The Needs Of Parents In The Context Of Physiological, Sociological, Psychological Determinants In The Postpartum Period

Introduction

The postpartum period, also known as the puerperium, refers to the time after delivery when maternal physiological changes related to pregnancy return to the non-pregnant state. In addition to physiologic changes and medical issues that may arise during this period, it is important that the PHN is aware of the psychological needs of the postpartum mother and her partner. In this essay the author will provide an overview of issues relating to the Physiological, sociological, and psychological, determinants in the postpartum period with reference to PHN interventions underpinned by evidence based practice.

Postnatal depression (PND) is the term used for depression that some women experience in the first year after having a baby, occurring in 10 to 15% of women within the first year of giving birth. Postnatal depression can last longer than three months, but if not treated, it can last longer. Thus, the earlier it is recognised, diagnosed and treated, the faster the recovery. The American Psychiatric Association (2000) outlined PND as a: ‘Serious mental health problem characterised by a prolonged period of emotional disturbance, occurring at a time of major life change and increased responsibilities in the care of a new born infant’. Postnatal depression can have a broad range of symptoms such as feeling sad, anxious, and alone, often accompanied by panic attacks and feelings that you may not enjoy being with people, even your baby. Other symptoms of postnatal depression include: loss of appetite, problems sleeping, crying easily, feeling rejected by your baby, and worrying a lot about your baby. Obsessive behaviour may be another sign of postnatal depression, such as fears about your baby dying, with some mothers having thoughts about harming their baby, but very few mothers ever act on this.

Higher prevalence rates have been reported among some populations with a very young maternal age, low education, low income, history of depression, and selected race/ethnicity, for example, possibly being African American. Obesity is another factor and depression is almost 40% higher among women who are obese than normal weight women and for this reason, it is imperative that health professionals understand women who are most at risk. Postnatal depression can cause problems for partners and spouses too if left untreated, PND can have detrimental consequences for the mother, infant and family, and can progress into clinical depression and suicide. The common feelings of exhaustion and anxiety while adjusting to an infant’s arrival with a significant decline in hormone production during the initial postnatal period is considered the baby blues. It is estimated that the ‘baby blues affects up to 80% of women and occurs within days of delivery’.

Various factors have been identified in relation to causing PND. These include an unsatisfactory marriage, loneliness and lack of adult company, complicated pregnancy/birth low family income and lower occupational status, limited social support, cigarette smokers, a history of depression/low self-esteem, role changes, low social class and life stressors during pregnancy.

Postnatal Depression

Investigations of PND rates in Ireland suggest wide variations. From 1990-2011, the percentage prevalence rates from 11% - 28.6% prevalence of PND and the prevalence of women in Ireland and internationally that suffer from PND stands at 19.7% and 17.3% respectively. Ireland along with other European countries offers little policy and legislative support for women with PND. In Scotland, because of this, emphasis was placed on multi-disciplinary work between primary care and mental health services (Scottish Executive, 2001c). These policy documents will help improve the care of mothers with PND. The Scottish executive also recognises the need for screening of PND, by the routine use of EPDS. Alder et al (2008) investigated the current policy and practice for PND in Scotland and found that 47% of policies and 68% of general practices were addressing the recommendations.

Ireland and Norway have many similarities from a geographic and demographic perspective and both have a strong focus on primary care and health. Ireland’s two-tier health care system has failed in many respects however in delivering services to meet people’s needs. In contrast to Ireland, Norway has universal health care for its entire population and free health care at the point of delivery. Despite this, guidelines for resolving PND are lacking in both Ireland and Norway (A Vision for Change, 2006; Norwegian Directorate of Health, 2004), with no resources increased either in Norway or in Ireland to help. There is also a need for clinical nursing service improvements, both from a resource and evidence based perspectives, specifically for the screening and management of PND. In Ireland and Norway, public health nurses (PHNs) provide a nursing service to new mothers and their infants in the community. Ireland has general public health nurses, which means they care for all persons within their defined geographic area from the cradle to the grave. The role of the PHN in PND will be picked up later in this essay.

Policy and Plans in Ireland

The WHO outlines that social support is necessary for maternal and infant well-being. In a report into the policies and practices of mental health in Europe it was found that out of 42 countries policies addressing women at risk (such as preventing PND) have been implemented in 6 countries and programmes have been implemented in 14 countries. This shows that the places like Ireland have a long way to go in protecting women with PND, as Ireland has no concrete policy or programmes in place for women suffering from PND.

