A Community‐Based Screening Initiative to Identify Mothers at Risk for Postpartum Depression

doi:10.1111/j.1552-6909.2010.01199.x

Journal of Obstetric, Gynecologic & Neonatal Nursing

Volume 40, Issue 1, January–February 2011, Pages 52-61

https://doi.org/10.1111/j.1552-6909.2010.01199.x Get rights and content

ABSTRACT

Objectives

To conduct a community‐based, postpartum depression (PPD) screening initiative, and recommend PPD screening practices.

Design

Descriptive correlational.

Settings

Two academic medical centers, a university research office, and participants' homes.

Participants

Five thousand one hundred and sixty‐nine postpartum women age 14 to 49 years.

Methods

The Agency for Healthcare Research and Quality (AHRQ) framework was implemented by identifying a cohort of mothers and conducting PPD screening followed by diagnostic evaluation of those with positive screens. Mothers in the postpartum period were recruited from two academic medical centers and screened for PPD at 4 to 6 weeks postpartum by telephone or mail using the Edinburgh Postnatal Depression Scale (EPDS). Mothers with EPDS scores ≥10 were invited to participate in the Structured Clinical Interview for DSM IV (SCID) to confirm PPD.

Results

Six hundred and seventy‐four (13%) women had EPDS scores ≥10; 185 women with elevated EPDS scores agreed to have a SCID diagnostic interview, and 144 were diagnosed with minor or major depression. A significantly higher percentage of women who self‐administered and mailed in the EPDS than women who were screened via telephone had scores ≥10. Elevated PPD scores were not associated with age or parity. Race/ethnicity identification other than White and having less than high school education were associated with higher PPD scores.

Conclusions

The AHRQ framework was effective in guiding a large‐scale PPD screening initiative by identifying mothers at risk for PPD. Results support previous findings regarding prevalence, selected risk factors, and continued use of the EPDS with SCID confirmation.

Section snippets

Background and Significance

Postpartum depression is a common childbirth complication with documented prevalence estimated at 13% (13, 14, 22, 23). Although combinations of risk factors are likely to contribute to any individual woman's vulnerability to PPD, accumulating evidence suggests that PPD affects a cross‐section of women and that factors such as prenatal depression and history of maternal depression, current stress, poor quality of relationships, young age, very low socioeconomic status or education, and possibly

Theoretical Framework

The CARE screening design followed the Agency for Healthcare Research and Quality (AHRQ) framework recommended by Gaynes et al. (2005) in their evidence report on the impact of PPD screening, intervention, and patient outcomes. This framework begins by identifying a cohort of mothers in the postpartum period with unknown mood state, follows with formal postpartum screening using a valid measure, proceeds with clinical diagnostic evaluation for those with positive screens, employs random group

Methods

The research reported here makes up Phase 1 of the study, CARE Intervention for Depressed Mothers and Their Infants. Phase 1 involved recruiting, screening, and diagnostic evaluation of postpartum women to determine depression status and eligibility for enrollment in the randomized clinical trial (RCT). Results presented here include a description of the key features of an effective PPD screening protocol for women in the community, prevalence rates obtained for telephone and mail‐in screening

Measures

Edinburgh Postnatal Depression Scale (EPDS). The EPDS (Cox, 1986; Cox et al., l987) was designed specifically to identify symptoms of PPD and is the most widely used PPD screening instrument with community‐based populations in the United States and internationally (13, 14). The EPDS was used in the current study to identify mothers who were at risk for PPD. The EPDS consists of 10 statements describing depressive symptoms with some reverse‐coded items with four possible responses, each scored

Procedures

The study protocol was approved by Partners Health Care Human Subjects Committee and the Boston College Human Subjects Committee. Following PPD screening for possible RCT eligibility, the research nurse explained the study and asked mothers with positive PPD screening scores if they were willing to have an advanced practice registered nurse (APRN) make a home visit for a follow‐up assessment interview (i.e., the SCID). For willing mothers, formal informed consent was obtained by the APRN at

