Depression is a condition that affects millions of people worldwide and is the highest cause of disease burden in women (Dennis and Dowswell, 2013). Postnatal depression has been defined by Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a major depressive condition that occurs in the 1-year period following childbirth, and is the most common condition affecting women during the perinatal period (Brealey et al, 2010). It is estimated that postnatal depression affects up to 25% of all childbearing women; however, its prevalence is often under-detected and under-diagnosed (Joseph, 2014). Postnatal depression is most prevalent within the first 3 months postpartum; with a peak onset at 4–6 weeks (Brealey et al, 2010). It is a significant public health concern as it is associated with impairment of the parental care of the child and is associated with long-term adverse effects on the child's growth and development (World Health Organization (WHO), 2012). Due to the impact that postnatal depression has on women, their children and their families, early screening, detection and intervention for all childbearing women is essential. There is evidence to promote the use of preventative interventions to reduce the onset of postnatal depression and the subsequent adverse effects associated with the condition.
In Australia, screening for postnatal depression is routine and is believed to be effective in the early detection of the disease, which enables prompt intervention and ultimately enhances outcomes for women and their children (Grussu and Quatraro, 2014). However, routine screening, universal in Australia and the US, is not standard practice in the UK.
The purpose of this paper is to provide midwifery students, newly qualified midwives and experienced midwives with an opportunity to develop and update their skills and knowledge on postnatal depression.
Background
Postnatal depression affects women from all socioeconomic and cultural backgrounds (Kim et al, 2014). However, there are certain factors that are believed to be positive indicators for developing postnatal depression, these include: a history of depressive or anxiety disorders, reduced self-esteem, increased social stressors, marital problems, lack of social support networks and low socioeconomic status (McLoughlin, 2013). It is also understood that women with a history of antenatal depression or previous postnatal depression are at significantly higher risk of developing postnatal depression (Jones et al, 2012).
Further risk factors for postnatal depression include women who are single, smoke cigarettes, are multiparous and report high levels of perceived stress (Guida et al, 2012), nutritional deficiencies, sleep impairment, history of assisted reproductive treatment and history of traumatic and complicated birth experiences (Ko et al, 2012).
Depression can have substantial adverse effects on a woman's health during the perinatal period. There are many adverse effects associated with postnatal depression on maternal wellbeing such as altered mood, sleep impairment, anorexia, impaired cognitive abilities and suicidal ideation (Miller et al, 2013). Postnatal depression is further linked with impaired maternal care of baby, reduced breastfeeding rates, lower rates of immunisation and poor compliance to safety such as car seat compliance (Sockol et al, 2011). Postnatal depression can have fatal ramifications and is associated with high rates of maternal suicide and, more rarely, infanticide (Miller et al, 2013). It is therefore imperative that midwives continually update their knowledge to recognise and facilitate care of women with postnatal depression.
Pharmacological interventions for preventing postnatal depression
It is well documented that pharmacological therapies such as antidepressants are effective in the treatment of depression and postnatal depression; however, there is evidence to suggest that a pharmacological treatment can also be effective in the prevention of postnatal depression (Smith and Rudolph, 2012). There have been positive results for the prevention of postnatal depression in a randomised, placebo-controlled trial using the antidepressant sertraline (Kim et al, 2014). This study found that women with a history of postnatal depression had a significant (43%) reduction in risk for developing further postnatal depression vs the placebo group. However, the use of antidepressants during the perinatal period is controversial as there are many contraindications with antidepressant therapy—pregnancy and breastfeeding (Miniati et al, 2014). Many women are hesitant to use antidepressants during pregnancy and while breastfeeding for fear of harm and long-term effects on the baby. Midwives should be aware of antidepressant therapies and provide appropriate education regarding efficacy and side effects, as well as education on antidepressant therapy and breastfeeding.
Non-pharmacological interventions for prevention of postnatal depression
An alternative treatment for the prevention of postnatal depression is the supplementation of omega-3 polyunsaturated fatty acids (PUFAs). Kaviani et al (2014) found a correlation between insufficient omega-3 maternal blood levels in the third trimester and the onset of depressive symptoms postpartum. However, according to another randomised control-led trial, the supplementation of PUFAs were found to have limited efficacy in the prevention of postnatal depression (Kim et al, 2014); and is therefore not supported as a preventive intervention. This is consistent with results from a Cochrane review (Miller et al, 2013), which found that omega-3 fatty acids had an insignificant impact on the prevention of postnatal depression.
