Screening for postpartum depression in a rural community

"It Took Away the Joy:" First American Mothers' Experiences with Postpartum Depression

BACKGROUND

Postpartum depression (PPD) is a devastating mental illness associated with adverse health outcomes for mother, child, and family. Higher PPD prevalence in First American women suggests a racial/ethnic disparity, yet little is known about how PPD is experienced from their perspective.

PURPOSE

To 1) describe First American women's PPD experiences and the meanings they ascribe to those experiences and 2) describe the cultural knowledge, influences, and practices during the perinatal period.

STUDY DESIGN AND METHODS

This phenomenological study used a community-based participatory research approach. Criterion and snowball sampling captured First American women who had PPD now or in the past (N = 8). Interviews used a semistructured guide and thematic analysis followed.

RESULTS

Mean age was 30.25 years. Most women were multigravidas (n = 7) and rated themselves as "very" (n = 4) or "mostly" (n = 3) Native American. Women were mostly of low socioeconomic status and had a history of depression (n = 7) and/or a history of prenatal depression (n = 6). Themes: 1) stressors that contributed to PPD; 2) how PPD made me feel; 3) what made my PPD better; 4) heritage-centered practices; 5) support through PPD; 6) how I felt after PPD; and 7) am I a good mother?

CLINICAL IMPLICATIONS

This study provides a better understanding of some First American women's PPD experiences that facilitates judgment of the importance of PPD within a cultural context. Clinicians need to create culturally appropriate responses to First American women's PPD needs.

Examining the Prevalence of Peripartum Depressive Symptoms in a Border Community

Introduction: Depression is one of the most common complications in pregnancy, affecting 10% to 20% of women. Untreated peripartum depression increases the risk of adverse life events, more considerable distress, homelessness, and illness later in life. This study explored the prevalence of peripartum depression and associated demographic characteristics in a population of low-income, Healthy Start program participants in one New Mexico county along the U.S.-Mexico border where knowledge of depression prevalence is lacking. Materials and Methods: Healthy Start caseworkers routinely administered the 10-item Edinburgh Postnatal Depression Scale (EPDS) to all pregnant and recently pregnant program participants between 2009 and 2017. Scores for the first prenatal screen, first postpartum screen, and all screens for 1453 women were studied. A score of >10 points out of a possible 30 indicated a positive screen. Screening outcome was examined in relation to age, race, ethnicity, primary language, and trimester of the prenatal screen. Crude and adjusted odds ratios were generated from logistic regression models. Results: Overall, 16.4% of women screened positive for depression. English-speaking women, non-Hispanic white women, and those ages >35 years were more likely to screen positive. Women >35 years also had higher odds of reporting thoughts of self-harm than younger women. Conclusion: In this low-income border population, non-Hispanic white, English-speaking women over the age of 35 were at the greatest risk of peripartum depression. These findings underscore the need for peripartum depression screening in this population.

Perceived social support and postpartum depression symptoms across geographical contexts: Findings from the 2016 Ohio Pregnancy Assessment survey

BACKGROUND

The purpose of this study was to examine the association between perceived social support and postpartum depression symptoms (PDS) and to understand how this association may differ for urban, suburban, rural Appalachian, and rural non-Appalachian women in Ohio.

METHODS

Data were obtained via the 2016 Ohio Pregnancy Assessment Survey (n = 3382), a representative sample of postpartum women in Ohio. We conducted bivariate analyses to assess the associations between self-perceived social support and PDS, and covariates. Univariate and multivariate logistic regressions were conducted using a modified Poisson distribution to estimate the association between social support and PDS, adjusting for sociodemographic characteristics. We also examined geographical context as an independent predictor of PDS and as an effect modifier for the association between social support and PDS.