The role of the mother is embedded into Irish society and is an intrinsic part of the first Constitution in 1937. In article 41.2 of the 1937 constitution, particular emphasis is placed on the role of the mother in ensuring the stability and protection of the family unit. Leahy-Warren et al. (2012suggest that PND can be difficult to detect because ‘new mothers are often reluctant to report depressive symptoms to health care professionals’ and other studies such as that of Ramsay (1993) found that ‘up to 50% of all cases of PND go undetected’. The legislation enacted in the Mental Health Act 2001 is limited in its protection of women suffering from PND in Ireland. Thus, while this act provides protection for women suffering from the sphere form of PND, puerperal psychosis, the Act does not provide protection to the majority of mothers affected by PND. Vision for Change in Ireland is another policy document that sets out the responsibilities in relation to mental health of the HSE, the Department of Health and Children and other departments. This policy document does not place emphasis on the less sphere onset of PND and provides no recommendation for community or social support for women with PND.

The Mental Health Ireland Strategy Plan 2015-2017 was set up to address mental health issues in Ireland, to provide high standards through training of health care workers, education and the promotion of positive mental well-being. The plan has outlined its main ethos of mental wellness as part of personal wellbeing to improve the overall health of the nation. This is an important step for women with PND. Currently, there is no policy for nurses in relation to dealing with people who have PND or depression. Thus, provision within nursing policy for women with PND needs to be created in order to treat women successfully.

Sociological Support

A lack of social support has been found to be a contributing factor to PND. Women often feel shame, embarrassment, and failure as mothers and as a result the mother can often be the biggest barrier to receiving help. Coupled with this, is the considerable ‘shortage of postnatal support services available in many countries’. The screening and treatment of women with PND has not been placed on a statutory footing, with legislation and policy providing little protection. Screening and treatment remains with healthcare professionals and their awareness of the condition. It describes how general practitioners might consider using an assessment tool such as the EPDS for detecting depression; however, it does not place any specific focus on PND. As such, further emphasis of PND should be placed on general practitioner services, with a need for screening if they suspect PND.

Supportive counselling has proved effective for women who are not in need of specialist help. Norway again is mentioned in relation to this support. Almost all women who give birth in Norway have contact with well-baby clinics and PHNs at least ten times during the first year of the child’s life, and these clinics provide regular and free health checks for all children from birth through 5 years of age. Typically, a PHN is responsible for preventive services for infants, children, adolescents and their families in a geographically defined area, including well baby clinics, school health services and youth health clinics (Andersson et al., 2006). Barak et al. (2008) also found that online support groups offer people a sense of control, self-confidence, feelings of more independence, social interactions, and improved feelings, all of which help in the screening and support of those with PND. These Peer support telephone calls have been widely used for a variety of health-related concerns, including PND (Dale et al., 2009). Dennis (2012) evaluated the voluntary mother’s experience of providing telephone peer support finding that phone peer support is an effective preventative intervention.

In Ireland, support can be seen from PND Ireland, founded in 1992 by Madge Fogarty following her personal experience of the condition. This support group utilises the telephone support mentioned above and it continues to operate monthly in Cork, providing the only known support group in Ireland for mothers suffering from PND. They also provide support via e-mail support, website, online discussion forum, and a drop in service by appointment. The current goal of the organisation is to establish support groups in other areas of Ireland and to draw awareness to senior figures in the HSE about the importance of support for mothers suffering from PND. In 2011, Nurture Post Natal Depression Support Service was also established and it currently links women with PND to low cost counselling in Dublin and this service hopes to provide a wider range of services in the future. Communicating And Relating Effectively (CARE) is another support, a relationship-focused behavioural nursing intervention, designed to promote responsive interaction over time between depressed mothers and their infants. By teaching the mother how to interpret her infant’s communication cues and by coaching her to try alternate behaviours, the nurses attempted to promote new maternal responses and skills. Finally, Mind Mothers is another support and sets out best practice principles, an educational e-learning tool for midwives, public health, and practice nurses, providing valuable resources in supporting the care offered to women during pregnancy and the post-natal period.

