Maternal mental health in Australia and New Zealand: A review of longitudinal studies

Mental health in the two years following hypertensive and normotensive pregnancy: The Postpartum, Physiology, Psychology and Paediatric follow-up (P4) cohort study

BACKGROUND

Postpartum mental illnesses and hypertensive disorders of pregnancy (HDP) are both common, and both associated with adverse maternal and child health outcomes. However, the relationship between them is unclear. This study aimed to investigate prevalence and symptom severity of depression, anxiety, and post-traumatic stress disorder (PTSD) 2-years postpartum in women with normal blood pressure (NBP) during pregnancy versus preeclampsia or gestational hypertension (GH).

METHODS

Two-years follow-up of the prospective Postpartum, Physiology, Psychology and Paediatric (P4) Cohort Study was conducted in metropolitan Australia. Prevalence and symptom severity of depression (Edinburgh Postnatal Depression Scale, EPDS > 12), anxiety (7-item Generalized Anxiety Disorder scale, GAD-7 ≥ 10) and PTSD (Posttraumatic stress Diagnostic Scale, PDS/PDS-5) were measured and calculated for women with NBP, preeclampsia and GH.

RESULTS

Among 365 participants (NBP: n = 271, preeclampsia: n = 75, GH: n = 19), 2-years postpartum depression prevalence was 3.9% (95% CI 2.3-6.4%): 4.4% after NBP, and 2.7% after preeclampsia (p = 0.53). Anxiety prevalence was higher after GH than NBP (15.8% versus 3.3%, p = 0.02). Prevalence of any mental illness (depression/anxiety/PTSD) was 5.9% (95% CI 3.8-8.8%); 5.6% after NBP, 4.1% after PE, and 15.8% after GH (p = 0.15). Although PTSD prevalence was low (1.4%), and similar between groups (p = 0.97), around 3 times more women after PE (8.1%), compared to NBP (2.5%), recalled childbirth as traumatic (p = 0.003).

CONCLUSIONS

Preeclampsia, although associated with persistent perceptions of traumatic childbirth, did not alter the risk of mental illnesses at 2-years postpartum. GH (albeit in a small subgroup) was associated with increased anxiety scores. Larger, multicentre studies are required to clarify relationships between HDP and postpartum mental illness.

TRIAL REGISTRATION

Retrospectively registered on 18/11/2013 with the Australian and New Zealand Clinical Trials Registry.

REGISTRATION NUMBER

ACTRN 12613 00,126 0718.

Adverse childhood experiences, emotional distress and dissatisfaction with motherhood among first-time mothers: Mediations and child differences

Despite the challenges associated with motherhood, studies have not consistently identified factors contributing to first-time mothers' dissatisfaction with motherhood in resource-limited regions. To fill this research gap, this study investigates how adverse childhood experiences (ACEs) result in first-time mothers' dissatisfaction with motherhood through emotional distress in Nigeria. Results from the partial least square structural equation model suggests that ACEs are associated with dissatisfaction with motherhood ( = 0.092; p < 0.01) and emotional distress ( = 0.367; p < 0.001). There is also a significant association between emotional distress and dissatisfaction with motherhood ( = 0.728; p < 0.001). Indirect path from first-time mothers' ACEs to dissatisfaction with motherhood through emotional distress shows significance ( = 0.267; 95% CI (0.213, 0.323); p < 0.001). In addition, the indirect path from first-time mothers' ACEs to dissatisfaction with motherhood through child emotional closeness showed significant dampening effects ( = 0.044; 95% CI (0.025, 0.066); p < 0.001). No serial impact of emotional distress and child emotional closeness was found in the study. The findings based on child gender indicated that only among first-time mothers of female children are ACEs predictors of dissatisfaction with motherhood. Trauma-informed interventions should be introduced in primary care settings to screen for ACEs and emotional dysfunctions among first-time mothers.

Trajectories of psychosocial environmental factors and their associations with asthma symptom trajectories among children in Australia

INTRODUCTION

Several psychosocial factors, such as maternal mental health and parents' financial hardship, are associated with asthma symptoms among children. So, we aim to investigate the changing patterns of important psychosocial environmental factors and their associations with asthma symptom trajectories among children in Australia.

METHODS

We considered asthma symptoms as wheezing (outcome) and psychosocial environmental factors (exposures) from 0/1 year to 14/15 years of the participants from the "Longitudinal Study of Australian Children (LSAC)" for this study. We used group-based trajectory modeling to identify the trajectory groups for both exposure and outcome variables. Associations between psychosocial factors and three distinct asthma symptom trajectories were assessed by multivariable logistic regression.

RESULTS

We included 3917 children from the LSAC birth cohort in our study. We identified distinct trajectories for maternal depression, parents' financial hardship, parents' stressful life events and parents' availability to their children from birth to 14/15 years of age. Compared to the "low/no" asthma symptom trajectory group, children exposed to a "moderate & increasing" maternal depression, "moderate & declining" parents' financial hardship, and "moderate & increasing" parents' stressful life events were significantly associated (relative risk ratio [RRR]: 1.55, 95% confidence interval [CI]: 1.27, 1.91; RRR: 1.40, 95%; CI: 1.15, 1.70; RRR: 1.77, 95%; CI: 1.45, 2.16) with "persistent high" asthma symptom trajectory.

CONCLUSION

Several psychosocial factors that are potential stressors for mental health increase the risk of having an adverse asthma symptom trajectory during childhood. Further attention should be given to reducing exposure to maternal depression, parents' financial hardship, and parents' stressful live events for long-term asthma control in children.

Unlocking big data to understand health services usage and government funding during pregnancy and early childhood, evidence in Australia

BACKGROUND

Maternity care is a high-volume and high-cost area of health care, which entails various types of service use throughout the course of the pregnancy. Thus, the aim of this study was to explore the most common reasons and related costs of health services used by women and babies from pregnancy to 12-month postbirth.

METHODS

We used linked administrative data from one state of Australia, which contained all births in Queensland between 01/07/2017 and 30/06/2018. Descriptive analyses were used to identify the 10 most frequent reasons and related costs for accessing inpatient, outpatient, emergency department, and Medicare services. These are reported separately for women and babies in different periods.

RESULTS

We included 58,394 births in our data set. The results have highlighted that there was relatively uniform use of inpatient, outpatient, and Medicare services by women and babies, with the 10 most common services accounting for more than half of the total services accessed. However, the emergency department service use was more diverse. Medicare services accounted for the greatest volume (79.21%) of service events but only 10.21% of the overall funding, compared with inpatient services, which accounted for less volume (3.62%) but the highest amount of overall funding (75.19%).

CONCLUSION

Study findings provide empirical evidence about the full spectrum of services used by birthing families and their babies, and could assist health providers and managers to understand the services women and infants actually access during pregnancy, birth, and postbirth.

The relationship of couples' time perspective to pregnant women's depression symptoms and stress: Preliminary results

OBJECTIVE

The aim of the study was to examine the relationship of a couple's time perspective to a woman's depression symptoms and stress.

METHOD

The participants were 48 pregnant women and 46 male partners of these women. The measurements have been taken during the first and third trimester. Women were examined by gynecologists during gynecological visits. During these visits measurements of gynecological pregnancy evaluation were administered. Then women completed online questionnaires: the Zimbardo Time Perspective Inventory Past Negative scale, the Dark Future Scale, the Edinburgh Postpartum Depression Scale and the Perceived Stress Scale at home. Men completed online questionnaires: the Zimbardo Time Perspective Inventory Past Negative scale, and the Dark Future Scale at home.

RESULTS

The results showed that women's past negative perspective in the first trimester was related to depression symptoms and stress in the first trimester. In the third trimester, women's future negative perspective was related to depression symptoms. Men's future negative perspective in the first trimester was related to women's stress in the first trimester. Moreover, the results suggest that the level of the woman's future negative perspective significantly increases during pregnancy.

CONCLUSIONS

Attitudes towards time of both the pregnant woman and her partner are related to the emotional state of the woman during pregnancy.

Online cognitive behaviour therapy for maternal antenatal and postnatal anxiety and depression in routine care

BACKGROUND

Perinatal depression and anxiety are associated with significant adverse effects for the mother and child. Online cognitive behavioural therapy (iCBT) can provide scalable access to psychological interventions to improve perinatal depression and anxiety, however, few studies have examined the effectiveness of these interventions in routine care. This study investigated the uptake and treatment outcomes of women living in the Australian community who enrolled in a pregnancy or postnatal iCBT program for their symptoms of depression and anxiety.

