Patient,provider, and system-level barriers and facilitators to addressing perinatal depression

Objective: To explore perinatal health care professionals’ perspectives on barriers and facilitators to addressing perinatal depression. Background: Perinatal depression is common and associated with deleterious effects on mother, foetus, child and family. Although the regular contact between mothers and perinatal health care professionals may make the obstetric setting ideal for addressing depression, barriers persist, and depression remains under-diagnosed and under-treated. Methods: Four 90-minute focus groups were conducted with perinatal health care professionals, including obstetric resident and attending physicians, licensed independent practitioners, nurses, patient care assistants, social workers and administrative support staff. Focus groups were transcribed, and resulting data were analysed using a grounded theory approach. Results: Participants identified patient-, provider- and system-level barriers and facilitators to addressing perinatal depression. Provider-level barriers included lack of resources, skills and confidence needed to diagnose, refer and treat perinatal depression. Limited access to mental health care and resources were identified as system-level barriers. Facilitators identified included targeted training for perinatal health care professionals’, structured screening and referral processes, and enhanced support and guidance from mental health providers. Conclusion: A complex set of interactions between women and perinatal health care professionals contributes to perinatal depression being untreated. Service gaps could be closed by addressing identified barriers through integrated obstetric and depression care and enhanced collaborations. Future intervention testing could include targeted training, improved access, and mental health provider support to empower perinatal health care professionals’ to address perinatal depression, and thereby improve delivery of depression treatment in obstetric settings.     

Perinatal Care for South Asian Immigrant Women and Women Born in Canada: Telephone Survey of Users

BackgroundPrevious research findings suggest that pregnant immigrant women receive less adequate perinatal care than pregnant non-immigrant women. This study was designed to assess the use of perinatal care services by newly immigrated South Asian women and Canadian-born women, and to determine any perceived barriers to receiving care.MethodWe conducted a telephone survey of women who delivered at an academic community hospital in Calgary, Alberta. Two groups of women were interviewed at seven weeks postpartum: South Asian women who had immigrated within the last three years, and Canadian-born women of any ethnicity. Women who spoke Hindi, Punjabi, and/or English were eligible. Interviews consisted mainly of closed-ended questions. The main outcomes we sought were the proportion of women receiving perinatal care (such as attending prenatal classes or fetal monitoring), and any perceived barriers to care.ResultsThirty South Asian and 30 Canadian-born women were interviewed. Most women in each group reported having pregnancy evaluations carried out. Fewer South Asian women than Canadian-born women understood the purpose of symphysis–fundal height measurement (60% vs. 90%, P = 0.015) and tests for Group B streptococcus (33% vs. 73%, P = 0.004). Thirteen percent of South Asian and 23% of Canadian-born women attended prenatal classes. Most women (87–97%) believed they had received all necessary medical care. Language barriers were most commonly reported by South Asian women (33–43% vs. 0 for Canadian-born women).ConclusionSouth Asian women considered language to be the most common barrier to receiving perinatal care. Such barriers may be overcome by wider availability of multilingual staff and educational materials in a variety of formats including illustrated books and videos.     

Strategies for improving perinatal depression treatment in North American outpatient obstetric settings

Objective: To identify core barriers and facilitators to addressing perinatal depression and review clinical, programmatic, and system level interventions that may optimize perinatal depression treatment. Method: Eighty-four MEDLINE/PubMed searches were conducted using the terms perinatal depression, postpartum depression, antenatal depression, and prenatal depression in association with 21 other terms. Of 7768 papers yielded in the search, we identified 49 papers on barriers and facilitators, and 17 papers on interventions in obstetric settings aimed to engage women and/or providers in treatment. Results: Barriers include stigma, lack of obstetric provider training, lack of resources and limited access to mental health treatment. Facilitators include validating and empowering women during interactions with health care providers, obstetric provider and staff training, standardized screening and referral processes, and improved mental health resources. Conclusion: Specific clinical, program, and system level changes are recommended to help change the culture of obstetric care settings to optimize depression treatment.     