Follow‐Up Procedures

During screening, and at any point in the 9‐month clinical trial, whenever a mother's depression score was in the moderate to severe symptom range (i.e., EPDS ≥13) or her response to EPDS Item 10 (that indicated thoughts of self‐harm) was positive (i.e.,hardly ever, sometimes, oryes quite often), the research nurse determined whether the mother was currently receiving any mental health treatment and subsequently encouraged the mother to contact her clinician immediately. If the mother was not

PPD Screening and Prevalence

CARE study nurses received signed PCFs from 7,212 mothers that indicated permission to contact these mothers at 4 weeks postpartum. Figure 1 details the disposition of the 7,212 mothers. Of these 7,212 mothers, 3,018 (42%) mothers received their questionnaires in the mail and 3,806 (53%) were screened by telephone. Of those who received mailed forms, 1,363 (19% of the total population) sent them back and 1,655 (23% of the total population) did not. In addition, 88 (1.2%) women returned opt‐out

SCID Diagnostic Interview Results

Of the 674 mothers with positive screens, 268 (39%) agreed to be considered for the Phase 2 9‐month RCT and 267 (39%) declined, 74 (11%) mothers were deemed to be too late with respect to study timelines, 52 (9%) mothers were not reached by phone or mail, and 16 (2%) mothers did not meet inclusion criteria. The available data elicited from mothers indicated that reasons for declining to participate and/or not completing the diagnostic interview visit included being unable to schedule the home

Discussion and Implications

In the screening (Phase 1) of the CARE study mothers with unknown mood state were screened for PPD and those with positive screens who agreed then participated in diagnostic evaluation. Willing mothers who qualified were subsequently randomly assigned for participation in the RCT (Phase 2), and referred for treatment options as necessary during follow‐up. Feasibility of the AHRQ framework was validated, as more than 5,000 mothers were willingly screened for PPD with the EPDS. Because mothers in

Conclusions

In summary, results presented here demonstrate that mothers were receptive to PPD screening, by telephone and by mail. The risk factors identified add to the growing knowledge about mothers who may be at increased risk for PPD. Our findings reinforce the recommendations of Gaynes et al. (2005) for continued research to test the effectiveness of methods for routine PPD screening, including examination of whether health outcomes are improved through such screening efforts. The success of our PPD

Acknowledgments

Funded by CARE Intervention for Depressed Mothers and Their Infants, National Institutes of Health, National Institute for Nursing Research Grant #R01 NR008033 (2004‐2010).