METHODS

1502 women commenced iCBT (529 pregnancy and 973 postnatal) and completed measures of anxiety and depression symptom severity, and psychological distress pre- and post-treatment.

RESULTS

35.0 % of women in the pregnancy program and 41.6 % in the postnatal program completed all 3 lessons, with lower pre-treatment depression symptom severity significantly associated with increased likelihood of perinatal program completion. Both iCBT programs were associated with medium pre- to post-treatment effect size reductions in generalised anxiety symptom severity (gs = 0.63 and 0.71), depression symptom severity (gs = 0.58 and 0.64), and psychological distress (gs = 0.52 and 0.60).

LIMITATIONS

Lack of control group and long-term follow-up, as well as detailed information on nature of the sample (e.g., health status, relationship status). Additionally, the sample was limited to Australian residents.

CONCLUSION

iCBT for perinatal anxiety and depression was associated with significant symptom improvement. Current findings support the use of iCBT in perinatal populations and its integration within routine healthcare provision.

Antenatal diet quality and perinatal depression: the Microbiome Understanding in Maternity Study (MUMS) cohort

BACKGROUND

Previous findings from research investigating the role of antenatal nutrition in preventing postpartum depression (PPD) are inconsistent. Our primary aim was to investigate the association between pregnancy diet quality and PPD. Our secondary aim was to investigate associations between (a) diet quality and depression during pregnancy and (b) depression during pregnancy and PPD.

METHODS

This analysis represents data from 73 women participating in the Microbiome Understanding in Maternity Study (MUMS) cohort in Sydney, Australia, which followed women from Trimester 1 of pregnancy to 1-year postpartum (PP). Participants' diet quality was assessed using the Australian Eating Survey at Trimester 1 and 3 to calculate diet quality, known as the Australian Recommended Food Score (lower diet quality defined as score <39; higher diet quality ≥39). Depression was assessed using the Edinburgh Depression Scale at Trimesters 1, 2, 3 and 6 weeks PP (defined as score ≥11).

RESULTS

Depression scores during pregnancy were significantly associated with depression score 6 weeks PP (Trimester 1: r = 0.66, Trimester 2: r = 0.69, Trimester 3: r = 0.67; all p < 0.001). Diet quality during pregnancy was not significantly correlated with 6-week PPD score. In unadjusted analysis, diet quality during pregnancy was not associated with pregnancy depression scores. When adjusted for age, parity and Trimester 1 body mass index, Trimester 1 physical activity levels and gestational weight gain, higher Trimester 3 diet quality was associated with reduced Trimester 3 depression only.

CONCLUSIONS

Depression scores during pregnancy were positively associated with PPD, highlighting the importance of screening for depression during pregnancy and postnatally. Larger longitudinal prospective studies may elucidate the association between diet quality and PPD.

Rurality as a predictor of perinatal mental health and well-being in an Australian cohort

OBJECTIVE

Perinatal emotional well-being is more than the presence or absence of depressive and anxiety disorders; it encompasses a wide range of factors that contribute to emotional well-being. This study compares perinatal well-being between women living in metropolitan and rural regions.

DESIGN

Prospective, longitudinal cohort.

PARTICIPANTS/SETTING

Eight hundred and six women from Victoria and Western Australia recruited before 20 weeks of pregnancy and followed up to 12 months postpartum.

MAIN OUTCOME MEASURES

Rurality was assessed using the Modified Monash Model (MM Model) with 578 in metropolitan cities MM1, 185 in regional and large rural towns MM2-MM3 and 43 in rural to remote MM4-MM7. The Structured Clinical Interview for DSM-IV (SCID-IV) was administered at recruitment to assess depression, and symptoms of depression and anxiety were measured using the Edinburgh Post-natal Depression Scale and the State and Trait Anxiety Scale, respectively. Other measures included stressful events, diet, exercise, partner support, parenting and sleep.

RESULTS

The prevalence of depressive disorders did not differ across rurality. There was also no difference in breastfeeding cessation, exercise, sleep or partner support. Women living in rural communities and who also had depression reported significantly higher parenting stress than metropolitan women and lower access to parenting activities.

CONCLUSIONS

Our study suggests while many of the challenges of the perinatal period were shared between women in all areas, there were important differences in parenting stress and access to activities. Furthermore, these findings suggest that guidelines and interventions designed for perinatal mental health should consider rurality.

The effects of social support on depression and anxiety in the perinatal period: A mixed-methods systematic review

BACKGROUND

The social support offered to women in the perinatal period can buffer against depression and anxiety. The sources and types of support that reduce maternal levels of depression and anxiety are not well understood.

AIMS

To investigate the effects of structural and functional support on depression and anxiety in women in the perinatal period, and to explore the experiences of women around support during the perinatal period.

METHOD

A comprehensive search of six electronic databases was undertaken. Relevant studies published from January 2010 to April 2020 were included (PROSPERO reference number: CRD42020194228). Quantitative and qualitative studies were eligible if they reported the effects of, or had themes related to receiving functional or structural support in the perinatal period on women's levels of depression or anxiety. Qualitative data was synthesised using a thematic synthesis method. Quantitative data could not be pooled due to the lack of comparable RCTs or cohort studies and was thus presented in a narrative form.

RESULTS

Fifty-one articles (41 quantitative and 10 qualitative studies) were included. Analysis of quantitative studies demonstrated that insufficient support from partner, friends and family was associated with greater risk of symptoms of depression and anxiety. Distance-delivered interventions (via internet or telephone) diminished levels of depression and anxiety. Qualitative data revealed three overarching themes: appreciating all forms of support in the perinatal period, recognising appropriate and inappropriate support from health professionals and services, and having barriers to mobilising functional and structural support.

LIMITATIONS

Grey literature was not explored and search strategies only included English, Spanish and Portuguese language articles. The reviewed studies were heterogeneous and for this reason, quantitative assessments were not feasible.

CONCLUSION

Support from specific sources such as family members, friends who are also mothers, health professionals, neighbours, supervisors, co-workers and online communities still need to be further investigated. Implications for health professionals involved in the care of women in the perinatal period are discussed.

Connecting hapū māmā (pregnant women) early to a lead maternity carer: striving for equity using the Best Start-Pregnancy Tool

Introduction In Aotearoa New Zealand, lead maternity carers (LMCs) provide maternity care through pregnancy and birth, until 6 weeks' postpartum. An early LMC connection in pregnancy is associated with better maternal and perinatal health outcomes. However, hapū māmā (pregnant women) may experience barriers to engaging with LMC, delaying screening, risk assessments, and education. These barriers contribute to inequitable health outcomes for Māori māmā and pēpi (Māori mothers and babies). A pro-equity approach to maternity care is warranted. Aim To investigate the LMC plan at the first point of contact with a primary care provider once pregnancy is confirmed, as well as selected risk factors to maternal and perinatal health for Māori and non-Māori hapū māmā. Methods Data entered by primary care providers into the Best Start-Pregnancy Tool were analysed for 482 pregnant women from November 2020 to December 2021. Results Most hapū māmā planned for midwifery care. About one-third of hapū māmā had engaged with a midwife before their first GP visit after a confirmed pregnancy. Māori hapū māmā were more likely to present with risk factors to maternal and perinatal health than non-Māori hapū māmā. Discussion Primary healthcare providers have an expectation to connect hapū māmā to a LMC by 10 weeks' gestation. More research is needed to identify how to best support Māori hapū māmā to access a LMC early in pregnancy. The Best Start Kōwae is an accessible online tool (currently in an implementation phase) for primary care providers and LMCs that promotes equitable health outcomes for Māori māmā and pēpi.

An examination of the association between marital status and prenatal mental disorders using linked health administrative data

Background

International research shows marital status impacts the mental health of pregnant women, with prenatal depression and anxiety being higher among non-partnered women. However, there have been few studies examining the relationship between marital status and prenatal mental disorders among Australian women.

Methods

This is a population-based retrospective cohort study using linked data from the New South Wales (NSW) Perinatal Data Collection (PDC) and Admitted Patients Data Collection (APDC). The cohort consists of a total of 598,599 pregnant women with 865,349 admissions. Identification of pregnant women for mental disorders was conducted using the 10^th version International Classification of Diseases and Related Health Problems, Australian Modification (ICD-10-AM). A binary logistic regression model was used to estimate the relationship between marital status and prenatal mental disorder after adjusting for confounders.