RESULTS

15.6% of survey respondents experienced PDS. Women with low levels of social support had slightly higher prevalence (aPR: 1.4, 95% CI: 1.0-2.1) of PDS compared to women with high social support. Geographic context was an independent predictor of PDS; women in rural Appalachia had significantly lower prevalence (aPR: 0.5, 95% CI: 0.2-0.9) of PDS compared to women in urban areas. We did not find that geographical context modified the relationship between social support and PDS (Wald P = .5).

CONCLUSIONS

Low social support was associated with increased PDS but did not reach statistical significance. Women living in rural Appalachia had a lower prevalence of PDS. Future studies should explore the reasons for lower rates of PDS in rural Appalachia.

Prevalence and risk factors associated with postnatal depression in a South African primary care facility

BACKGROUND

The prevalence and factors that influence postnatal depression (PND) vary according to context.

AIM

To determine the prevalence and factors associated with PND in the postnatal clinic of a large community health centre.

SETTING

This study was conducted at Levai Mbatha Community healthcare centre, in Evaton, South of Gauteng.

METHOD

In a cross-sectional study, the Edinburg Postnatal Depression Scale (EPDS) was administered on 227 consecutive mothers during postnatal clinic visits. In addition, sociodemographic and clinical information were collected. Analysis included descriptive statistics, chi-square test and logistic regression. A score of greater than 13 on the EPDS screened positive for PND.

RESULTS

Participants' mean age was 27 years, and most completed less than grade 12 education (52.4%), were single (55.5%), were employed or had a working partner (60%) and had no previous PND (97%). The proportion of participants screening positive was 38.8%. In the adjusted logistic regression, completing only primary school education (odds ratio [OR]: 9.11; 95% confidence interval [CI]: 1.03-80.22; p = 0.047), using contraceptive prior to index pregnancy (OR: 2.05; 95% CI: 1.12-3.72; p = 0.019) and reporting a thought of self-harm or infanticide (OR: 7.08; 95% CI: 5.79-22.21; p = 0.000) significantly increased the risk of PND. In contrast, having a relationship with the father of the index child (OR: 0.42; 95% CI: 0.18-0.94; p = 0.037) mitigated this risk.

CONCLUSION

The proportion of women screening positive for PND was high in the study setting and was concomitant with significant risk of suicide or infanticide. This highlights the need to screen and consider PND as a vital sign during postnatal visits, especially in the face of low educational attainment, failed contraception and poor or no relationship with the father of the index child.

Self-Care for Health in Rural Hispanic Women at Risk for Postpartum Depression

OBJECTIVE

To determine factors that affect self-care of rural Hispanic women at risk for postpartum depression (PPD).

METHODS

This study was a descriptive cross-sectional design based on the key concepts of Orem's Self-care Deficit Nursing theory. Data were collected from 223 Hispanic postpartum women residing in Mecca, North Shore, and Thermal in California by an interviewer-administered survey. Four instruments were utilized: Edinburgh Postnatal Depression Scale (EPDS) for PPD, Multidimensional Scale of Perceived Social Support for social support, Duke University Religion Index (DUREL) for spirituality, and Self Rated Abilities for Health Practices for self-care.

RESULTS

The prevalence of women at risk for PPD was about 43 %. Social support, spirituality, and self-care ability were significantly correlated in women with PPD. Social support was a strong factor in predicting self-care ability for 'Nutrition', 'Psychological well-being', 'Exercise', and 'Responsible Health Practices' in the rural Hispanic women at risk for PPD.

CONCLUSIONS

The study findings can enable nurses and healthcare professionals to develop effective tailored interventions to assist rural Hispanic women's abilities to perform self-care for health, and in particular, during the postpartum period.

