Chapter Two of DNP Scholarly Project Paper
Chapter 2: Literature Review
A review of the literature was conducted using CINAHL, MEDLINE, Google Scholar, nursing and medical databases, and professional and governmental agencies, articles and research studies dating from 2014-2018. The search mainly focused on areas including postpartum depression, postpartum depression treatment, postpartum depression education, and postpartum depression outcomes in mothers and infants, and evidence-based screening recommendations for perinatal depression. This review evaluates the literature, lists gaps and formulates conclusions based on the best available current evidence.
Risk Factors for Postpartum Depression
Ghaedrahmati et al. (2017) states thatPPD has no exact cause. If a woman has a history of premenstrual symptoms, previous depression, PPD in a previous pregnancy, prenatal high anxiety, and maternity blues have all been consistently demonstrated as risk factors for PPD (Mehta & Mehta, 2014). However, not having the gender the parents wanted baby can contribute to PPD (2017). Having low self-esteem will impact parents stress levels and can also contribute to PPD (2017). Alaheri et al. (2018) found that mothers who were satisfied with their families are less likely to develop PPD.
Prevalence of Postpartum Depression
According to the Centers for Disease Control (CDC) and Prevention, 11–20% of women in the postpartum period have a form of depression (2018). Depression during pregnancy and postpartum is the most common complication of pregnancy and childbirth (2018). Untreated PPD can have a lifelong effect on the health and well-being of both the mother and child (2018). For this reason, The U.S. Preventative Task Force (USPSTF) recommends screening for pregnant, postpartum, as well as the general population (Sui, 2016). Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (Sui, 2016). The recommendation was given a B grade, based on the quality and strength of the evidence about potential benefits and harm for screening for this purpose (Sui, 2016).
Postpartum Depression Diagnosis
PPD is generally defined in the literature as clinical depression that begins within the first year of giving birth (Therivel & Teska, 2018). The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) includes a specifier for major depression with peripartum onset that requires that the onset of depressive symptoms occurs during pregnancy or within four weeks of giving birth (Therivel & Teska, 2018). Depression that begins during pregnancy, or within the first year postpartum, also is referred to as perinatal depression (Therivel & Teska, 2018).
Maternal and Infant Outcome
With postpartum depression, feelings of sadness and anxiety can be extreme and might interfere with a woman’s ability to care for herself or her family. Centers for Medicare and Medicaid Services stated PPD can increase related health costs, hinder the development of the child, and create negative social outcomes (2016). Children living with mothers with depression may be at risk for long-term physical and behavioral health consequences (USPTF, 2016).
Stephens et al. (2016) performed a systematic search to identify articles published in English between 2000 and 2014. The search revealed that early identification and treatment of postnatal depression can reduce negative impacts on women, children, and families (2016). Therefore, screening and treating maternal depression is imperative (2016).
Screening for Postpartum Depression
The effectiveness of any screen depends upon its sensitivity, specificity, timing, frequency, and follow-up (Franca & McManus, 2018). The US Preventative Services Task Force recommends screening for perinatal depression because it is associated with a decrease in depressive symptoms (Franca & McManus, 2018). Several screening instruments have been validated for use during the perinatal period to assist with systematically identifying patients with perinatal depression (ACOG, 2018).
One screening tool is the Edinburgh Postnatal Depression Scale (EPDS). It is a ten-item self-reporting measure in which items on the scale correspond to symptoms of clinical depression (Myers et al., 2018). Myers et al. (2018) suggests women should not be routinely screened for depression if there are no established referral programs for those who screen positive (2018).
Postpartum depression has a high prevalence and its early detection and treatment improves the prognosis of both mother and child (Zee-van de Berg et al., 2017). Screening for postpartum depression may be valuable to improve detection and mother and child outcomes, if implemented in the right setting (2017). Depression can be treated effectively in several ways, but many cases of PPD remain undetected, partly because mothers face barriers to discuss their feelings (2017). Also, partly because the professionals they encounter do not recognize the symptoms or fail to discuss them (2017).
The Loudon et al. (2016) retrospective cohort consisted of the entire population of women who delivered an infant and returned for their six-week postpartum follow-up appointment at the Mount Sinai Hospital OB/GYN Ambulatory Practice between January 1, 2010 and December 31, 2013. The study revealed that by incorporating a clinical decision module within the health record, it confirmed the ability to screen and identify PPD symptoms in 99.5 % of the Mount Sinai Hospital OB/ GYN Ambulatory Practice over a 4-year period (2016). The effectiveness of adding a hard stop instruction direct to the health practitioners provided an appropriate way to address a barrier to identifying PPD at the practitioner level (2016). The results of this study suggest that executing a system as such in a postpartum care setting can improve adherence to quality guidelines with the potential to improve patient outcomes (2016).
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Fortunately, the Patient Protection and Affordable Care Act included PPD screening in its definition of comprehensive women’s preventive care. New Jersey was the first state to require physicians in obstetrics/gynecology, pediatrics, and internal/family medicine to screen women for PPD. A subsequent evaluation found no difference in the mental health care utilization of women with Medicaid coverage; the authors suspected this was partly because physicians were not paid for screening.
Wilkinson, Anderson, & Wheeler (2016) conducted a theoretical study with 1000 women between the ages of (18–49 years) who have given birth to at least one infant in the past year. In total, 29 more women with PPD achieved remission in the intervention compared to the usual care branch (32 in intervention vs. 3 in usual care) (2016). Screening and treating women for PPD is cost-effective (2016).