Results

Of the included pregnant women, 241 (0.04%), 107 (0.02%) and 4359 (0.5%) were diagnosed with depressive disorder, anxiety disorder, and self-harm, respectively. Non-partnered pregnant women had a higher likelihood of depressive disorder (Adjusted Odds Ratio (AOR) = 2.75; 95% CI: 2.04, 3.70) and anxiety disorder (AOR = 3.16, 95% CI: 2.03, 4.91), compared with partnered women. Furthermore, the likelihood of experiencing self-harm was two times higher among non-partnered pregnant women (AOR = 2.00; 95% CI: 1.82, 2.20) than partnered pregnant women.

Conclusions

Non-partnered marital status has a significant positive association with prenatal depressive disorder, anxiety disorder and self-harm. This suggests it would be highly beneficial for maternal health care professionals to screen non-partnered pregnant women for prenatal mental health problems such as depression, anxiety and self-harm.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05045-8.

Postnatal depression and anxiety during the COVID-19 pandemic: The needs and experiences of New Zealand mothers and health care providers

Objective

The postnatal period is a vulnerable time for women's mental health, particularly within the context of the COVID-19 pandemic. This study interviewed Auckland-based mothers and healthcare providers to find out their perspectives on the needs and experiences of women with postnatal mental health concerns within the pandemic context.

Design

Semi-structured interviews were conducted via video conferencing.

Setting

Interviews were conducted between May and July 2021 during the COVID-19 pandemic.

Participants

Participants included eight mothers who gave birth during the first year of the pandemic (between January and December 2020) and self-identified as experiencing postnatal depression and/or anxiety, and three healthcare providers who support women with postnatal mental illness. All participants were based in Auckland, New Zealand.

Measurements and Findings

Interviews were analysed using thematic analysis. Five main themes were identified including (1) uncertainty and anxiety, (2) financial and work stress, (3) importance of the “village”, (4) inner resilience, and (5) “no one cared for mum”. The participants’ stories reflected a period of uncertainty, anxiety, and isolation. A lack of focus on mothers’ mental health during postnatal healthcare appointments was evident, as well as a lack of support services to refer the women to should they reach out for help.

Key Conclusions and Implications for Practice

The results of this study highlight the importance of prioritising safe, in-person access to healthcare providers and sources of social support for postnatal women during pandemic lockdowns to help reduce isolation during this vulnerable time. Improving accessibility to a range of treatment options for those with mild to moderate mental illness also needs to be a priority. A dedicated postnatal mental health support line could be beneficial to broaden the support options available to mothers, both within and outside the pandemic context. More focus on mental health training for midwives and other postnatal healthcare providers such as well child nurses is also recommended, to increase their ability to support women struggling with postnatal mental illness.

The enduring impact of birth: Women's birth perceptions, postpartum depressive symptoms, and postpartum depression risk

BACKGROUND

Postpartum depression (PPD) and related maternal mood disorders affect anywhere from 7% to 19% of postpartum women. Although historically a neglected issue, there has been a strong impetus in the past few decades to implement routine, universal screening and to address PPD as a major public health concern. Still, there has been relatively little analysis of how the quality of the birth experience influences subsequent maternal mental health. We examine the relationship between perceived birth experience and two PPD screeners (Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale).

METHODS

Data came from waves I and II of the Listening to Mothers data set. This is the only national survey of US women's childbirth and postpartum experiences. In logistic and linear regression models, we used a 12-item "feeling" index (perceived birth experience) to predict (a) overall PPD screener scores, and (b) likelihood of meeting the clinical cutoff for depression risk. We also controlled for other known socio-demographic and obstetric risk factors.

RESULTS

Perceived birth experience strongly and consistently predicted both PPD screener measures, and in both forms-raw scores and clinical cutoffs. By contrast, other known risk factors had inconsistent results across the two screeners.

DISCUSSION

Perceived birth experience should be considered more central in assessing PPD. It may also be more robust than the PPD screeners used in practice, and therefore, could be a more reliable predictor of PPD. Providers should consider how the improved social-psychological quality of women's birth experience can act as a buffer to PPD and other postpartum concerns.

High levels of depressive symptoms and low quality of life are reported during pregnancy in Cape Coast, Ghana; a longitudinal study

Background

Significant rates of anxiety, depressive symptoms, and low quality of life (QoL) have been found among pregnant women in developed countries. These psychosocial disturbances have not been adequately assessed during pregnancy in many developing countries.

Methods

Women were recruited in their first trimester of pregnancy (< 13 weeks; n = 116) and followed through to their 2^nd (n = 71) and 3^rd (n = 71) trimesters. Questionnaires were used to collect data on anxiety symptoms (Beck Anxiety Inventory; BAI), depressive symptoms (Center for Epidemiological Studies-Depression Inventory; CES-D), and quality of life (RAND SF-36; QoL). Psychometric analyses were used to determine the reliability of the questionnaires in this context. The proportion of pregnant women with psychosocial disturbances at each trimester was determined. Repeated measures ANOVA were used to examine changes in psychosocial outcomes over time; and generalized estimating equation to determine if gestational age predicted the psychosocial outcomes whilst controlling for sociodemographic variables.

Results

Participants were aged 27.1 ± 5.2 years, on average. Psychometric analyses revealed a 4-factor solution for BAI (18 items), 1-factor solution for CES-D (13 items) and 4-factor solution for RAND SF-36 (26 items). The prevalence estimate of psychosocial disturbances was 34%, 10%, 2% (anxiety), 49%, 31%, 34% (depressive symptoms), and 46%, 37%, 59% (low QoL) for 1^st, 2^nd and 3^rd trimesters, respectively. Gestational age and food insecurity were significant predictors of depressive symptoms, anxiety symptoms and QoL.

Conclusions

In this population of Ghanaian women, the levels of depressive symptoms and low QoL observed across pregnancy should be recognized as major public health problems and efforts to address these should be put in place. Addressing food insecurity may be a major step to solve not only the physical needs of the pregnant woman but also the psychological needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13299-2.

Depression, anxiety and posttraumatic stress disorder six months following preeclampsia and normotensive pregnancy: a P4 study

Background

Mental health is an integral part of overall health. Mental health disorders following childbirth are common and poor maternal mental health has consequences for both the mother and her infant. Preeclampsia is also relatively common in pregnancy but there is little known about the intersection between these two important conditions. Gaining a better understanding of the psychological consequences following preeclampsia is important, especially the link with depression, anxiety and posttraumatic stress disorder. If women who experience preeclampsia are recognised as being at increased risk of poor mental health, targeted screening in the postpartum period should be implemented.

Aims

To describe the prevalence and symptom severity of depression, anxiety and posttraumatic stress disorder at six months postpartum in women, who had a diagnosis of preeclampsia, compared to those who had normal blood pressure in pregnancy.

Methods

The mental health component of the prospective cohort study, the Postpartum, Physiology, Psychology and Paediatric follow-up study (P4 Study) was used. Women diagnosed with preeclampsia (n = 90) and those who were normotensive during pregnancy (n = 302) completed the Edinburgh Postnatal Depression Scale, General Anxiety Disorder Scale, and the Posttraumatic Stress Diagnostic Scale or Posttraumatic Stress Diagnostic Sclae-5 at six months postpartum.

Results

At six months postpartum, depressive scores were similar in both groups but a higher proportion of women from the preeclampsia group scored above the threshold for depression (2% v 7% p = 0.04). There were no differences between the groups in the prevalence or severity of anxiety or PTSD. However, more women in the preeclampsia group reported their birth experience as a traumatic event (1% vs 7%, p = 0.01). On correlation testing and modelling, booking Edinburgh Postnatal Depression Scale score, any mental health history, experiencing birth as traumatic and the General Anxiety Disorder Scale score were independent predictors of postpartum Edinburgh Postnatal Depression Scale scores.

Conclusion

The postpartum clinical care of women with preeclampsia often focusses on the immediate physical health issues, but these women may also benefit from mental health screening. Targeted screening of preeclamptic women in the postpartum period may lead to more timely referral and initiation of treatment.

Trial registration

Retrospectively registered on 18/11/2013 with the Australian and New Zealand Clinical Trials Registry. Registration Number: ACTRN12613001260718.