Prevalence and predictors of positive screening for postpartum depression in minority parturients in the South Bronx

It is reported that the rates of perinatal depressive disorders are high in ethnic minority groups from non-English speaking countries. However, very few studies have compared the prevalence of positive screening for postpartum depression (PPD) in minority communities living in an inner city. The goal of this study is to determine the prevalence and the predictors of positive screening for postpartum depression in minority parturients in the South Bronx. The study is a chart review of 314 minority parturients, Black or Hispanic, screened for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) tool. The overall prevalence of a positive EPDS screen among Black and Hispanic women was similar, 24.04 and 18.75%, respectively. The Black immigrant cohort had comparable positive screens with 23.81 as African Americans. Hispanic women born in the USA had the least prevalence of positive screens, 7.14%, and those who moved from the Dominican Republic and Puerto Rico had a prevalence of 17.24% of positive screens. The women who immigrated from Mexico, Central America, or South America had the highest prevalence of positive screens for PPD, 32.26%. As to the socioeconomic status (SES), there was a significant increase of 27.04 vs. 13.95% (P < 0.019) in positive screens for PPD for the unemployed mothers. Overall, Black and Hispanic parturients had similar rates of positive screens for PPD. Among the Hispanic women, immigrants had higher rates of positive screens, with those from Mexico, Central, and South America as the highest. The hospital experience did not affect the rates of positive screens. Neither did the SES with one exception; those unemployed had the higher rates of positive screens.

An Integrative Review of Postpartum Depression in Rural U.S. Communities

AIM

This study's aim is to synthesize and summarize the literature on postpartum depression (PPD) in U.S. rural populations.

BACKGROUND

Internationally, PPD has a high prevalence in rural communities. Although women in rural U.S. communities have higher rates of depression outside of the postpartum time period, little study has been conducted on PPD in U.S. rural populations. It is unknown whether rural women in the United States have high rates of PPD as is common in rural populations internationally.

DESIGN

We used integrative literature review using Whittemore and Knafl's (2005) methodology.

DATA SOURCES AND METHODS

We searched the databases MEDLINE, CINAHL, PsycINFO, and Academic Search Premier with the words "postpartum depression" or "postnatal depression" and the word "rural."

RESULTS

We found 11 articles with empirical data that met the criteria and thus were included in the review. Seven articles were quantitative, two were qualitative, one was mixed methods, and one was a nonexperimental design. Five foci emerged in the literature including (a) screening and prevalence, (b) demographic factors, (c) program creation and implementation, (d) mental health care seeking, and (e) social support. The results suggest that prevalence of PPD may be higher in rural U.S. areas, that implementing PPD prevention and screening programs for rural women is feasible, and that women in rural areas rely on informal networks and may face a stigma for seeking mental health care.

CONCLUSIONS

Further research is needed on PPD in rural U.S.

POPULATIONS

Specifically, this research should focus on the mix of variables found throughout this review such as race and income level. Nurses should lead for changes in clinical practice and policy that increase screening and interventions for PPD in rural communities.

Postpartum depression and its psychosocial correlates: A longitudinal study among a group of women in Turkey

The postpartum period is a window of risk for psychological disturbances and particularly for depressive symptoms. This study explored the relationships between postpartum depression and prepartum depressive symptoms, marital adjustment, support from family, previous depressive symptomology, and pregnancy planning. A total of 128 women who were receiving prenatal care at a state hospital in Istanbul, Turkey, and who were in the last trimester of their pregnancy participated in the first phase of the study. Of these, eighty-seven women also participated in the second phase, during the 3-6 month postpartum period. The results indicated that depressed mood in the last trimester of pregnancy, family support, care and support from spouse, previous depression history, and unplanned pregnancy were significant risk factors for postpartum depressive symptoms; significant differences were found for study variables as a function of women's scores on the Edinburgh Postnatal Depression Scale in pregnancy and in the postpartum period. The recommendation is made to use screening tools, like the Edinburgh Postnatal Depression Scale, in the course of routine prenatal care, and to refer women with Edinburgh Postnatal Depression Scale scores above the cutoff score for further clinical examination.

