Fisher and Wynter - Prevention of postnatal mental health problems in women: Implications for maternal and child health nurses

PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMS IN WOMEN: IMPLICATIONS FOR MATERNAL AND CHILD HEALTH NURSES

JANE FISHER & KAREN WYNTERJean Hailes Research UnitSchool of Public Health and Preventive MedicineMonash University

Medicine, Nursing and Health SciencesAUSTRALIAS NATIONAL PERINATAL DEPRESSION INITIATIVELaunched in 2009.Objectives are to:improve prevention and early detection of antenatal and postnatal depression and provide better support and treatment for expectant and new mothers experiencing depression. (Austin et al., 2011)2AUSTRALIAS NATIONAL PERINATAL DEPRESSION INITIATIVEIn the first three years the main focus has been to:Implement screening using the Edinburgh Postnatal Depression Scale during pregnancy and four to six weeks postpartum;Train midwives, maternal, child and family health nurses, general practitioners and Aboriginal health workers in screening and first-line treatment;Build referral pathways to care; BUT, as yet little national focus on prevention.3PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMS Prevention strategies include: Indicated: current symptoms;

Targeted: at risk of developing symptoms;

Universal: offered to all women

(Mrazek et al, 1994; Lumley and Austin, 2001; Lumley et al 2004)

4PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMSUniversal prevention strategies:Implemented in primary care;

Accessible and non stigmatising;

Provide a mental health promoting milieu;

Address potentially modifiable risk factors using evidence-informed approaches.

5RISKS FOR POSTNATAL DEPRESSIONSystematic reviews conclude:past history of psychopathology, including depression during pregnancy; coincidental adverse life events;

poor marital relationship; low social support. (Scottish Intercollegiate Guidelines for Postnatal Depression and Puerperal Psychosis, 2001)

6Nevertheless most research has focused on depressionSystematic reviews conclude that there are moderate to strong associations with four risk factors for depression after childbirth in women;The first two are arguably difficult to modify, but there is potential to modify the second twoRISK FOR POSTNATAL DEPRESSIONLess consistent evidence for:unintended or unwelcome pregnancy;longer time to conception;operative childbirth;not breastfeeding; personal coping style;unemployment;(Scottish Intercollegiate Guidelines for Postnatal Depression and Puerperal Psychosis, 2001)

7Lower level evidence for other factors all of which are difficult to change;However, there are others that are less well acknowledged:

Serious exhaustion causing impaired functioning is very common, but because the work of mothering an infant is not dignified with the language of work, it is not regarded as occupational fatigue;Little investigation of the psychological consequences of critical coercion, intimidation and other forms of emotional abuse and almost none about family violence.As yet, risks for anxiety are less well understood.

PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMSPrediction of maternal psychological functioningAntenatal prediction of postnatal depression through screening during pregnancy?Low positive predictive values; No test met criteria for routine use antenatally.

(Austin and Lumley, 2003; Austin 2003)

8Substantial data about prevalence and determinants, but much more limited about preventive strategies:A number of approaches:Identification through a screening process in pregnancy of women at risk of depression after birth;Reviews conclude that positive predictive values and specificity are low;No currently available screening instrument for postpartum mood disturbance meets criteria for routine inclusion in antenatal care;Events after childbirth are relevant.

UNIVERSAL ANTENATAL INTERVENTIONS TO REDUCE PNDUniversal antenatal interventions to prevent postpartum mood disturbance:Additional antenatal classes, including men with practical key messages (Gordon et al, 1960; Midmer et al, 1995);

Continuous ante- to postnatal midwife care (Shields et al, 1997; Waldenstrom et al, 1999, Biro et al, 1999);

Information about depression, help seeking and recovery (Hayes et al, 2001).(Austin 2003; Austin 2004)9None of the published universal antenatal interventions which only included women had shown an improvement in rates of postpartum depression in treated groups, However, the two trials that included men had promising findings:Gordon et al did not control for cluster effects or have a reproducible outcome measure: assessed emotional upsets;Midmer et al reduced anxiety at postpartum follow up.