Animal models of postpartum depression revisited

Postpartum depression (PPD) is a heterogeneous mood disorder and the most frequent psychiatric complication of the postnatal period. Given its potential long-lasting repercussions on the well-being of the mother and the infants, it should be a priority in public health. In spite of efforts devoted to clinical investigation and preclinical studies, the underlying neurobiological mechanisms of this disorder remain unknown in detail. Much of the progress in the area has been made from animal models, especially rodent models. The aim of this mini-review is to update the current rodent models in PPD research and their main contributions to the field. Animal models are critical tools to advance understanding of the pathophysiological basis of this disorder and to help the development of new therapeutic strategies. Here, we group PPD models into 2 main categories (Models based on hormone manipulations, Models based on stress exposure), each of which includes different paradigms that reflect risk factors or physiological conditions associated with this disease. Finally, we provide an overview of emerging models that provide new perspectives on the study of possible pathophysiological factors related to PPD, to contribute to tackling potential therapeutic targets.

One-year trajectories of postpartum depressive symptoms and associated psychosocial factors: findings from the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study

BACKGROUND

Trajectories of postpartum depressive symptoms up to 1 year after childbirth and the related risk factors remain unclear. Accordingly, this study aimed to examine the 1-year trajectories of postpartum depressive symptoms and their associated risk factors.

METHODS

A total of 22,493 pregnant women were recruited between July 2013 and September 2016 in the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study in Japan. Among them, 11,668 women with no missing data were included in the analyses. Depressive symptoms were assessed at 1 month and 1 year postpartum using the Edinburgh Postnatal Depression Scale. Multinominal logistic regression analysis was conducted after adjusting for covariates.

RESULTS

The prevalence of depression was 13.9% at 1 month and 12.9% at 1 year postpartum. We identified four depression trajectories, i.e., "persistent (depressed throughout the 1 year postpartum)" (6.0%), "recovered (depressed at 1 month postpartum and recovered within a year)" (7.9%), "late-onset (became depressed after 1 month postpartum)" (6.8%), and "resilient (not depressed throughout 1 year postpartum)" (79.2%). Psychological distress during pregnancy was significantly associated with all trajectories (persistent: odds ratio [OR]=10.24, 95% confidence interval (CI)=8.40-12.48; recovered: OR=3.78, 95%CI=3.28-4.36; and late-onset: OR=3.96, 95%CI=3.40-4.62).

LIMITATIONS

Postpartum depression was evaluated only by a self-administered questionnaire and the dropout rate was not neglectable.

CONCLUSIONS

This study highlighted the high prevalence of depressive symptoms at 1 year postpartum and found that half of the depressive symptoms at 1 year were late-onset. The findings suggest the necessity of long-term follow-up (up to 1 year) for perinatal mental health.

Accidental death during pregnancy and puerperium from 2009 to 2019 in Hunan, China: a cross-sectional study

OBJECTIVE

Few studies have analysed accidental maternal deaths. This study analysed the basic situation and classification of maternal accidental deaths and compared the differences between urban and rural areas.

DESIGN

A cross-sectional study on accidental deaths during pregnancy and puerperium from 2009 to 2019 in Hunan Province.

SETTING

Hunan Province, with a population of 74 million, has an area of 210 000 km² and 123 counties/districts.

PARTICIPANTS

A collection of 239 cases of accidental death during pregnancy and puerperium in Hunan Province from 2009 to 2019, including 181 cases of rural pregnancy and puerperium and 58 cases of urban pregnancy and puerperium.

MAIN OUTCOME MEASURE

Classification of accidental mortality of pregnant women.

RESULTS

A total of 239 accidental deaths occurred in Hunan Province, with an accidental mortality rate of 2.8 per 100 000 live births. The accidental mortality rate in rural areas (3.2 per 100 000 live births) was higher than in urban areas (2.0 per 100 000 live births). The proportion of accidental deaths among pregnancy-related deaths showed an upward trend. The main types of accidental deaths were suicide (1.0 per 100 000 live births), traffic accidents (0.8 per 100 000 live births), accidental poisoning/overdose and assault/homicide (0.2 per 100 000 live births), and other accidents (0.6 per 100 000 live births). Maternal accidental deaths were mainly concentrated in low-income families, in rural areas and in those with low level of education. 74.5% of accidental deaths occurred before childbirth. 49.2% of pregnant women gave birth by caesarean section.

CONCLUSION

In response to the different causes of accidental maternal death, public health programmes and policy interventions should pay special attention to maternal suicide and traffic injuries.

Prevalence and incidence of postpartum depression and environmental factors: The IGEDEPP cohort

BACKGROUND

IGEDEPP (Interaction of Gene and Environment of Depression during PostPartum) is a prospective multicenter cohort study of 3310 Caucasian women who gave birth between 2011 and 2016, with follow-up until one year postpartum. The aim of the current study is to describe the cohort and estimate the prevalence and cumulative incidence of early and late-onset postpartum depression (PPD).

METHODS

Socio-demographic data, personal and family psychiatric history, as well as stressful life events during childhood and pregnancy were evaluated at baseline. Early and late-onset PPD were assessed at 8 weeks and 1 year postpartum respectively, using DSM-5 criteria.

RESULTS

The prevalence of early-onset PPD was 8.3% (95%CI 7.3-9.3), and late PPD 12.9% (95%CI 11.5-14.2), resulting in an 8-week cumulative incidence of 8.5% (95%CI 7.4-9.6) and a one-year cumulative incidence of PPD of 18.1% (95%CI: 17.1-19.2). Nearly half of the cohort (N = 1571, 47.5%) had a history of at least one psychiatric or addictive disorder, primarily depressive disorder (35%). Almost 300 women in the cohort (9.0%) reported childhood trauma. During pregnancy, 47.7% women experienced a stressful event, 30.2% in the first 8 weeks and 43.9% between 8 weeks and one year postpartum. Nearly one in five women reported at least one stressful postpartum event at 8 weeks.

CONCLUSION

Incident depressive episodes affected nearly one in five women during the first year postpartum. Most women had stressful perinatal events. Further IGEDEPP studies will aim to disentangle the impact of childhood and pregnancy-related stressful events on postpartum mental disorders.

Who is the main caregiver of the mother during the doing-the-month: is there an association with postpartum depression?

BACKGROUND

To examine the relationship between the main caregiver during the "doing-the-month" (a traditional Chinese practice which a mother is confined at home for 1 month after giving birth) and the risk of postpartum depression (PPD) in postnatal women.

METHODS

Participants were postnatal women stayed in hospital and women who attended the hospital for postpartum examination, at 14-60 days after delivery from November 1, 2013 to December 30, 2013. Postpartum depression status was assessed using the Edinburgh Postnatal Depression Scale. Univariate and multivariable logistic regressions were used to identify the associations between the main caregiver during "doing-the-month" and the risk of PPD in postnatal women.

RESULTS

One thousand three hundred twenty-five postnatal women with a mean (SD) age of 28 (4.58) years were included in the analyses. The median score (IQR) of PPD was 6.0 (2, 10) and the prevalence of PPD was 27%. Of these postnatal women, 44.5% were cared by their mother-in-law in the first month after delivery, 36.3% cared by own mother, 11.1% by "yuesao" or "maternity matron" and 8.1% by other relatives. No association was found between the main caregivers and the risk of PPD after multiple adjustments.

CONCLUSIONS

Although no association between the main caregivers and the risk of PPD during doing-the-month was identified, considering the increasing prevalence of PPD in Chinese women, and the contradictions between traditional culture and latest scientific evidence for some of the doing-the-month practices, public health interventions aim to increase the awareness of PPD among caregivers and family members are warranted.

Prevalence of maternal antenatal and postnatal depression and their association with sociodemographic and socioeconomic factors: A multicentre study in Italy

BACKGROUND

Perinatal depression is a widespread and burdensome mental disorder. The objectives of this study were to assess the prevalence of both antenatal and postnatal depression in a large sample of women in Italy and to analyse their association with sociodemographic and socioeconomic factors.

METHODS

Cross-sectional data from eleven healthcare centres located throughout Italy (2017-2018) were analysed (n = 1471). Depressive disorder was assessed with the Edinburgh Postnatal Depression Scale (EPDS), and sociodemographic and socioeconomic factors were also measured. Prevalences by perinatal period and by sociodemographic and socioeconomic factors were estimated, and their associations were evaluated using logistic regression models. All analyses were stratified by perinatal period: antenatal (i.e., from conception to delivery) vs. postnatal (i.e., the nine months after delivery).