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Changing risk factors for postpartum depression in mothers admitted to a perinatal center
2023, Pediatrics and Neonatology
Citation Excerpt :
A study of a Japanese regional cohort24 and a prospective study of mothers whose infants were hospitalized in the NICU in other developed countries25 reported that maternal aging was associated with an increased risk of PPD. However, path model analysis in mainland China26 and Israel27,28 showed that younger maternal age was a risk factor for PPD. Other community-based or regional cohort studies did not report maternal age as a risk factor for PPD.29
The Edinburgh postnatal depression scale (EPDS) is commonly used in screening for major postpartum depression (PPD). We explored the clinical factors associated with score changes.
Mothers (n=1,287) who delivered a single live-born infant in Kokura Medical Center in Japan during 2018–2019 were analyzed. The EPDS-Japanese version was conducted at the first and fourth weeks after childbirth. Scores of ≥9 were considered to indicate an increased risk of PPD.
The scores improved during the four-week period (5.03±0.12 to 3.79±0.10). Primiparity, Cesarean section (CS), and a low Apgar score were identified as initial risk factors, however, primiparity remained in the multivariate analysis (aOR 2.02, 95% CI 1.37–2.97). Age ≥35 years was associated with worsened scores (aOR 1.88, 95%CI 1.01–3.51), but CS improved (aOR 0.38, 95%CI 0.21–0.70). Primiparity, CS, and neonatal respiratory support were the initial risk factors, while infant anomaly was a late risk factor in mothers whose infants were admitted to the neonatal intensive care unit (NICU) (aOR 3.35, 95%CI 1.31–8.56). In mothers of infants with an NICU stay of ≥4 weeks, infant anomaly was associated with worsened scores (aOR 6.61, 95%CI 1.11–39.3), while respiratory support was associated with improved scores (aOR 0.09, 95%CI 0.01–0.65). Twenty-six mothrs with worsened scores received psychiatric support; three developed PPD. Two of the three were ≥35 years of age, neither of their infants had anomalies.
Maternal aging and infant anomaly were risk factors for PPD. PPD occurred in mothers with worsened EPDS scores after mental care. Puerperants with worsening risk factors should be targeted to control PPD.
Effect of Fathers’ Presence and Involvement in Newborn Care in the NICU on Mothers’ Symptoms of Postpartum Depression
2020, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
To determine the prevalence of symptoms of postpartum depression (PPD) and examine how fathers’ presence and involvement in the care of their newborns affect symptoms of PPD within the first 2 weeks after birth among mothers with newborns in the NICU.
Observational cohort study.
Open-bay, 40-bed, tertiary level NICU in Eastern Canada.
Mothers (N = 105) of newborns who were anticipated to survive and required more than 5 days of hospitalization in the NICU.
Participants completed the Postpartum Depression Screening Scale (PDSS) 14 days after they gave birth. They kept daily diaries to record the amount of time that fathers spent by the newborns’ bedsides (i.e., presence) and actively caring for their newborns (i.e., involvement such as skin to skin). Participants completed daily diaries from the time of enrollment in the study until their newborns were discharged home. We analyzed the data using linear regression; score on the PDSS was the dependent variable, and fathers’ presence and involvement were the independent variables. We adjusted for covariates.
The prevalence of positive screening for symptoms of major PPD was 24.1% (n = 20), and the prevalence of significant symptoms of PPD was 27.7% (n = 23). Participants reported that fathers were present in the NICU an average of 3.8 hours per day and were actively involved with their newborns 53% of the time. Fathers’ involvement was significantly associated with lower scores on the PDSS (adjusted β = −3.85; 95% confidence interval [CI] [−6.10, −1.60]). A history of anxiety was significantly associated with greater scores on the PDSS (adjusted β = 12.06, 95% CI [2.07, 22.05]). Maternal age and income less than $50,000 CAD were marginally associated with greater scores on the PDSS (adjusted β = −0.86, 95% CI [−1.77, 0.05] and adjusted β = 10.69, 95% CI [−0.73, 22.11], respectively). The overall explained variance in the PDSS scores with the independent variables was R² = 0.35.
Fathers’ involvement in the care of their newborns in the NICU was significantly associated with fewer symptoms of PPD among mothers. We recommend research with targeted interventions to promote fathers’ involvement in the NICU to potentially mitigate the symptoms of PPD among mothers of newborns in the NICU.
Postpartum depression: A multi-disciplinary approach to screening, management and breastfeeding support
2019, Archives of Psychiatric Nursing
Postpartum depression (PPD) is a common condition affecting 11%-20% of all postpartum women. Depression can have significant consequences for both mother and infant. There are many risk factors associated with PPD, all of which contribute to an inflammatory response in the mother. An inverse relationship exists between PPD and breastfeeding; women with PPD are less likely to have a positive breastfeeding experience which can lead to early weaning, while long-term exclusive breastfeeding is associated with decreased rates of PPD. A multi-disciplinary approach to managing PPD, including strong breastfeeding support, will lead to improved mental health outcomes for women and their children.
Vitamin D: Effects on human reproduction, pregnancy, and fetal well-being
2018, Journal of Steroid Biochemistry and Molecular Biology
Pregnancy places exceptional demands on vitamin D and calcium availability; thus, their deficiencies during pregnancy threaten the woman and her fetus. Globally, vitamin D and other micronutrient deficiencies are common during pregnancy, especially in developing countries where pregnant women have less access to nutritional supplements. Vitamin D deficiency has been reported to be as high as 40% among pregnant women. As a pregnancy progresses, the requirements for vitamin D increase and thus, can worsen preexisting hypovitaminosis D. Consequently, hypovitaminosis D is increasingly associated with a higher incidence of fetal miscarriage, preeclampsia, gestational diabetes, bacterial vaginosis, and impaired fetal and childhood growth and development. This review explores the recent advances in the understanding of vitamin D and the pivotal role it plays in human reproduction, with an emphasis on pregnancy and its outcomes. Given the seriousness of the issue, there is a pressing need for clinicians to become aware of the risks associated with not identifying and correcting vitamin D deficiency. Identifying and correcting vitamin D deficiency, including safe exposure to sunlight, is particularly relevant for those who seek assistance with fertility issues or prenatal counseling, and those in the beginning of their pregnancy. The data point to a significant protective effects of vitamin D during pregnancy when the 25(OH)D serum level exceeds 30 ng/mL before pregnancy and during the first trimester and, sufficient levels are maintained throughout the pregnancy.
Nurse-Led Initiatives to Implement Universal Screening for Perinatal Emotional Complications
2017, Nursing for Women's Health
Citation Excerpt :
Although screening for other complications of pregnancy, such as gestational diabetes, has become the standard of care in all settings, screening for psychiatric disorders has not. The body of literature on the topic suggests that even when maternity care providers do use a screening tool, implementation, documentation, and interventions are inconsistent (Farr et al., 2014; Horowitz, Murphy, Gregory, & Wojcik, 2011; Schaar & Hall, 2013). As a result, women are likely to fall through the cracks.
Perinatal emotional complications are the most common pregnancy complications in the United States. This article reviews three recent studies that illustrate the prevalence of and risk factors for perinatal emotional complications and sheds light on the inconsistency of screening by health care providers in acute care and outpatient settings. Also presented is an example of nurse-led quality improvement initiatives aimed at implementing universal screening in a rural New England county, which resulted in 100% screening with the Edinburgh Postnatal Depression Scale across health care facilities within the community, as well as a system-wide change in the approach to identifying and treating perinatal emotional complications.
Randomized controlled trial to prevent postpartum depression in mothers on public assistance
2016, Journal of Affective Disorders
Postpartum depression (PPD) is a significant and common public health problem for women. Aims: To examine the efficacy of an intervention based on the principles of interpersonal therapy (IPT) in reducing the risk of PPD in pregnant women. Methods: Randomized controlled trial of 205 pregnant women who were 18 years old or older, on public assistance, and at risk for PPD. Participants (mean age=23; 38% Hispanic and 23% Black) were randomized to either the IPT group intervention (n=104) or the treatment as usual control (TAU) program (n=101). Results: At 6 months, the overall depression rate in the intervention group (16%) was lower than the control group (31%) and the effect of the intervention was statistically significant at p<0.05. Limitations: It is unknown if findings will generalize to a more heterogeneous sample of women than the current study, such as women from a range of socio-economic and cultural backgrounds, or marital status. There was a differential amount of contact between TAU and intervention conditions. Conclusions: An IPT based intervention during the prenatal period has the potential to reduce cases of PPD within 6 months postpartum in at risk mothers on public assistance.