Magnitude and risk factors for postpartum symptoms: a literature review

BACKGROUND

The prevalence of postpartum depression worldwide varies from 0.5% to 60.8% in the first 12 months postpartum using self-reported questionnaire. This review aims to update the current magnitude of postpartum depression based on self-reported questionnaire and clinical interview and explore its associated factors in developed and developing countries.

METHODS

A literature search conducted between 2005 and 2014 identified 203 studies, of which 191 used self-reported questionnaire in 42 countries and 21 used structured clinical interview in 15 countries. Nine studies used a combination of self-reported questionnaire and clinical interview.

RESULT

The prevalence of postpartum depression varies from 1.9% to 82.1% in developing countries and from 5.2% to 74.0% in developed countries using self-reported questionnaire. Structured clinical interview shows a much lower prevalence range from 0.1% in Finland to 26.3% in India. Antenatal depression and anxiety, previous psychiatric illness, poor marital relationship, stressful life events, negative attitude towards pregnancy, and lack of social support are significant contributors to postpartum depression.

LIMITATION

All studies are included irrespective of the methodological quality, such as small sample size and their inclusion could affect the generalizability of the results.

CONCLUSION

The current prevalence of postpartum depression is much higher than that previously reported, and similar risk factors are documented. A culturally sensitive cut-off score with adequate psychometric properties of the screening instruments should be available. In future studies, examining the physical, biological, and cultural factors in qualitative studies and in those with adequate methodological qualities is recommended.

Utilization of psychiatric services by postpartum women in a predominantly minority, low-socioeconomic-status, urban population

This study describes the utilization of health care services related to psychiatric diagnoses in an inner city community health organization with a largely Hispanic population of low socioeconomic status. We reviewed the frequency and timing of postpartum mental health diagnoses among 5,731 patients who delivered babies and were followed-up for postpartum care. 286 women (5 %) had at least one mental health diagnosis. The rates in white, black, and Hispanic women were 12, 8, and 5 % respectively (p < .05). White and black women were 2.5 (95 % CI 1.24, 5.07), and 1.62 (95 % CI 1.09, 2.40) times more likely to have a mental health diagnosis, respectively, compared to Hispanic women. The most common diagnoses were mood disorders (64 %) followed by anxiety disorders (29 %). 87 % of cases were diagnosed after 4 weeks postpartum. The postpartum mental health diagnosis rate seen here is lower than might be expected, particularly among Hispanic women. Possible explanations are discussed.

A comparison of effectiveness of hepatitis B screening and linkage to care among foreign-born populations in clinical and nonclinical settings

Hepatitis B (HBV) is an urgent, unmet public health issue that affects Asian Americans disproportionately. Of the estimated 1.2 million living with chronic hepatitis B in USA, more than 50% are of Asian ethnicity, despite the fact that Asian Americans constitute less than 6% of the total US population. The Centers for Disease Control and Prevention recommends HBV screening of persons who are at high risk for the disease. Yet, large numbers of Asian Americans have not been diagnosed or tested, in large part because of perceived cultural and linguistic barriers. Primary care physicians are at the front line of the US health care system, and are in a position to identify individuals and families at risk. Clinical settings integrated into Asian American communities, where physicians are on staff and wellness care is emphasized, can provide testing for HBV. In this study, the Asian Health Coalition and its community partners conducted HBV screenings and follow-up linkage to care in both clinical and nonclinical settings. The nonclinic settings included health fair events organized by churches and social services agencies, and were able to reach large numbers of individuals. Twice as many Asian Americans were screened in nonclinical settings than in health clinics. Chi-square and independent samples t-test showed that participants from the two settings did not differ in test positivity, sex, insurance status, years of residence in USA, or education. Additionally, the same proportion of individuals found to be infected in the two groups underwent successful linkage to care. Nonclinical settings were as effective as clinical settings in screening for HBV, as well as in making treatment options available to those who tested positive; demographic factors did not confound the similarities. Further research is needed to evaluate if linkage to care can be accomplished equally efficiently on a larger scale.