UNIVERSAL POSTNATAL INTERVENTIONS TO REDUCE DEPRESSIONSeven universal trials of postnatal interventions:Postnatal hospital stayDebriefing (Priest et al, 2003); Midwife listening (Lavender et al, 1998);Changes to postnatal care:Earlier postnatal visit to a GP (Gunn et al, 1998);10 X 3 hour home visits of increased practical and emotional support (Morrell et al, 2000);Information pack invitation to new mothers group (Reid, 2002);Enhanced postnatal care by trained home visitors (MacArthur et al, 2002);Enhanced postnatal care and community education (Small et al, 2007).

(Austin, Lumley and Mitchell, 2004) 10Systematic reviews of controlled trials, clinical trials or randomised controlled trials (Austin, Lumley and Mitchell, 2004):Debriefing not effective; midwife listening effective at 3 weeks postpartum, but extremely high rates in standard care arm mean that it is regarded as an outlier; Early postnatal visits to GP; enhanced home visits and information pack + invitation were not effective in reducing depressive symptoms at any point postpartum;MacArthurs intervention large difference in mean EPDS scores in an intensive intervention embedded in existing community based health visitor care.Not duplicated in the PRISM study in AustraliaPREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMS: Why were most interventions unsuccessful?Methodologically robust studies, so the findings are perplexing:Aimed to reduce depression, rather than anxiety, which is prevalent and problematic;Did not distinguish between new onset or recurrent conditions;Modifiable or non-modifiable risk factors?Addressed low social support by providing increased professional support;

11All studies were adequately powered, analyzed by intention to treat, had properly concealed random allocation to trial arms and blinded assessment of outcomes. and carefully designed, so speculation about why most failed:Conceptualizations of mental health problems: only looked for or addressed depression and might have had effects on anxiety or adjustment disorders, but did not assess these;Failed to examine for differences between de novo and recurrent mental health problems;Did not make clear arguments about which risk factor was being addressed and whether it was modifiable: psychiatric history and coincidental adverse events less modifiable, but social support is potentially modifiable however, Addressed low social support by providing increased professional support, rather than addressing a womans intimate social relationships;NEGLECTED BUT POTENTIALLY MODIFIABLE RISK FACTORSInfant behaviour:Prolonged crying; Resistance to soothing;Dysregulated sleeping and feeding;Irritability;

(Fisher, Feekery and Rowe-Murray, 2002; Fisher, Rowe and Feekery, 2004)12Follow up and outcome studies at residential early parenting centers have revealed two factors that are strongly predictive of postpartum mood disturbance and that have not been considered in preventive interventions to date: Unsettled, dysregulated infant behaviour especially prolonged crying, resistance to soothing and frequent waking after short sleeps which are often associated with feeding difficulties: a difficult baby NEGLECTED BUT POTENTIALLY MODIFIABLE RISK FACTORSPartner behaviours:Being unavailable through long hours in employment and independent leisure;Rigid gender stereotypes about the division of labour;Limited participation in unpaid workload of infant care and household tasks;Lack of sensitive emotional support;Criticism and coercive control; (Fisher, Feekery and Rowe-Murray, 2002)13Although the relationship with the intimate partner is consistently identified as a risk factor, in most studies this is not described and none of the postnatal interventions addressed it directly;In investigations of women admitted to early parenting services, the behaviours associated with more severe and sustained symptoms were identified and are potentially modifiable;General lack of availability often made worse by the de-regulated workplace in which people are expected to work prolonged hours, but made even worse by pursuing leisure activities that do not include the partner or baby;Gender stereotypes about division of labour what constitutes work, in particular that he is working and she is not;Limited involvement in the household, in particular in care of the baby;Lack of empathy and recognition of her work and anxiety;Criticism about her management of the household and the baby

NEGLECTED BUT POTENTIALLY MODIFIABLE RISK FACTORSOccupational fatigue: Increased, but unrecognised, workload of infant care and household tasks;Frequently interrupted sleep;Insufficient sleep;Contributes to:Irritability, poor concentration, reduced functional efficiency.

14Lack of recognition of the increased workload because of gender stereotypes about what constitutes work, which leads to disabling occupational fatigue.

CHANGE IN MATERNAL DEPRESSION (EPDS)

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