title: Self-exclusion from health care in women at high risk for postpartum depression.
abstract: BACKGROUND
  A significant proportion of women who are vulnerable to postnatal depression refuse to engage in treatment programmes. Little is known about them, other than some general demographic characteristics. In particular, their access to health care and their own and their infants' health outcomes are uncharted.
  
  
  METHODS
  We conducted a nested cohort case-control study, using data from computerized health systems, and general practitioner (GP) and maternity records, to identify the characteristics, health service contacts, and maternal and infant health outcomes for primiparous antenatal clinic attenders at high risk for postnatal depression who either refused (self-exclusion group) or else agreed (take-up group) to receive additional Health Visiting support in pregnancy and the first 2 months postpartum.
  
  
  RESULTS
  Women excluding themselves from Health Visitor support were younger and less highly educated than women willing to take up the support. They were less likely to attend midwifery, GP and routine Health Visitor appointments, but were more likely to book in late and to attend accident and emergency department (A&E). Their infants had poorer outcome in terms of gestation, birthweight and breastfeeding. Differences between the groups still obtained when age and education were taken into account for midwifery contacts, A&E attendance and gestation; the difference in the initiation of breast feeding was attenuated, but not wholly explained, by age and education.
  
  
  CONCLUSIONS
  A subgroup of psychologically vulnerable child-bearing women are at particular risk for poor access to health care and adverse infant outcome. Barriers to take-up of services need to be understood in order better to deliver care.
authors.affiliation: School of Psychology, University of Reading, 3 Earley Gate, Whiteknights, Reading RG6 6AL. lynne.murray@reading.ac.uk
authors.forename: Lynne
authors.initials: L
authors.lastname: Murray
authors.forename: Matt
authors.initials: M
authors.lastname: Woolgar
authors.forename: Joseph
authors.initials: J
authors.lastname: Murray
authors.forename: Peter
authors.initials: P
authors.lastname: Cooper
mesh_terms: D000328:Adult; D001942:Breast Feeding; D016022:Case-Control Studies; D019052:Depression, Postpartum / Q000453:epidemiology / Q000628:therapy*; D004739:England / Q000453:epidemiology; D005260:Female; D005865:Gestational Age; D006801:Humans; D007231:Infant, Newborn; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology; D011295:Prenatal Care / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012044:Regression Analysis; D012307:Risk Factors; D016312:Treatment Refusal / Q000706:statistics & numerical data*