Effect of stay in a postpartum care institution on postpartum depression in women

IntroductionPregnancy and childbirth can cause substantial psychological and social changes and may lead to mental disorders. Women who are discharged directly from the maternity hospital after delivery without social support may have postpartum psychological health issues. Rarely have studies focused on the effect of postpartum care institutions on postpartum depression in women.MethodsWe conducted a longitudinal study in Taiwan from January 2017 to July 2018. The data were collected via questionnaires administered at four time points: the first trimester of pregnancy (n = 309), the second trimester of pregnancy (n = 269), the third trimester of pregnancy (n = 257) and six weeks postpartum (n = 252). Among the participants, 130 women stayed in e postpartum care institutions, while 122 did not stay in an institution. Analysis included student t test, chi-square test, and difference in differences analysis. Linear regression analysis was used to determine the independence of the related factors for postpartum depression.ResultsThe women who stayed at postpartum care institutions (n = 130) had a higher education status, higher income, higher percentage of assisted reproductive technology (ART) treatment, higher cesarean section rate, and lower postpartum Edinburgh Perinatal Depression Scale (EPDS) scores (14.6% vs. 27.8%) compared with those who did not stay at postpartum care institutions. Among the women who stayed in postpartum care institutions, the average EPDS scores were 8.74 ± 0.46 and 8.15 ± 0.49 in the ART and natural pregnancy groups at baseline (3rd month), respectively, and there was no significant difference (p = 0.59). The EPDS scores in the ART group significantly declined at the 6th month (difference = −0.67, p<0.05), 9th month (difference = −2.00, p<0.01) and postpartum (difference = −4.01, p<0.01). Multivariate linear regression analysis indicated that postpartum care institutions was the main factor (r = 1.38, p = 0.014) correlating to postpartum depression in women.ConclusionProviding maternal and infant care in postpartum care institutions allows the mother to rest; and the professional guidance from the medical staff can provide the necessary support and help mothers to learn. Postpartum care institutions can decrease the incidence and severity of postpartum depression.     

Learning Needs of Postpartum Women: Does Socioeconomic Status Matter?

Abstract: Background : Little is known about how information needs change over time in the early postpartum period or about how these needs might differ given socioeconomic circumstances. This study's aim was to examine women's concerns at the time of hospital discharge and unmet learning needs as self‐identified at 4 weeks after discharge. Methods : Data were collected as part of a cross‐sectional survey of postpartum health outcomes, service use, and costs of care in the first 4 weeks after postpartum hospital discharge. Recruitment of 250 women was conducted from each of 5 hospitals in Ontario, Canada (n = 1,250). Women who had given vaginal birth to a single live infant, and who were being discharged at the same time as their infant, assuming care of their infant, competent to give consent, and able to communicate in one of the study languages were eligible. Participants completed a self‐report questionnaire in hospital; 890 (71.2%) took part in a structured telephone interview 4 weeks after hospital discharge. Results : Approximately 17 percent of participants were of low socioeconomic status. Breastfeeding and signs of infant illness were the most frequently identified concerns by women, regardless of their socioeconomic status. Signs of infant illness and infant care/behavior were the main unmet learning needs. Although few differences in identified concerns were evident, women of low socioeconomic status were significantly more likely to report unmet learning needs related to 9 of 10 topics compared with women of higher socioeconomic status. For most topics, significantly more women of both groups identified learning needs 4 weeks after discharge compared with the number who identified corresponding concerns while in hospital. Conclusions : It is important to ensure that new mothers are adequately informed about topics important to them while in hospital. The findings highlight the need for accessible and appropriate community‐based information resources for women in the postpartum period, especially for those of low socioeconomic status. (BIRTH 32:2 June 2005)     

Postpartum health, service needs, and access to care experiences of immigrant and Canadian-born women

OBJECTIVE: To describe immigrant women's postpartum health, service needs, access to services, and service use during the first 4 weeks following hospital discharge compared to women born in Canada. DESIGN: Data were collected as part of a larger cross-sectional study. SETTING: Women were recruited from 5 hospitals purposefully selected to provide a diverse sample. PARTICIPANTS: A sample of 1,250 women following vaginal delivery of a healthy infant; approximately 31% were born outside of Canada. MAIN OUTCOME MEASURES: Self-reported health status, postpartum depression, postpartum needs, access to services, service use. RESULTS: Immigrant women were significantly more likely than Canadian-born women to have low family incomes, low social support, poorer health, possible postpartum depression, learning needs that were unmet in hospital, and a need for financial assistance. However, they were less likely to be able to get financial aid, household help, and reassurance/support. There were no differences between groups in ability to get care for health concerns. CONCLUSIONS: Health care professionals should attend not only to the basic postpartum health needs of immigrant women but also to their income and support needs by ensuring effective interventions and referral mechanisms.     