The influence of geographic isolation on late preterm infant and mother outcomes

PURPOSE

Risk of adverse outcome in late-preterm infants (born between 34 and 36 weeks and 6 days' gestation) is heightened for those living in geographic isolation (GI). We examined the relationships between GI and several mother and infant outcomes.

SUBJECTS AND DESIGN

This was a tricenter cross-sectional study of 38 English-speaking late-preterm infant/mother dyads admitted to neonatal intensive care in a predominately rural Midwestern state. Eligibility for the study included English-speaking mothers and their biologically born late-preterm infants with no known anomalies. METHODS AND MAIN OUTCOME: Outcomes included maternal knowledge of infant development (Knowledge of Infant Development Inventory) and competence (Competence in Preterm Infant Care questionnaire), maternal perception of vulnerability (Vulnerable Baby Scale ([VBS]), risk, and temperament (Pictorial Assessment of Temperament ([PAT]). Infant readmission and follow-up data were also examined. Potential covariates included any use of the Internet for healthcare information, demographic data, and mother and infant health history and were obtained from medical records and from the mother. Level of GI was determined by time and distance traveled (minutes) from the mother's primary residence to the closest regional healthcare center.

RESULTS

Study participants traveled 61 ± 58 miles and 72 ± 62 minutes on average. The Mean ± SD scores on assessment were as follows: Knowledge of Infant Development Inventory 77 ± 10, and Competence in Preterm Infant Care questionnaire 90 ± 14, VBS 27.5 ± 3.5, and PAT 17.5 ± 3. Bivariate associations were observed between distance and time and VBS scores (P = .03 for both). Multiple regression analysis showed significant relationship between time (P = .02) and PAT scores when maternal education (0.09) and the number of hours spent in the NICU (P = .01) were entered into the model. The association between time traveled and VBS scores became marginally significant when maternal age and Internet use were entered into the regression models. The odds for a mother to perceive her infant at risk for suboptimal outcomes were 6 times greater for each 1-hour additional travel time (odds ratio = 6.0; 95% confidence interval: 1.3-36; P = .001). There was no association between GI and readmission rate and follow-up care. Readmission rate was 8%, and anticipatory guidance was found to be inadequate.

CONCLUSION

Remote access to appropriate healthcare services elicits more than legitimate concerns for the late preterm infant and warrants further investigation with consideration for how services might be more easily accessed for this at-risk group.

South African Indian Women Screened for Postpartum Depression: A Multiple Case Study of Postpartum Experiences

Postpartum depression is a debilitating condition with negative psychosocial implications. Given a dearth of literature on prevalence or experiences of postpartum depression in South Africa, we sought to understand the experiences of South African Indian women screened for postpartum depressive symptoms. Ten low-income women screened using the Edinburgh Postnatal Depression Scale at primary health care clinics at two locations in KwaZulu-Natal were interviewed, using a multiple case study qualitative method, to understand their experiences within a biopsychosocial framework. The data were analysed thematically with the assistance of NVivo 8. In line with other studies on postpartum depression, the study revealed that interpersonal issues, abusive relationships, economic hardships, and a lack of adequate social support precipitated or aggravated depressive feelings in the postpartum period.

Associations between physical activity and postpartum depressive symptoms

BACKGROUND

Postpartum women are at increased risk for developing depression, which can contribute to the ill health of the mother and her family. Previous research indicates that mothers who are physically active during leisure experience lower levels of postpartum depressive symptoms than do inactive mothers. The objective of this investigation was to examine the associations between total and domain-specific moderate to vigorous physical activity (MVPA) and depressive symptoms postpartum.

METHODS

Data were obtained from 550 women who participated in the Pregnancy, Infection, and Nutrition (PIN) Postpartum Study, a prospective cohort of mothers who delivered liveborn infants from October 2002 to December 2005 in North Carolina. Three-month postpartum MVPA was investigated as a predictor of 12-month postpartum depressive symptoms.