RESULTS

With a cut-off score set at 12 points, the prevalence of perinatal depression was 6.4% during pregnancy and 19.9% in the postnatal period, and the odds ratio for postpartum vs. antepartum depression was 3.65 (2.56-5.39). High economic status was associated with an approximate fivefold reduction in odds of depression in the antenatal period (ORa: 0.23, 95%CI: 0.10-0.54) and about a sixfold reduction in the postnatal period (ORa: 0.15, 95%CI: 0.05-0.45).

LIMITATIONS

The data were cross-sectional. The EPDS has a sensitivity of 55.6%.

CONCLUSION

The prevalence of perinatal depression in Italy is strongly associated with socioeconomic disadvantages. Early procedures to evaluate socioeconomic status and the provision of economical support for mothers might reduce the prevalence of perinatal depression and its direct and indirect costs.

Maternal depression symptoms during the first 21 months after giving birth

Aims:

The first year after childbirth involves a major transition for women, which can accentuate inadequacies and feelings of powerlessness, making them vulnerable to depression. The aim of this study was to investigate the prevalence and frequency of maternal postpartum depressive symptoms at different times after giving birth (0–21 months).

Methods:

Data were collected cross-sectionally using a web questionnaire containing the Edinburgh Postnatal Depression Scale (EPDS). A total of 888 mothers with children in the age range 0–21 months responded.

Results:

The results showed different levels of depression over the range of months included in the study. The overall prevalence using EPDS ⩾ 12 was 27.8%. There were higher levels at 9–12 months and 17–21 months. The highest levels of symptoms of depression were found at nine, 12, and 17 months after birth, and the lowest levels at two and 16 months.

Conclusions:

Many mothers experience symptoms of depression after giving birth that can continue well beyond the child’s first year. We have identified different levels of depression at different points in time after giving birth, with highs and lows throughout the first 21 months. This highlights a need to screen for depression more than once during the first years, as well as a closer cooperation between midwives and child healthcare nurses in supporting mothers in the transition to motherhood. This is an important aspect of public health, which not only involves mothers with symptoms of depression, but also their ability to care for their child and a possible negative impact on the child’s development.

The impact of introducing a national scheme for paid parental leave on maternal mental health outcomes

Paid maternity leave is an essential component of a progressive society. It can enhance postnatal health, improve mother and child wellbeing, and deliver better labor market outcomes for mothers. We evaluate the impact of the introduction of Australia's national Paid Parental Leave (PPL) scheme in 2011 and complementary Dad and Partner Pay (DAPP) in 2013 on maternal mental health. Using a sample of 1480 births to eligible, partnered women between 2004 and 2016 and examining a range of mental health outcomes from the Household, Income, andLabour Dynamics in Australia survey, we find depression likelihood reduced significantly in post-reform years. When focusing on post-DAPP years and women whose partners had concurrent access to DAPP, significant mental health improvements were found across a wider range of measures including the Mental Component Summary score and specific Short Form-36 items with a high sensitivity for detecting major depression. Subgroup analysis suggests significant improvements applied specifically to first-time mothers and mothers with employer-paid maternity leave and unpaid leave entitlements. These results suggest that an increase in PPL and DAPP entitlements for mothers without access to employer-paid and unpaid leave entitlements, particularly those in less secure employment, may further reduce postnatal depression and improve health equity in Australia.

Postnatal Depression Risk Factors: An Overview of Reviews to Inform COVID-19 Research, Clinical, and Policy Priorities

The disruption of normal life due to the COVID-19 pandemic is expected to exacerbate extant risk factors for mental health problems. This may be particularly true for women who give birth during the crisis, especially those at risk for postnatal depression. Maternal postnatal depression has been identified as a public health issue with profound impacts on maternal and child well-being. Evidence from previous crises (e.g., earthquakes, terrorist attacks) has shown that crises significantly impact maternal mental health and some perinatal health outcomes. The aims of this paper were therefore to conduct a review to identify the established risk factors for maternal postnatal depression, and generate evidence-based hypotheses about whether the COVID-19 crisis would likely increase or decrease postnatal depression rates based on the identified risk factors. Several databases were searched during May-June 2020 for review papers (i.e., systematic reviews, meta-analyses, qualitative syntheses) using the following keywords: Depression, perinatal, postnatal, postpartum, systematic, review, predictors. Risk factors were extracted in conjunction with indicators for their strength of evidence (i.e., effect sizes, qualitative coding). Risk factors were critically evaluated in relation to their susceptibility to the impacts of the COVID-19 crisis. It was hypothesized that several health policies that were necessary to reduce the spread of COVID-19 (e.g., required restrictions) may be simultaneously impacting a range of these known risk factors and placing a larger number of women at heightened risk for postnatal depression. For instance, factors at a strong risk of being exacerbated include: Perceived low social support; exposure to traumatic events during or prior to pregnancy; significant life events occurring during pregnancy; and high stress associated with care of children. Future research and policy implications are discussed, including how policy makers could attempt to ameliorate the identified risk factors for postnatal depression following the current COVID-19 pandemic.

Perinatal depression and anxiety of primipara is higher than that of multipara in Japanese women

The proportion of women who experience a depressive state after delivery differs between primiparas and multiparas, so it is important to clarify the different factors related to depression between the two groups. In this study, we confirmed the differences in depressive states, the perinatal period, and social support between primiparas and multiparas, and clarified their characteristics. Data were extracted from a prospective cohort questionnaire survey conducted on pregnant women in Japan that included sociodemographic questions, the Edinburgh Postnatal Depression Scale, and the Japanese version of the Social Support Questionnaire. We carried out the chi-square test, Student's t-test, and analysis of covariance to compare responses between primiparas and multiparas. A total of 1138 primiparas and 380 multiparas provided valid responses. We found that primiparas had higher rates of experiencing maternity blues and postpartum depression than multiparas. We also found that primiparas had higher anxiety scores than multiparas. Primiparas with postpartum depression perceived a lower number of persons available to provide social support than primiparas without postpartum depression. These findings suggest that it is important to provide pregnant women, especially for primiparas, with information that allows them to increase the number of people who can provide them with support.

Sense of Coherence Mediates the Links between Job Status Prior to Birth and Postpartum Depression: A Structured Equation Modeling Approach

Postpartum depression (PPD) has detrimental effects on the health of the mother, child and family. Socio-demographic variables can influence PPD. Sense of coherence (SOC) is a personal resource that mitigates the experience of stressful events. We hypothesized that SOC would have a protective effect against PPD over time. The aim was to investigate the effects of socio-demographic factors and SOC on PPD at birth (T1) and nine months postpartum (T2). A longitudinal study of primiparous women (n = 114; age range 18-47 years) measured PPD, SOC and socio-demographics at T1 and T2. The majority were married, had no economic difficulties and were employed before birth. Results showed that PPD at T1 (15.8%) declined to 6.2% (T2). Job status was positively associated with SOC at T1. The structured equation model accounted for 27% of the variance in PPD (T2). In the first pathway, job status was linked to PPD (T2) via SOC at T1 and T2. In the second, SOC and PPD (T1) and SOC (T2) mediated the link between job status and PPD (T2). Results and clinical implications are discussed in the context of the theory of conservation of resources. An intervention for enhancing SOC is recommended for woman at risk of PPD.

Prevalence of Positive Mental Health and Associated Factors Among Postpartum Women in Canada: Findings from a National Cross-Sectional Survey

Objectives

The objectives of this study were to compare the prevalence of three positive mental health (PMH) outcomes (self-rated mental health, life satisfaction, sense of community belonging) in postpartum women to the general population, and to examine the relationship between protective factors and the three PMH outcomes among postpartum women.

Methods

The national cross-sectional Survey on Maternal Health (n = 6558) was analyzed. Analyses were weighted and 95% confidence intervals were calculated. Three adjusted logistic regression models were generated. To compare this sample to the general population of women, estimates from the Canadian Community Health Survey—Annual Component (2018) were used.

Results

Compared to the general population of women, a larger proportion of postpartum women reported a strong sense of community belonging. The odds of postpartum women with high self-rated physical health having high self-rated mental health were approximately seven times greater (aOR 6.9, 95% confidence interval [CI] 5.9, 8.1) than postpartum women with lower self-rated physical health. The absence of symptoms of postpartum depression (PPD) or generalized anxiety disorder (GAD) and high self-rated physical health were significantly associated with all three PMH outcomes. Frequent availability of maternal support was associated with greater odds of high life satisfaction (aOR 1.6, 95% CI 1.4, 1.9) and sense of community belonging (aOR 1.4, 95% CI 1.2, 1.6).