The PHN’s Intervention

Moving from the broad supports above to the more specific, the role of the Public Health Nurse (PHN) in screening and treating PND is paramount. Morrell et al. (2000) and MacArthur et al. (2002) illustrated the role of nurses in providing support with PND, providing a service that was flexible to the individual needs of the postnatal women. The PHN used symptom checklists and EPDS to identify health needs and guidelines for the management of these needs. Circular 41/2000 sets out the PHN services to be provided, which includes, in relation to the essay’s topic: To provide safe, comprehensive clinical nursing services for patients’ care needs and priorities. To liaise with hospitals and other care professionals. To provide support, education and preventive services (including screening, disease control, immunisation, breastfeeding support). To provide assessment, identification of, need for and supervision of home help and home care attendant services. To provide ongoing monitoring of infant, child, maternal and family health, including home visits. To complete records and supply reports, as required.

The PHNs screening duties help prevent PND. The most common tool used to measure PND is the Edinburgh Postnatal Depression Scale (EPDS) created by Cox et al. in 1987. It’s important to note that the EPDS was designed as a screening tool, not a diagnostic tool to detect PND (Cox et al., 1987). This self-reporting screening tool has been proven as an effective means of measuring PND. However, the EPDS has been criticised for ignoring psychosocial factors that contribute to PND symptoms such as lack of social support and significant life events. It has been found that simultaneous administration of the EPDS and Goldberg’s (1978) 12-item General Health Questionnaire (GHQ) could substantially improve identifying women with PND.

Another important intervention that the PHN will use is that of Health Teaching. This intervention can contribute to improving health outcomes for mother and baby in the postnatal period. The HSE Breastfeeding Action Plan (2016-2021) states that breastfeeding is an important determinant of a child’s future physical and mental health, as breastfeeding “is important for normal growth and development, it provides nourishment and health protection, it strengthens bonding and nurturing between mother and infant, and promotes infant mental health”. Thus, the PHN’s intervention of teaching breastfeeding and supporting mothers and protecting breastfeeding in the postnatal period is an important one in helping to identify and treat PND (Leahy-Warren et al., 2009).

In Ireland today, there are issues regarding breastfeeding during the postnatal period. Thus, the PHN must have knowledge about the importance of breastfeeding for the health of babies and families and will need to observe and assess a breastfeed through the use of the Breastfeeding Observation Assessment Tool (BOAT), a resource developed to assist PHNs to identify if breastfeeding is effective and to support mothers to continue. The mother should also be educated as to why breast milk is best for babies, as breastfeeding has a range of advantages including nutritional, immunological and psychological benefits, the latter of which is important in preventing PND. As we have seen so far, screening forms an important part of intervention and prevention, allowing the PHN to identify PND. In Ireland, recommendations were made for interventions like screening to address PND, which helped mothers effectively take care of themselves and their babies.

Conclusion

In order to achieve affective screening, the PHN must remove any fears the mother may have of being diagnosed with PND or fears their child may be removed from the family. Health teaching then is also about informing and educating the mother and her family on the important role of initiation supporting and sustaining breast feeding (Keller et al, 2004), as, infancy and early childhood are critical stages in life regarding psychological and cognitive development. According to the Mind Mothers study, mental health problems during and after pregnancy have implication for the physical and psychological welfare of both the mother and her baby. The PHN must therefore intervene by providing support to mothers to reduce the risk of PND.

However, some studies have shown that PHNs lack knowledge on mental health problems and did not always prioritise women’s mental health needs. According to Leahy-Warren (2007), the husbands/partners of first-time mothers need to be more involved also in antenatal and postnatal care and the study showed the need for public health nurses and midwives to work together to facilitate social support for first-time mothers on an evidence-based basis.

Another problem is that, although in Ireland, recommendations are made for interventions to address PND, screening for PND is currently not a routine component of the PHN postnatal visit, and thus, many women may not be assessed (Leahy-Warren, 2012), even though there is growing evidence that PND can be effectively treated and possibly prevented. All postnatal depression screening and assessment must be combined with a treatment chain and systematic referral procedures. Public health nurses have the most contact with mothers and new babies in the postpartum period and therefore are in a prime position to assess for PND and provide support. As such, and according to Negron et al. (2013), it is important to identify social support resources needs of new mothers to facilitate their transition to motherhood and recovery after childbirth.