RESULTS

Those who participated in MVPA had two times the odds of developing elevated depressive symptoms at 12 months postpartum than those with no MVPA (odds ratio [OR] 2.00, 95% confidence interval [CI] 0.71-6.75). Different associations were suggested when examining domain-specific MVPA. Those participating in adult and child care and indoor household MVPA at 3 months postpartum had more than double the odds of developing elevated depressive symptoms at 12 months postpartum (OR 2.66, 95% CI 1.03, 8.11 and OR 2.72, 95% CI 0.96-10.18, respectively). Work MVPA conferred a doubling of the odds (OR 1.95, 95% CI 0.46-7.13), but recreational and outdoor household MVPA showed no associations with depressive symptoms.

CONCLUSIONS

Associations between MVPA and depressive symptoms differed by domain among postpartum women. Future studies of postpartum depressive symptoms should explore reasons for differences in physical activity by domain.

Rural residence and risk for perinatal depression: a Canadian pilot study

Few studies have examined whether rural residence is associated with increased or decreased risk for postpartum depression (PPD). To address this research gap, this pilot study examined rates of depressive symptoms and perceived social support among women living in rural (population <10,000), semi-rural (population 10,000-20,000), and urban (downtown Toronto, population approximately 2.5 million) areas. Women were consecutively recruited at 25-35 weeks gestation from midwifery clinics and hospital-based prenatal care practices in two catchment areas and asked to complete a demographic questionnaire including postal code. On the basis of their responses, rural, semi-rural, and urban mothers were contacted by telephone at 36 weeks gestation (baseline) and 6-8 weeks postpartum (primary outcome). During each assessment, participants completed standardized measures of social connectedness, mental health, and health service utilization, including the Edinburgh Postnatal Depression Scale (EPDS) and the Medical Outcome Study Social Support Scale. A total of 87 participants [N = 23 rural (R), N = 23 semi-rural (SR), N = 41 urban (U)] were recruited into the study. There were no statistically significant differences between groups in mean EPDS scores during pregnancy (U = 7.1, SR = 5.3, R = 5.3, p = 0.15) or at 6 weeks postpartum (U = 5.3, SR = 4.4, R = 4.2, p = 0.43). The proportion of women with EPDS scores >12 similarly did not differ between groups. There were few statistically significant differences between groups on indicators of social connectedness; however, urban women reported significantly lower scores on measures of social network diversity and social capital than either the semi-rural or rural groups. This pilot study is limited by its small sample size; however, our data do not support the hypothesis that there are clinically important differences in risk for PPD associated with rural residence. Further studies examining potential relationships between indicators of social connectedness and perinatal mental health may be warranted.

The epidemiology of hospitalized postpartum depression in New York State, 1995-2004

PURPOSE

The purpose of this study is to describe the patterns of hospitalization for depression in the year after delivery in relation to social, demographic, and behavioral characteristics.

METHODS

Data on births were linked to hospitalizations for depression over the subsequent year to describe the frequency and patterns of hospitalized postpartum depression among 2,355,886 deliveries in New York State from 1995 to 2004. We identified "definite postpartum depression" based on International Classification of Diseases (ICD) codes indicative of "mental disorders specific to pregnancy," and "possible postpartum depression" by ICD codes for hospitalization with any depressive disorders.

RESULTS

In New York State, we identified 1363 women (5.8 per 10,000) who were hospitalized with definite postpartum depression, and 6041 women (25.6 per 10,000) with possible postpartum depression, with lower risks in the New York City area. Postpartum depression was more common in later years and among mothers who were older, Black, smokers, lacking private insurance, and with multiple gestations, and was rarer among Asians. For possible postpartum depression, socioeconomic gradients were enhanced.

CONCLUSIONS

Risk of hospitalized postpartum depression is strongly associated with socioeconomic deprivation and varies markedly by ethnicity, with direct implications for screening and health services, also providing suggestions for etiologic studies.