Conclusions

Our study demonstrated that availability of maternal support, self-rated physical health and absence of symptoms of PPD or GAD were associated with PMH among postpartum women. As physical health had the strongest association with mental health, we encourage further examination of this relationship.

Electronic supplementary material

The online version of this article (10.1007/s10995-020-02920-8) contains supplementary material, which is available to authorized users.

Economic burden of maternal morbidity - A systematic review of cost-of-illness studies

Aim

To estimate the economic burden of common health problems associated with pregnancy and childbirth, such as incontinence, mental health problems, or gestational diabetes, excluding acute complications of labour or birth, or severe acute adverse maternal outcomes.

Methods

Searches for relevant studies were carried out to November 2019 in Medline, Embase, CINAHL, PsycINFO and EconLit databases. After initial screening, all results were reviewed for inclusion by two authors. An adapted version of a previously developed checklist for cost-of-illness studies was used for quality appraisal. All costs were converted to 2018 Euro using national consumer price indices and purchasing power parity conversion factors.

Results

Thirty-eight relevant studies were identified, some of which reported incremental costs for more than one health problem (16 gestational diabetes, 13 overweight/obesity, 8 mental health, 4 hypertensive disorders, 2 nausea and vomiting, 2 epilepsy, 1 intimate partner violence). A high level of heterogeneity was observed in both the methods used, and the incremental cost estimates obtained for each morbidity. Average incremental costs tended to be higher in studies that modelled a hypothetical cohort of women using data from a range of sources (compared to analyses of primary data), and in studies set in the United States. No studies that examined the economic burden of some common pregnancy-related morbidities, such as incontinence, pelvic girdle pain, or sexual health problems, were identified.

Conclusion

Our findings indicate that maternal morbidity is associated with significant costs to health systems and society, but large gaps remain in the evidence base for the economic burden of some common health problems associated with pregnancy and childbirth. More research is needed to examine the economic burden of a range of common maternal health problems, and future research should adopt consistent methodological approaches to ensure comparability of results.

Depression Following Major Life Transitions in Women: A Review and Theory

Depression can occur due to common major life transitions, such as giving birth, menopause, retirement, empty-nest transition, and midlife crisis. Although some of these transitions are perceived as positive (e.g., giving birth), they may still lead to depression. We conducted a systematic literature review of the factors underlying the occurrence of depression following major life transition in some individuals. This review shows that major common life transitions can cause depression if they are sudden, major, and lead to loss (or change) of life roles (e.g., no longer doing motherly or fatherly chores after children leave family home). Accordingly, we provide a theoretical framework that explains depression caused by transitions in women. One of the most potential therapeutic methods of ameliorating depression associated with life transitions is either helping individuals accept their new roles (e.g., accepting new role as a mother to ameliorate postpartum depression symptoms) or providing them with novel life roles (e.g., volunteering after retirement or children leave family home) may help them overcome their illness.

Perinatal maternal mental health and infant socio-emotional development: A growth curve analysis using the MPEWS cohort

Pregnancy and the early post partum period are widely understood as a critical period for the infant's emotional development and the earliest influence shaping social interaction. The present study aims to understand the potential influence of both antenatal and postnatal maternal anxiety and depressive symptoms on socio-emotional outcomes in offspring aged 12 months. The study used longitudinal data from a prospective cohort study on Australian pregnant women and their children. Data were available for 282 mothers and their children. Maternal depressive and anxiety symptoms were measured in early pregnancy, trimester three of pregnancy, six and 12 months postpartum. Social and emotional development in children was measured using the Brief Infant and Toddler Social Emotional Assessment (BITSEA) at 12 months. Using growth curve analysis of 4 waves of repeated measurement to examine intercept and slope, we found that both initial maternal depression and anxiety symptom levels, and the growth of these symptoms over time, predicted more problems with children's social and emotional development. In the final model anxiety accounted for 19% of the variance in child socio-emotional problems and depression 23% of variance. The results emphasise the importance of perinatal maternal mental health as a potential risk factor for child development. This carries important implications for policy development, such as the need to build early identification and early intervention models in to the current clinical practice for perinatal care, specifically, to develop targeted screening, assessment and interventions to address maternal mental health issues for at-risk parents during pregnancy, and continuing monitoring of young children whose mothers have experienced perinatal mental health difficulties.

The role and competence of midwives in supporting women with mental health concerns during the perinatal period: A scoping review

Perinatal mental health problems are linked to poor outcomes for mothers, babies and families. Despite a recognition of the significance of this issue, women often do not receive the care they need and fall between the gap of maternity and mental health services. To address this, there is a call for reform in the way in which perinatal mental healthcare is delivered. This paper responds to this by exploring the role and competence of midwives in delivering mental healthcare. Using a scoping review methodology, quantitative and qualitative evidence were considered to answer the research question 'what is the nature of the evidence relevant to the provision of mental health interventions by midwives?' To identify studies, the databases PubMed, Maternity and Infant Care, Science Citation Index, Social Sciences Citation Index, Medline, Science Direct and CINAHL were searched from 2011 to 2018, and reference lists of included studies were examined. Studies relevant to the role of midwives in the management and treatment of perinatal mental health issues were included; studies focussed on screening and referral were excluded. Thirty papers met inclusion criteria, including studies about the knowledge, skills, and attitudes of midwives and student midwives; the effectiveness of educational interventions in improving knowledge and skills; the delivery of counselling or psychosocial interventions by midwives; and barriers and enablers to embedding midwife-led mental healthcare in practice. Synthesis of the included studies indicates that midwives are interested in providing mental health support, but lack the confidence, knowledge and training to do so. This deficit can be addressed with appropriate training and organisational support, and there is some evidence that midwife-led counselling interventions are effective. Further research is needed to test midwife-led interventions for women with perinatal mental health problems , and to develop and evaluate models of integrated perinatal mental healthcare.

How does perinatal maternal mental health explain early social inequalities in child behavioural and emotional problems? Findings from the Wirral Child Health and Development Study

BACKGROUND

This study aimed to assess how maternal mental health mediates the association between childhood socio-economic conditions at birth and subsequent child behavioural and emotional problem scores.

METHODS

Analysis of the Wirral Child Health and Development Study (WCHADS), a prospective epidemiological longitudinal study of the early origins of child mental health (n = 664). Household income at 20-weeks gestation, a measure of socio-economic conditions (SECs) in pregnancy, was the main exposure. The outcome measure was externalising and internalising problems, as measured by the Child Behaviour Checklist at 5 years. We assessed the association of household income with child behavioural outcomes in sequential linear models adjusting for maternal mental health in the pre- and post- natal period.

RESULTS

Children of mothers in more disadvantaged households had higher scores for externalising behaviour with a difference of 3.6 points comparing the most affluent to the most disadvantaged families (the socio-economic (SEC) gap). In our regression model adjusting for baseline confounders, comparing children of mothers in the most disadvantaged households to the least disadvantaged, we found that most disadvantaged children scored 45 percentage points (95% CI 9, 93) higher for externalising problems, and 42% of this difference was explained in the fully adjusted model. Adjusting for prenatal maternal depressive symptomology attenuated the SEC gap in externalising problems by about a third, rendering the association non-significant, whilst adjusting for pre- and post-natal maternal mental health attenuated the SEC gap by 42%. There was no significant relationship between household income and internalising problems.

CONCLUSION

Social disadvantage is associated with higher child externalising behaviour problems score at age 5, and about 40% of this was explained by maternal perinatal mental health. Policies supporting maternal mental health in pregnancy are important to address the early emergence of inequalities in child mental health.

Engagement with perinatal mental health services: a cross-sectional questionnaire survey

BACKGROUND

Perinatal depression and/or anxiety disorders are undertreated pregnancy complications. This is partly due to low rates of engagement by women. This study aimed to identify barriers and facilitators to women accessing perinatal mental health services in an outer metropolitan hospital in Queensland, Australia.

METHODS

Data was collected from pregnant women through a cross-sectional survey. Women rated the extent certain factors influenced their engagement. Respondents were separated into three groups: women who were not offered a referral to perinatal mental health services, women who were offered a referral but did not engage, and women who engaged.