The effects of clinical aromatherapy for anxiety and depression in the high risk postpartum woman - a pilot study

ObjectivesThe aim of this study was to determine if aromatherapy improves anxiety and/or depression in the high risk postpartum woman and to provide a complementary therapy tool for healthcare practitioners.DesignThe pilot study was observational with repeated measures.SettingPrivate consultation room in a Women's center of a large Indianapolis hospital.Subjects28 women, 0–18 months postpartum.InterventionsThe treatment groups were randomized to either the inhalation group or the aromatherapy hand m’technique. Treatment consisted of 15 min sessions, twice a week for four consecutive weeks. An essential oil blend of rose otto and lavandula angustifolia @ 2% dilution was used in all treatments. The non-randomized control group, comprised of volunteers, was instructed to avoid aromatherapy use during the 4 week study period. Allopathic medical treatment continued for all participants.Outcome measurementsAll subjects completed the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder Scale (GAD-7) at the beginning of the study. The scales were then repeated at the midway point (two weeks), and at the end of all treatments (four weeks).ResultsAnalysis of Variance (ANOVA) was utilized to determine differences in EPDS and/or GAD-7 scores between the aromatherapy and control groups at baseline, midpoint and end of study. No significant differences were found between aromatherapy and control groups at baseline. The midpoint and final scores indicated that aromatherapy had significant improvements greater than the control group on both EPDS and GAD-7 scores. There were no adverse effects reported.ConclusionThe pilot study indicates positive findings with minimal risk for the use of aromatherapy as a complementary therapy in both anxiety and depression scales with the postpartum woman. Future large scale research in aromatherapy with this population is recommended.     

Risk factors for positive postpartum depression screen in women with private health insurance and access to care

Abstract

Objective: To determine risk factors for a positive postpartum depression screen among women with private health insurance and 24/7 access to care.

Study design: Retrospective cohort study of all patients delivered by a single MFM practice from April 2015 to September 2016. All patients had private health insurance and 24/7 access to care. All patients were scheduled to undergo the Edinburgh Postnatal Depression Scale (EPDS) at their 6-week postpartum visit and a positive screen was defined as a score of 10 or higher, or a score greater than zero on question 10 (thoughts of selfharm). Using logistic regression, risk factors for postpartum depression were compared between women with and without a positive screen.

Results: Of the 1237 patients delivered, 1113 (90%) were screened with the EPDS. 81 patients (7.3, 95%CI 5.9–9.0%) of those tested had a positive screen. On regression analysis, risk factors associated with a positive screen were nulliparity (aOR 1.8, 95%CI 1.1, 2.9), cesarean delivery (aOR 1.7, 95%CI 1.1, 2.8), non-White race (aOR 2.0, 95%CI 1.1, 3.5), and a history of depression or anxiety (aOR 4.6, 95%CI 2.6, 8.1). Among the 100 women with a history of depression or anxiety, selective serotonin reuptake inhibitor (SSRI) use in the postpartum period was not associated with a reduced risk of a positive screen (25.5% in those taking an SSRI versus 18.4% of those not taking an SSRI, p?=?.39).

Conclusions: Among women with private health insurance and access to care, the incidence of a positive screen for postpartum depression is approximately 7%. The use of an SSRI did not eliminate this risk. All women should be screened for postpartum depression.     

Latent class analysis of health,social, and behavioral profiles associated with psychological distress among pregnant and postpartum women during the COVID-19 pandemic in the United States

Background

There is a growing body of literature documenting negative mental health impacts from the COVID-19 pandemic. The purpose of this study was to identify risk and protective factors associated with mental health and well-being among pregnant and postpartum women during the pandemic.