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RESEARCHA Community‐Based Screening Initiative to Identify Mothers at Risk for Postpartum Depression

ABSTRACT

Objectives

Design

Settings

Participants

Methods

Results

Conclusions

Section snippets

Background and Significance

Theoretical Framework

Methods

Measures

Procedures

Follow‐Up Procedures

PPD Screening and Prevalence

SCID Diagnostic Interview Results

Discussion and Implications

Conclusions

Acknowledgments

Journal of Psychosomatic Research

American Journal of Obstetrics and Gynecology

Diagnostic and statistical manual of mental disorders

A meta‐analysis of predictors of postpartum depression

Nursing Research

Maternal depression and child behavior problems

Journal of Advanced Nursing

Predictors of postpartum depression

Nursing Research

Postpartum depression screening scale

Nursing Research

Prevalence, stability, and socio‐demographic correlates of depressive symptoms in black mothers during the first 18 months postpartum

Maternal Child Health

Detection of postpartum depression at well‐child visits

Pediatrics

Postnatal depression: A guide for health professionals

Detection of postnatal depression

British Journal of Psychiatry

Structured clinical interview for DSM‐IV axis disorders (SCID‐1): Clinician version administration booklet: Biometrics Research Department

Perinatal depression

Agency for Healthcare Research and Quality

A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women

Acta Psychiatrica Scandinavica

Promoting responsiveness between mothers with depressive symptoms and their infants

Journal of Nursing Scholarship

Postpartum depression

Journal of Perinatology

Community‐based postpartum depression screening

Psychiatric Services

RESEARCH
A Community‐Based Screening Initiative to Identify Mothers at Risk for Postpartum Depression