RESULTS

A total of 218 women participated. A response rate of 71% was achieved. 38.1% of participants did not believe themselves knowledgeable about mental illness in the perinatal period, and 14.7% did not recall being asked about their mental health during their pregnancy. Of those participants who recalled being asked about their mental health, 37.1% were offered a referral. Of these, just over a third (36.2%) accepted, and out of this group, 40% attended an appointment. Regardless of referral and engagement status, the factors identified as influencing participant engagement were time restraints, lack of childcare support, and encouragement by family and health care professionals. Stigma was not identified as a barrier.

CONCLUSIONS

Perinatal mental health service engagement could be improved by health services: ensuring universal screening and actively engaging women in the process: assisting with childcare; improving appointment immediacy and accessibility; and educating health care professionals about their influence on women's engagement.

'I need help': Reasons new and re-engaging callers contact the PANDA-Perinatal Anxiety and Depression Australia National Helpline

In Australia, the PANDA-Perinatal Anxiety & Depression Australia National Helpline (the Helpline) offers support to callers impacted by emotional health challenges in the perinatal period. Callers receive counselling from professional staff and peer support from volunteers. An understanding of factors that contribute to callers' experiences of emotional distress, as well as potential barriers and facilitators to help-seeking, can be used to inform future service design and delivery. A caller intake form is completed by Helpline staff when an individual contacts the service for the first time, or re-engages after a period of non-contact. We analysed all intake forms of individuals calling about their own emotional wellbeing from the middle month of each season in 2014: January, April, July, and October. Content analysis was undertaken, focusing on caller profile, patterns of help-seeking, and reasons for caller engagement. Of the 365 calls, the majority were from women (n = 358, 98%) who were pregnant (n = 59, 16%) or had a child ≤12 months of age (n = 241, 75%). Many were seeking support regarding depression (n = 186, 51%) or anxiety (n = 162, 44%), with a number seeking help for both (n = 71, 20%). Almost a third were identified as being 'at risk', including a number who were experiencing thoughts of suicide or self-harm. Complex interrelating factors contributed to callers' emotional distress, including: stressful life events; pregnancy, birthing and parenting experiences; social isolation; and histories of mental health difficulties. Significant numbers of parents experience emotional health challenges in the perinatal period, but many do not receive adequate treatment. Complex factors contribute to callers' distress, highlighting the need for health professionals to undertake thorough psychosocial assessments during the perinatal period so those that need additional support are identified, and appropriate care provided. Telephone Helplines like PANDAs assist overcoming barriers to care and provide specialised perinatal mental health support to families.

Impact of infant crying on mothers with a diagnosis of borderline personality disorder: A qualitative study

Mothers with borderline personality disorder (BPD) and their infants often have compromised relationships. To further understand the complexities, this study explored (a) the experiences of mothers with BPD in response to infant crying and (b) how these parenting responses impact on mothers' interpersonal functioning with significant others. Six mothers with clinical BPD were recruited from a mother-baby psychiatric unit and interviewed using an interpretative phenomenological analysis (IPA) approach. Transcripts of the semistructured interviews were coded for themes and subthemes. Dominant themes revealed that mothers with BPD entered motherhood in a psychologically fragile state, hypersensitive to experiencing intense physiological-emotional pain and cognitive chaos in response to infant crying. Automatic maladaptive flight-fright responses including suicide attempts were common. A novel theme revealed some mothers' split identity, and only the "mother" part could attend to infant crying. Finally, the data provided an understanding of the detrimental domino effect on close family. Mothers also highlighted gaps in accessibility of current mental health services and parenting programs, and their desire to prevent the intergenerational transmission of attachment problems and BPD symptoms to offspring. Clinical implications include antenatal BPD screening, psychoeducation about infant crying, and greater access for programs supporting the whole family to improve outcomes.

Does Antenatal Social Support Affect the Relationships Between Intimate Partner Violence During Pregnancy And Perinatal Mental Health?

Intimate partner violence (IPV) causes adverse perinatal mental health outcomes; however, few studies have identified why. We focused on antenatal social support to reveal how it affects the relationship between IPV during pregnancy and mental health outcomes. A prospective cohort study was conducted during the third trimester and 1-month postnatal. The relationship between IPV during pregnancy and antenatal depressive symptoms, which were associated with mother–infant bonding failure and postnatal depressive symptoms, was affected by mother’s satisfaction with antenatal social support. Perceived social support for abused women must be increased to prevent antenatal depressive symptoms and adverse postnatal mental health outcomes.

Physical discomfort in early pregnancy and postpartum depressive symptoms

PURPOSE

Pregnancy examinations conducted in general practice focus mainly on identifying high-risk pregnancies and pregnancy complications. The pregnancy health record has a biomedical focus, and consequently the woman's mental well-being may receive less attention. The aim of this study was to evaluate the extent to which early pregnancy-related symptoms should be considered as indicators of an increased risk of postpartum depression.

MATERIALS AND METHODS

For a prospective cohort of 1508 pregnant women, the presence of 11 pregnancy-related symptoms was recorded at the first prenatal care consultation together with background information about socio-demography and health. Depression was assessed 8 weeks postpartum with the major depression inventory (MDI) and depression was considered present if MDI > 20. Multivariable logistic regression was used to assess the association between pregnancy-related symptoms and postpartum depressive symptoms, and to adjust for potential confounders.

RESULTS

A high depression score (MDI score >20) 8 weeks postpartum was found among 6.6% of the women and showed apparent associations with physical discomfort in early pregnancy, such as back pain and pelvic cavity pain. Analysis of confounding revealed, however, that signs of vulnerable mental health, present in early pregnancy, explained most of these associations.

CONCLUSIONS

Indicators of an increased risk of postpartum depressive symptoms may be found in early pregnancy. Pregnancy-related pain in the first trimester may be a sign of psychological vulnerability or an aspect of an existing depressive state that calls for attention.

Illawarra Born cross-generational health study: feasibility of a multi-generational birth cohort study

Background

There is a strong interest in the concept of developmental origins of health and disease and their influence on various factors “from cradle to grave”. Despite the increasing appreciation of this lifelong legacy across the human life course, many gaps remain in the scientific understanding of mechanisms influencing these formative phases. Cross-generational susceptibility to health problems is emerging as a focus of research in the context of birth cohort studies.

The primary aim of the Illawarra Born study is to make scientific discoveries associated with improving health and wellbeing across the lifespan, with a particular focus on preventable chronic diseases, especially mental health. This birth cohort study will follow and collect data from three cohorts representing different stages across the lifespan: infants, adults (parents) and older adults (grandparents). The multi-generational, cross-sectional and longitudinal design of this birth cohort study supports a focus on the contributions of genetics, environment and lifestyle on health and wellbeing. The feasibility of conducting a multi-generational longitudinal birth cohort project was conducted through a small pilot study.

Methods/design

The purpose of this paper is to report on the feasibility and acceptability of the research protocol for a collaborative cross-generation health study in the community and test recruitment and outcome measures for the main study. This feasibility study included pregnant women who were intending to give birth in the Illawarra-Shoalhaven region in Eastern Australia. The area includes a large, regional referral hospital, with capacity to treat specialist and complex cases. Pregnant women were asked to participate in five data collection waves beginning at 22 weeks gestation and ending with a 6-month post-partum appointment. Recruitment was then extended, via the pregnant women, to also include fathers and maternal grandmothers.

Discussion

This feasibility study focused on the perinatal period and collected data across three multi-disciplinary domains including mental health, diet, exposures to toxins and the role of these in maternal and infant outcomes. Forty-one families participated in extensive data collection from 22 weeks gestation to 6-months post-partum. Factors impacting on viability and feasibility including recruitment solutions provide the basis for a large-scale study.

The frequency of maternal morbidity: A systematic review of systematic reviews

Background

Estimates of the burden of maternal morbidity are patchy.

Objective

To conduct a systematic review of systematic reviews of maternal conditions to: (1) make available the most up‐to‐date frequency estimates; (2) identify which conditions do not have reliable estimates; and (3) scrutinize the quality of the available reviews.

Search strategy

We searched Embase, MEDLINE, and CINAHL, combining terms for pregnancy, frequency (e.g. prevalence, incidence), publication type, and specific terms for each of 121 conditions.

Selection criteria

We included peer‐reviewed systematic reviews aiming to estimate the frequency of at least one of the conditions in WHO's list of maternal morbidities, with estimates from at least two countries.

Data collection and analysis

We present the frequency estimates with their uncertainty bounds by condition, region, and pregnancy/postpartum period. We also assess and present information on the quality of the systematic reviews.

