.For this, we have produced a form containing questions that evaluate the vulnerability of woman to the development of postpartum psychosis, such as adolescent agegroup, marriage status, occupation, income, planning and wanting of pregnancy, parity, family and paternal support, family and personal history of mental illness.This questionnaire would constitute a risk scale iii (Figure 1) for the development of iii The researchers created this device as a preventative therapeutic proposal for postpartum mental problems, postpartum mental transformation that awards points directly proportional to the influence that each risk factor contributes towards the manifestation of disturbances, or, in other words, the greater the number of points, the greater the risk.The pregnant would be classified as low, moderate or high risk and associated with suggestions for specific treatments that can be followed by a health professional, according to the result.
With prior identification, in the prenatal stage, the women in risk of developing disturbances of mood or other types of postpartum psychological problems, the health professional has the possibility to act preventatively by directing them to psychotherapeutic aid, which could result in a significant reduction of depressive symptoms and avoid possible negative consequences, like harmful effects in the mother-baby interaction and the child's development.
Some methodological limitations in this study deserve consideration.As the data registered in the users' forms did not make reference to obstetric history and newborn information, it was impossible to us to analyze the incidences of some risk factors cited in the literature.In relation to the family and personal history of mental illness, they did not include medical diagnostics, being registered only to relatives of the users and/or their families.There was also an impediment caused by the management of the District Mental Hospital from carrying out interviews with the users and/or their family, by preventing direct contact between them and the researchers, which would make possible the collection of more specific data, with the objective of complementing the privacy of information presented by the forms.

Figure 1 .
Figure 1.Support from family during pregnancy/postpartum cycle for women that used CAPS in Recife, who showed some type of postpartum mental illness during the period from 2002 to 2005.

Figure 2 .
Figure 2. Support from father of child during pregnancy/postpartum cycle for women that used CAPS in Recife, who showed some type of postpartum mental illness during the period from 2002 to 2005.

Figure 3 .
Figure 3. Family history of mental illness for women that used CAPS in Recife, who showed some type of postpartum mental illness during the period from 2002 to 2005.

Figure 4 .
Figure 4. Personal history of mental illness for women that used CAPS in Recife, who showed some type of postpartum mental illness during the period from 2002 to 2005.

Figure 5 .
Figure 5. Risk scale for the development of postpartum mental problems.

Table 1 .
Characteristic of women that used a CAPS in Recife, who displayed some type of postnatal mental illness according to the variables: age bracket, ethnicity, education, marriage status, income, and work status for the period from 2002 to 2005.
*Note: Brazilian minimum salary in April 2006 is equivalent to approximately US$ 150.00.