Farr et al. (2014) sought to evaluate provision of prenatal education and screening at delivery, estimate the prevalence of postpartum depressive symptoms, and identify venues where additional screening and education could occur. Two-thirds (67.0%) of women reported that a prenatal care provider discussed depression with them and 89.6% were screened for depression at hospital delivery Farr et al., 2014). In 2006, through the support of its governor and in collaboration with New Jersey’s Health Department, New Jersey was the ﬁrst state to enact a law mandating education and screening for depression among postpartum women (2014). The law states that prenatal care providers shall provide education to women about postpartum depression to increase detection and treatment of the disorder (2014). Additionally, the law speciﬁes that all licensed healthcare professionals providing postnatal care to women should screen new mothers for PPD symptoms prior to discharge from the birthing facility and at the ﬁrst few postnatal follow-up visits (2014). The results concluded that prenatal education and screening for PPD at the hospital is feasible and often results in the majority of women being educated and screened (2014).
Education and Professional Development
The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) believes all pregnant and postpartum women should be screened for mood and anxiety disorders (2015). Nurses are in key positions to screen women to provide education regarding perinatal mood and anxiety disorders to pregnant and postpartum women and their families and ensure appropriate treatment referrals (AWHONN, 2015). According to Legere et al. (2017) to effectively serve perinatal mood disorders, healthcare facilities that serve pregnant women, new mothers, and newborns should have policies and protocols that address screening, education, as well as staff training regarding these disorders (2017). Early recognition is difficult given that it is often an invisible mental illness and difficult for health-care providers to detect (2017). A lack of concrete, continuing education and professional development strategies being implemented consistently and strategically can create barriers to nurses, midwives, and all health-care providers possessing the necessary skills and competencies to effectively detect symptoms and deliver high-quality, evidence-based care to perinatal women experiencing depression (2017). Lack of education may also contribute to stigmatization and undesirable attitudes expressed by health-care providers, which further jeopardizes the patient’s care (2017). Positive outcomes occurred regardless of whether the content was focused on assessment and care during the antenatal, perinatal, or the postpartum period, and regardless of various modalities used (2017). The study suggests that regardless of how the content is delivered or for how long, any professional development education on perinatal depression will enhance some aspects of provider confidence knowledge and is certainly more effective than no education at all (2017).
Logsdon et al. (2018) revealed that teaching new mothers about postpartum depression can assist mothers in overcoming barriers to depression treatment. Nurses play a key role in encouraging postpartum depression education for perinatal nurses (2018). The study revealed new mothers viewed depression screening and receiving information on community resources as a positive part of their care (2018). It will be important that communication between inpatient and community caregivers be improved so that new mothers can benefit from seamless depression assessment, evaluation, and treatment (2018).
Farr et al. (2014) conducted a study on mothers who delivered live infants during 2009 and 2010 in New Jersey. Data on EPDS scores assessed at delivery were recorded on birth records and were linked to survey data from the Pregnancy Risk Assessment Monitoring System (PRAMS) (2014). The study revealed that 67% of the women had been educated on depression by a prenatal care provider and 89.6% were screened for PPD at the hospital after delivery. Among the 13% of women with depressive symptoms at delivery or later in the postpartum period, over a third were participants in the Women, Infants, and Children program (WIC) participants, 13% to 32% had an infant in the neonatal intensive care unit (NICU), over 80% attended the maternal postpartum check-up, and over 88% of their infants attended one well baby visit (Farr et al., 2014). The study concluded that prenatal education and screening for depression at hospital delivery is feasible (2014).
Literature suggests that larger health care systems with established organizational operations are better positioned to help implement education on PPD, screening programs, as well as evaluate treatment protocols (Logsdon et al., 2018). This study has shown that collaboration among multiple specialty departments can lead to high PPD screening rates and appropriate PPD treatment initiation in a large health care system (2018).
Logsdon et al. (2012) suggests healthcare professionals play an important role in either promoting self-seeking behaviors or hindering it. Logsdon et al. (2012) suggest significant PPD treatment barriers include inappropriate assessments paralleled with an insufficient knowledge about PPD. However, the opposite occurs when healthcare professionals minimized a mother’s feelings and symptoms, she then became hesitant to pursue treatment (2012). The mothers also described dissatisfaction with their obstetricians due to the fact their family physicians had limited time for counseling and preferred to prescribe antidepressants versus offering counseling in adjunct to pharmacotherapy.
The common theme noted from all the literature reviewed is that women should be screened and treated for postpartum depression. It is a cost-effective intervention and should be considered as part of usual postnatal care, which aligns with the recently proposed recommendations from the U.S. Preventive Services Task Force. Recent literature suggests that no matter how education is delivered or for how long, any professional development education on perinatal depression will enhance knowledge and is certainly better receiving no education at all. Based on the information obtained from recent literature, screening pregnant women admitted to the hospital has the potential to improve patient safety and quality of care. This will ensure that those suffering from depression or those who are at risk for depression are identified early and provided with resources to prevent possible complications. Since nurses are in key positions to screen and educate on postpartum depression, it is imperative that they are knowledgeable to properly educate and screen to ensure patients receive the appropriate treatment.
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