References

1. A Vision for Change (2006) Report on the Expert Group on Mental health Policy. Dublin, Ireland, Stationery Office.
2. Abell, S. (2007) ‘Postpartum depression’, Clinical Pediatrics, 46, pp. 290–291.
3. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (4th ed. text rev.). Washington, DC:
4. Andersson, H.W., S. O. Ose, and R. Norvoll (2006) Public Health Nurses’ competence [Helsesøsters kompetanse]. SINTEF Helse. Oslo, Norway.
5. Appleby, L. (2003) ‘The treatment of postnatal depression by health visitors: Impact of brief training on skills and clinical practice’, Journal of Affective Disorders, 77(3), pp. 261–266.
6. Barak, A., Nissim, M., and Suler, J. (2008) ‘Fostering empowerment in online support groups’, Computers in Human Behaviour, 25(5), pp. 1867-1883.
7. Beck, C. T., & Gable, R. K. (2000) ‘Postpartum depression screening scale: Development and psychometric testing’, Nursing Research, 49(5), pp. 272–282.
8. Beck, C. T. (2001) ‘Predictors of postpartum depression: An update’, Nursing Research, 50(5), pp. 275–285.
9. Beck, C. T. (2006) ‘Postpartum depression: It isn’t just the blues’, American Journal of Nursing, 106(5), pp. 41–50.
10. Boyce, P., Stubbs, J., and Todd, A. (1993) ‘The Edinburgh postnatal depression scale: Validation for an Australian sample’, Australian and New Zealand Journal of Psychiatry, 27, pp. 472-476.
11. Brugha, T. S., C. J. Morrell, P. Slade, and S. J.Walters (2011) ‘Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care’, Psychological Medicine, 41(4), pp. 739–748.
12. Clancy, A., P. Leahy-Warren, M. R. Day, and H. Mulcahy (2013) ‘PrimaryHealth Care: comparing public health nursing models in Ireland and Norway’, Nursing Research and Practice.
13. Cox J.L. & Holden J. (2003) Perinatal Mental Health: A Guide to The Edinburgh Postnatal Depression Scale. (EPDS) Gaskell, London.
14. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987) ‘Detection of postnatal depression: Development of the 10 item Edinburgh Postnatal Depression Scale’, British Journal of Psychiatry, 150, pp. 782–786.
15. Dale H., Lee A. (2016) ‘Behavioural Health Consultants in Integrated Primary Care Teams: A Model for Future Care’, BMC Family Practice 17(97), pp 2-9.
16. Fettling, L. (2002) Postnatal Depression; A practical guide for Australian families. Menbourne, ID Communications.
17. Freeman, M., Wright, R., Watchman, M., Wahl, R., Sisk, F., and Weibrecht, J. (2005) ‘Postpartum Depression Assessments at Well-Baby Visits: Screening Feasibility, Prevalence, and Risk Factors’, Journal of Women's Health, 14(10), pp. 929-935.
18. Gavin, N.I, Gaynes B.N, (2005) ‘Perinatal depression: a systematic review of prevalence and incidence’, Obstet Gynecol. 106(5 Pt 1), pp. 071–1083.
19. Gaynes, B.N, Gavin N (2005) ‘Perinatal depression: prevalence, screening accuracy, and screening outcomes’, Evidence report/technology assessment119, pp.1-8.
20. Glavin, K., Smith, L., Sorum, R., & Ellefsen, B. (2010) ‘Redesigned community postpartum care to prevent and treat postpartum depression in women – a one-year follow-up study’, Journal of Clinical Nursing, 19(21–22), pp. 3051–3062.
21. Halbreich, U., and Karkun, S. (2006) ‘Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms’, Journal of Affective Disorders, 91(1), pp. 97–111.
22. Henshaw, C., Foreman, D., and Cox, J. (2004) ‘Postnatal blues: a risk factor for postnatal depression’, Journal of Psychosomatic Obstetrics and Gynecology, 25, pp. 267–272.
23. Higgins, A. (2017) Perinatal mental health: an exploration of practices, policies, processes and education needs of midvives and nurses within maternity and primary care services in Ireland. Dublin: HSE
24. Hung, C. H., and Chung, H. H. (2001) ‘The effects of postpartum stress and social support on postpartum women's health status’, Journal of Advanced Nursing, 36(5) pp.676-684.
25. Johnstone, S.J., Boyce, P.M., and Hickey, A.R. (2001) ‘Obstetric risk factors for postnatal depression in urban and rural community samples’, Australian and New Zealand Journal of Psychiatry, pp.3569–3574.