Methods

This was a cross-sectional, anonymous online survey study distributed to pregnant and postpartum (within 6 months) women identified through electronic health records from two large healthcare systems in the Northeastern and Midwestern United States. Survey questions explored perinatal and postpartum experiences related to the pandemic, including social support, coping, and health care needs and access. Latent class analysis was performed to identify classes among 13 distinct health, social, and behavioral variables. Outcomes of depression, anxiety, and stress were examined using propensity-weighted regression modeling.

Results

Fit indices demonstrated a three-class solution as the best fitting model. Respondents (N = 616) from both regions comprised three classes, which significantly differed on sleep- and exercise-related health, social behaviors, and mental health: Higher Psychological Distress (31.8%), Moderate Psychological Distress (49.8%), and Lower Psychological Distress (18.4%). The largest discriminatory issue was support from one's social network. Significant differences in depression, anxiety, and stress severity scores were observed across these three classes. Reported need for mental health services was greater than reported access.

Conclusions

Mental health outcomes were largely predicted by the lack or presence of social support, which can inform public health decisions and measures to buffer the psychological impact of ongoing waves of the COVID-19 pandemic on pregnant and postpartum women. Targeted early intervention among those in higher distress categories may help improve maternal and child health.     

Delivering perinatal depression care in a rural obstetric setting: a mixed methods study of feasibility,acceptability and effectiveness

Objectives: Universal screening for depression during pregnancy and postpartum is recommended, yet mental health treatment and follow-up rates among screen-positive women in rural settings are low. We studied the feasibility, acceptability and effectiveness of perinatal depression treatment integrated into a rural obstetric setting.

Methods: We conducted an open treatment study of a screening and intervention program modified from the Depression Attention for Women Now (DAWN) Collaborative Care model in a rural obstetric clinic. Depression screen-positive pregnant and postpartum women received problem-solving therapy (PST) with or without antidepressants. A care manager coordinated communication between patient, obstetrician and psychiatric consultant. We measured change in the Patient Health Questionnaire 9 (PHQ-9) score. We used surveys and focus groups to measure patient and provider satisfaction and analyzed focus groups using qualitative analysis.

Results: The intervention was well accepted by providers and patients, based on survey and focus group data. Feasibility was also evidenced by recruitment (87.1%) and retention (92.6%) rates and depression outcomes (64% with >50% improvement in PHQ 9) which were comparable to clinical trials in similar urban populations.

Conclusions for practice: DAWN Collaborative Care modified for treatment of perinatal depression in a rural obstetric setting is feasible and acceptable. Behavioral health services integrated into rural obstetric settings could improve care for perinatal depression.     

Does Supplementary Prenatal Nursing and Home Visitation Support Improve Resource Use in a Universal Health Care System? A Randomized Controlled Trial in Canada

ABSTRACT: Background: The addition of supplementary prenatal support may improve the health and well‐being of high‐risk women and families. The objective of this randomized controlled trial was to examine the impact of supplementary prenatal care on resource use among a community‐based population of pregnant women. Methods: Pregnant women from three urban maternity clinics were randomized (a) to current standard of physician care, (b) to current standard of care plus consultation with a nurse, or (c) to (b) plus consultation with a home visitor. Participants were 1,352 women who received 3 telephone interviews. The primary outcome was resource use (e.g., attended prenatal classes, used nutritional counseling). Results: Overall, those in the nurse intervention group were more likely to attend an “Early Bird” prenatal class and parenting classes, and to use nutrition counseling and agencies that assist with child care. Women provided with extra nursing and home visitation supports were more likely to use a written resource guide, nutrition counseling, and agencies that assist with child care. Among women at higher risk (e.g., language barriers, young maternal age, low income), the nurse intervention significantly increased use of early prenatal classes, whereas the nurse and home visitor intervention significantly increased use of the written resource guide and nutrition counseling. The intervention substantially increased the amount of information received on numerous pregnancy‐related topics but had little impact on resource use for mental health and poverty‐related needs. Among those with added support, resource use among low‐risk women was generally greater than among high‐risk women. Conclusions: Additional support provided by nurses, or nurses and home visitors, can successfully address informational needs and increase the likelihood that women will use existing community‐based resources. This finding was true even for high‐risk women, although this intervention did not reduce the difference in resource use between high‐ and low‐risk women. (BIRTH 33:3 September 2006)     