Main results

Out of 11 930 found, 48 reviews were selected and one more was added. From 49 reviews we extracted 34 direct and 60 indirect frequency estimates covering 35 conditions. No review was available for 71% of the conditions on the WHO list. The extracted estimates show substantial maternal morbidity, spanning the time before and beyond childbirth. There were several gaps in the quality of the reviews. Notably, one‐third of the estimates were based only on facility‐based studies.

Conclusions

Good‐quality systematic reviews are needed for several conditions, as a research priority.

This study highlights that substantial maternal morbidity occurs along the pregnancy–postpartum continuum, and that conducting quality systematic reviews is a priority research gap.

'Modelling a Secure-Base' for Women with Complex Needs: Attachment-Based Interventions Used by Perinatal and Infant Mental Health Clinicians

Infant well-being is intrinsically linked to maternal physical and emotional well-being. Internationally health services have implemented policies to identify women at risk of mental health problems and developed effective care pathways. The aim of this paper is to describe how perinatal and infant mental health clinicians perceive their role and the attachment-based interventions they use in their work. The study comes from a larger mixed methods study, which examined two specialist perinatal and infant mental health services in New South Wales (Australia). Two hundred and forty-four medical records were reviewed, and six perinatal and infant mental health clinicians participated in in-depth semi-structured interviews. Data were analysed by content and thematic analysis. One overarching theme, modelling a secure base and three supporting themes, enhancing reflective capacity, enhancing emotional regulation and enhancing empathy emerged from the analysis. These findings demonstrate how perinatal and infant mental health clinicians use attachment theory to inform practice by modelling "holding" and being a secure-base for women. They also provide a clearer understanding of perinatal mental health practice and can be used to inform educational programs for multidisciplinary mental health professionals particularly those working with women and infants.

Identifying perinatal depression with case-finding instruments: a mixed-methods study (BaBY PaNDA – Born and Bred in Yorkshire PeriNatal Depression Diagnostic Accuracy)

Background

Perinatal depression is well recognised as a mental health condition but < 50% of cases are identified in routine practice. A case-finding strategy using the Whooley questions is currently recommended by the National Institute for Health and Care Excellence.

Objectives

To determine the diagnostic accuracy, acceptability and cost-effectiveness of the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to identify perinatal depression.

Design

A prospective diagnostic accuracy cohort study, with concurrent qualitative and economic evaluations.

Setting

Maternity services in England.

Participants

A total of 391 pregnant women.

Main outcome measures

Women completed the Whooley questions, EPDS and a diagnostic reference standard (Clinical Interview Schedule – Revised) during pregnancy (20 weeks) and postnatally (3–4 months). Qualitative interviews were conducted with health professionals (HPs) and a subsample of women.

Results

Diagnostic accuracy results: depression prevalence rates were 10.3% during pregnancy and 10.5% postnatally. The Whooley questions and EPDS (cut-off point of ≥ 10) performed reasonably well, with comparable sensitivity [pregnancy: Whooley questions 85.0%, 95% confidence interval (CI) 70.2% to 94.3%; EPDS 82.5%, 95% CI 67.2% to 92.7%; postnatally: Whooley questions 85.7%, 95% CI 69.7% to 95.2%; EPDS 82.9%, 95% CI 66.4% to 93.4%] and specificity (pregnancy: Whooley questions 83.7%, 95% CI 79.4% to 87.4%; EPDS 86.6%, 95% CI 82.5% to 90.0%; postnatally: Whooley questions 80.6%, 95% CI 75.7% to 84.9%; EPDS 87.6%, 95% CI 83.3% to 91.1%). Diagnostic accuracy of the EPDS (cut-off point of ≥ 13) was poor at both time points (pregnancy: sensitivity 45%, 95% CI 29.3% to 61.5%, and specificity 95.7%, 95% CI 93.0% to 97.6%; postnatally: sensitivity 62.9%, 95% CI 44.9% to 78.5%, and specificity 95.7%, 95% CI 92.7% to 97.7%). Qualitative evaluation: women and HPs were supportive of screening/case-finding for perinatal depression. The EPDS was preferred to the Whooley questions by women and HPs, mainly because of its ‘softer’ wording. Whooley question 1 was thought to be less acceptable, largely because of the terms ‘depressed’ and ‘hopeless’, leading to women not revealing their depressive symptoms. HPs identified a ‘patient-centred’ environment that focused on the mother and baby to promote discussion about mental health. Cost-effectiveness results: screening/case-finding using the Whooley questions or the EPDS alone was not the most cost-effective strategy. A two-stage strategy, ‘Whooley questions followed by the Patient Health Questionnaire’ (a measure assessing depression symptomatology), was the most cost-effective strategy in the range between £20,000 and £30,000 per quality-adjusted life-year in both the prenatal and postnatal decision models.

Limitations

Perinatal depression diagnosis was not cross-referenced with women’s medical records so the proportion of new cases identified is unknown. The clinical effectiveness and cost-effectiveness of screening/case-finding strategies was not assessed as part of a randomised controlled trial.

Conclusions

The Whooley questions and EPDS had acceptable sensitivity and specificity, but their use in practice might be limited by low predictive value and variation in their acceptability. A two-stage strategy was more cost-effective than single-stage strategies. Neither case-finding instrument met National Screening Committee criteria.

Future work

The yield of screening/case-finding should be established with reference to health-care records. The clinical effectiveness and cost-effectiveness of screening/case-finding for perinatal depression needs to be tested in a randomised controlled trial.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

An evaluation of routine antenatal depression screening and psychosocial assessment in a regional private maternity setting in Australia

BACKGROUND

There is limited information relating to routine depression screening and psychosocial assessment programs in private maternity settings in Australia.

AIMS

To describe the psychosocial profile of a sample of private maternity patients who participated in a depression screening and psychosocial risk assessment program as part of routine antenatal care, and to explore women's experience of receiving this component of pregnancy care.

MATERIALS AND METHODS

We conducted a retrospective medical records audit of 455 consecutive women having a routine psychosocial assessment and referral. Assessment was undertaken using the Edinburgh Postnatal Depression Scale (EPDS) and the Antenatal Risk Questionnaire (ANRQ) for psychosocial risk; 101 women completed a feedback survey about their experience of receiving routine psychosocial care.

RESULTS

Of the 87.7% of women who completed both EPDS and ANRQ, 4.3% scored 13 or more on the EPDS. On the ANRQ, 25.3% of women endorsed one risk factor, 11.6% two risk factors and 10.5% three or more risk factors. Elevated EPDS scores were associated with major stresses in the last 12 months, high trait anxiety and significant past mental health issue/s. Acceptability of depression screening and psychosocial risk assessment was high.

CONCLUSIONS

This study highlights the need for, and acceptability of, depression and psychosocial assessment in the private maternity sector. These findings are particularly timely given the provision of new Medicare Benefits Scheme items for obstetricians to undertake psychosocial assessment (both antenatally and postnally) in line with recommended clinical best practice.

Commonly occurring adverse birth outcomes and maternal depression: a longitudinal study

OBJECTIVES

Little is known about whether commonly occurring adverse birth outcomes have a long-term impact on the mental health of mothers. The aim of this study was to investigate whether commonly occurring adverse birth outcomes predicted mothers' depressive-symptom trajectories over a 27-year period following the birth of a baby.

STUDY DESIGN

Longitudinal study.

METHODS

Participants comprised a sub-group of women from the longitudinal cohort of the Mater and University of Queensland Study of Pregnancy. Maternal depression was measured at six time points from the first clinic visit of an index pregnancy to 27 years after birth. A semi-parametric mixture model was used to identify three symptom trajectories of low-stable, moderate-stable and moderate-rising depression. Multinomial logistic regression was then used to determine whether a number of commonly occurring birth outcomes predicted moderate-stable and/or moderate-rising depression trajectories over the subsequent 27 years. Sociodemographic and behavioural factors were used to adjust for possible confounding.

RESULTS

After adjustment for potential confounders, none of the adverse birth outcomes predicted subsequent maternal depression trajectories. Teenage pregnancy, not completing high school, low family income, obesity, poorer quality partnership and not exercising, measured at women's first clinic visit, and small social networks at three to five days after birth, were significantly associated with women's moderate-rising depressive-symptoms trajectory over 27 years.

CONCLUSIONS

Commonly occurring adverse birth outcomes do not predict long-term depressive trajectories. A number of sociodemographic and behavioural factors present at the index pregnancy predict women's long-term pattern of depression throughout their reproductive life course.