26. Leahy-Warren, P., McCarthy, G., and Corcoran, P. (2012) ‘First-time mothers: social support, maternal parental self-efficacy and postnatal Depression’, Journal of Clinical Nursing, 21(1), pp. 388-397.
27. P. Leahy-Warren and G. McCarthy (2007) ‘Postnatal depression: prevalence, mothers’ perspectives, and treatments’, Archives of Psychiatric Nursing, 21(2), pp. 91–100.
28. Flynn, A; Leahy-Warren, P. (2010) 'Neonatal nurses knowledge and beliefs regarding kangaroo care with preterm infants in an Irish neonatal unit'. Journal of Neonatal Nursing, 16.
29. Lee, D.T.S., Yip, A.S.K., and Chiu, H.F.K. (2000) ‘Screening for postnatal depression using the double test strategy’, Psychosomatic Medicine, 62, pp. 258–263.
30. Lewis, C., Daly Byers, A., Deann Malard, S., and Dawson, G. (2010) ‘Challenges in diagnosing and treating Postpartum Blue, Depression and Psychosis’, The Alabama Counselling Association Journal, 36(1), pp.5-15.
31. MacArthur, C., Winter, H., Bick, D., Knowles, H., Lilford, R., Henderson, C., Lancashire, R., Braunholtz, D., and Gee, H. (2002) ‘Effects of redesigned community postnatal care on women's health 4 months after birth: A cluster randomised controlled trial’, The Lancet, 359(9304). pp.378-385.
32. Milgrom, J., Mendelsohn, J., and Gemmill, A. (2011) ‘Does Postnatal Depression screening work? Throwing out the bathwater, keeping the baby’, Journal of Affective Disorders, 132, pp. 301-310.
33. Molyneaux E., Poston L., Khondoker M., Howard LM. (2016) ‘Obesity, antenatal depression, diet and gestational weight gain in a population cohort study’, Arch Womens Mental Health 19(9), pp. 899-907.
34. Morrell, C.J., Spiby, H., and Stewart, P. (2000) ‘Costs and effectiveness of community postnatal support workers: a randomised controlled trial’, British Medical Journal, 321, pp. 593–598.
35. Navarro, P., Ascaso, C., Esteve, L.G., Aguado, A.T., and Santos, R.M. (2001) ‘Postnatal Psychiatric Morbidity: A validation study of the GHQ-12 and the EPDS as screening tools’, General Hospital Psychiatry, 29(1), pp. 463-475.
36. Negron R., Martin A., Almog M., Balbierz A., Howell EA. (2013) ‘Social support During the postpartum period: Mothers views on Needs, Expectations, and Mobilization of support’, Matern Child Health journal 17(2), pp. 616-623
37. Norwegian Directorate of Health (2004) Norwegian Directorate of Health, The municipalities’ work for health promotion and prevention in well baby clinics and school health services. Veileder til forskrift av 3. Norway.
38. O’Hara, M.W., and Swain, A.M. (1996) ‘Rates and risk of postnatal depression – a meta-analysis’, International Review of Psychiatry, 8, pp. 37–54.
39. Ramsay, R. (1993) ‘Postnatal depression’, The Lancet, 341 (1358), pp.3213-3217.
40. Russell, S. (2006) ‘Barriers to care in postnatal depression’, Community Practitioner, 79, pp.110-111
41. Scottish Executive. (2001c) Scottish Executive: nursing for health: a review of the contribution of nurses, midwives and health visitors to improving the public’s health. Scotland, Edinburgh Scottish Executive.
42. Sharpe, D., Hay, D., Pawlby, S. (1995) ‘The impact of postnatal depression on boys intellectual development’, Journal of Child Psychology, 36, pp. 1315-1337.
43. Thomas, L., Clarke, T., and Kroliczak, A. (2008) ‘Implementation of peer support demonstration project for HIV Caribbean immigrants: a descriptive paper’, Journal of Immigrant & Refugee Studies, 6, pp. 526–544.
44. Tussing and Wren (2006) How Ireland Cares, the Case for Health Care Reform. New Island, Dublin, Ireland.
45. Ugarriza, D.N. (2004) ‘Group therapy and its barriers for women suffering from postpartum depression’, Archives of Psychiatric Nursing, 18, pp.39-48.
46. World Health Organization (2010). Women’s health.
47. Xie, R., He, G., Koszycki, D., Walker, M., and Wen, S. (2009) ‘Prenatal Social Support, Postnatal Social Support, and Postpartum Depression’. 19(9), pp. 637-643.