Factors implicated in moderating the risk for depression and anxiety in high risk pregnancy

Objective: The aim of the study was to evaluate depressive and anxious symptoms while examining the impact of self-esteem, social support and coping strategies on these symptoms in women who have been hospitalised for high-risk pregnancies. Method: Fifty-five women from the south of France area hospitalised or on bed rest for high-risk pregnancy completed five scales: the Edinburgh Post-Natal Depression Scale (EPDS), the High Risk Pregnancy Stress Scale (HRPSS), the Revised Prenatal Coping Inventory (NuCPI), the ‘Questionnaire du Soutien Social Perçu’ (QSSP), and the Rosenberg Self-Esteem Scale (RSES). Results: The results show that over half of these women manifest symptoms characteristic of pre-natal depression and the entire sample showed high levels of anxiety symptoms. Predictive factors for depression included informational support and self-esteem; for anxiety, predictive factors were patient age and EPDS scores. Conclusion: This study underscores the importance of providing appropriate psychological support for women with high-risk pregnancies in order to avoid depressive disorders and any potential negative consequences on the perinatal period.     

A comparison of two measures to screen for emotional health difficulties during pregnancy

ABSTRACT

Objective: To compare the performance of a generic mood questionnaire (Matthey Generic Mood Questionnaire, MGMQ) against the established Edinburgh Postnatal Depression Scale (EPDS) in perinatal mental health mood screening.

Background: Many perinatal clinical services use the EPDS to screen for depression, and some may consider using it to screen for anxiety. A new scale, the MGMQ, is designed to screen for a wide variety of emotions, not just depression or anxiety. It comprises a generic distress question, an impact question, as well as two clinical questions. Its brevity, and categorical scoring format, may also mean it is less susceptible than the EPDS to needing a myriad of different screen-positive scores for women from different cultures and during different perinatal time periods.

Methods: Two hundred and ten Italian women in their third trimester of pregnancy completed the EPDS and MGMQ while attending routine antenatal clinic appointments or antenatal classes in the north of Italy, between 2015 and 2016.

Results: The Distress and Lower Impact question thresholds showed acceptable receiver operating characteristics with the various EPDS screen positive thresholds. The Higher Impact question threshold, however, had lower than acceptable sensitivity. By contrast, the EPDS was poor at detecting women who on the MGMQ said that they were distressed and significantly bothered by their mood. The possible reasons for the discrepancies in screen-positive status between the two measures are discussed.

Conclusion: The MGMQ is a useful tool to aid in screening for a wide range of emotional difficulties in the perinatal period.     

Antenatal and postnatal depression – Are Polish midwives really ready for them?

ObjectiveBefore January 2019, no established solutions regarding the screening, assessment, and treatment of patients suffering from perinatal depression existed in Poland. From 2019, a new standard of perinatal care has imposed the obligation to monitor the mental state of women during pregnancy and in the postpartum period on the healthcare providers (mainly on midwives). Thus, our study aimed to evaluate midwives’ knowledge about prenatal and postnatal mental health disorders in the first six months of implementing the new standard of perinatal care in Poland.DesignPolish midwives completed a survey consisting of the Test of Antenatal and Postpartum Depression Knowledge by Jones, Creedy, and Gamble (2001) and questions related to a hypothetical case study of a depressed woman named “Mary”, developed by Buist and colleagues (2006). The midwives also rated their perceived knowledge and skills in assessing women’ mental health condition.SettingThe study was conducted in four Polish cities: Gdansk, Olsztyn, Szczecin, Wroclaw, and the surrounding rural areas.Participants111 Polish midwives with varied professional experience and socio-demographic characteristics participated in the study.Measurements and findingsAmong all of their professional responsibilities, the midwives self-rated their knowledge and skills in assessing the mental state of patients as the lowest ones. A subsequent objective assessment revealed their insufficient knowledge about antenatal and postnatal depression and the ways of treatment of these disorders.Key conclusionsMidwives are not properly prepared for the new tasks resulting from the Polish standard of perinatal care: specifically, for the assessment of a woman's mental state.Implications for practiceFurther trainings are required to ensure midwives’ competency and knowledge about the assessment and dealing with mental disorders of patients who experience prenatal and postpartum depression.     

A two-centred pragmatic randomised controlled trial of two interventions of postnatal support

Objectives To establish whether providing additional postnatal support during the early postnatal months influences women's physical and psychological health and to identify health service benefits.
Design Pragmatic randomised controlled trial with a  2 × 2  factorial design with two interventions.
Setting Community centres, Ayrshire and Grampian, Scotland.
Population One thousand and four primiparous women, 83% completed the baseline questionnaire, 71% at six months.
Methods (1) An invitation to a local postnatal support group run weekly with a facilitator, starting two weeks postpartum. (2) A postnatal support manual, posted two weeks postpartum.
Main outcome measures Data regarding primary outcome postnatal depression (Edinburgh Postnatal Depression Scale, EPDS), secondary outcomes, general health measures (SF-36), social support (SSQ6), use of health services and women's views of interventions were collected at two weeks postpartum and at three and six months.
Results There were no significant differences in EPDS scores between the control and trial arms at three and six months, nor were there differences in the SF-36 and the SSQ6 scores. The 95% CI for the difference in EPDS effectively excluded a change in mean score of more than 10% with either intervention. There were no differences in health service attendances in primary or secondary care between the control and trial arms. Of those women who attended the groups, 40% attended six or more. Women reported favourably on the 'pack' with the majority reading it a few times and feeling that it was aimed at them.
Conclusions Wide-scale provision by the National Health Service of either support groups or self-help manuals is not appropriate if the aim is to improve measurable health outcomes.     

Predictive validity of the Postpartum Depression Predictors Inventory-Revised (PDPI-R): A longitudinal study with Portuguese women

ObjectiveThis study examined the predictive validity of the prenatal and postnatal versions of the Postpartum Depression Predictors Inventory-Revised (PDPI-R) in European Portuguese women, considering two gold standards to determine postpartum depression (PPD).DesignProspective longitudinal study conducted between November 2015 and September 2017.SettingOne public referral maternity hospital in the central region of Portugal.ParticipantsA total of 140 Portuguese women participated in the study.MeasurementsParticipants completed the PDPI-R during the second trimester of pregnancy (T1) and at 6 weeks postpartum (T2). At T2, participants also answered the Edinburgh Postnatal Depression Scale (EPDS). During the fourth month postpartum (T3), women were interviewed with the Structured Clinical Interview for DSM-IV Disorders, and between 6 and 9 months postpartum (T4), they completed the EPDS.FindingsRates of clinically significant depressive symptoms (EPDS ≥ 10) were 16.4% (23/140) at T2 and 23.2% (23/99) at T4. Six (4.3%) women met the criteria for a clinical diagnosis of PPD (major depressive episode) at T3. Overall, the postnatal version of the PDPI-R performed better than did the prenatal version (average area under the curve = 82% vs. 71%), but both versions accurately predicted women who developed a clinical diagnosis of PPD, at a cut-off score of 4.5 for the prenatal version (sensitivity = 83.3%; specificity = 85.8%) and 9.5 for the postnatal version (sensitivity = 83.3%; specificity = 94.8%).Key conclusions and implications for practiceDespite the low prevalence of PPD (albeit consistent with prior estimates of major depression at three months postpartum), this clinical condition has very serious consequences for the mother, the baby and the whole family when present. The PDPI-R is a valid screening tool to estimate the psychosocial risk for developing PPD among Portuguese women and can be used in research (e.g., for cross-cultural comparisons) and clinical practice. The recommended cut-off scores could assist health professionals (namely, midwives) in identifying the women who would benefit from appropriate referrals and/or closer monitoring to prevent them from developing PPD.