Peer-support telephone programmes are likely to help prevent postnatal depression
There is substantial evidence to support that increased maternal social support can provide protection against the development of postnatal depression (Hahn-Holbrook et al, 2013). Women who receive adequate support, specifically from their partner, report less stress in their personal relationship, which in turn provides protection against the development of postnatal depression. Involvement of partner and family in antenatal care and antenatal education can have a positive impact on a woman's health and wellbeing (Morton, 2014). It is argued that women who accept additional social support and are satisfied with the quality of the assistance are less likely to develop postnatal depression (Saligeh et al, 2014). It is important for the midwife to assess a woman's social support network, encourage involvement of partners or immediate family during antenatal care and have an awareness of interventions that can enhance women's support systems.
One such intervention to enhance maternal social support likely to be associated with the prevention of postnatal depression, is peer-support telephone programmes. A recent trial was conducted that evaluated the development and implementation of a peer-support telephone-based programme (Dennis, 2014). The trial involved telephone contact provided by volunteers to new mothers following discharge from hospital, to assess for depressive symptoms and provide appropriate support. It demonstrated cost-effectiveness as well as high levels of satisfaction from both telephone support programme volunteers and women; and is recommended as a framework for further development of telephone-based support for women at high risk of developing postnatal depression.
There is also mounting evidence regarding psychological interventions for the prevention of postnatal depression such as cognitive behaviour therapy. Cognitive behaviour therapy is a psychological intervention that focuses treatment on adapting a person's behaviours, emotions and thought processes; and is hypothesised to be beneficial in the prevention of postnatal depression (Bittner et al, 2014). Cognitive behaviour therapy may be effective in reducing depressive and anxiety symptoms in pregnant women, if conducted in the antenatal period. It can also be modified to be culturally sensitive and acceptable to woman from different backgrounds. A combination of technology and cognitive behaviour therapy in the form of an online programme exists, and may be effective in the prevention of postnatal depression for at risk women (Schneider et al, 2014). The online programme is easily accessible and free to use; it yielded positive results from scientific trials in reducing symptoms of anxiety and depression for up to 12 months. A short cognitive behaviour therapy training course for midwives, especially those working in a community setting, may be beneficial in enhancing the management of women at risk of postnatal depression. Midwives should be aware of some of the psychological interventions such as cognitive behaviour therapy as well as any psychological interventions that are technology-based.
As well as psychological and psychosocial interventions, it is argued that regular antenatal exercise may be effective in reducing women's risk of developing postnatal depression. There is a correlation between sedentary activity of women during pregnancy and development of postnatal depression: pregnant women who exercise less than 1 day per week have an increased risk of developing postnatal depression by 34% according to Guida et al (2012). Pregnant women who participate in regular moderate intensity physical activity have an enhanced general sense of wellbeing and improved perceptions of health status. Therefore, midwives should discuss the potential benefits of physical activity with women, including the decreased risk of developing postnatal depression and recommendation of light-to-moderate exercise.
The Edinburgh Postnatal Depression Scale (EPDS) is the recommended tool for universal screening of depression in women during the perinatal period (Joseph, 2014). The EPDS provides a risk score, which is then used to determine appropriate care and management; including referral and follow-up. A score of 10–12 should require follow-up and reassessment while a positive indication of thoughts of self-harm requires immediate follow-up and referral. It is important to note that the EPDS along with other screening tools only provide an indication of risk for depression; they are not diagnostic tools and should be used in conjunction with clinical assessment (Daniels, 2013).
There is substantial evidence to support the use and efficacy of the EPDS, and women and health professionals have reported positively on the ease of use, understanding and appropriateness of the EPDS (Brealey et al, 2010; Choi et al, 2012).
Placentophagy: Evidence for prevention against postnatal depression?
Placentophagy is a traditional practice that is becoming more prevalent in the Western world and is the cause of much controversy. Placentophagy is the process involving ingestion of the maternal placenta usually via encapsulation and uses traditional Chinese medicine to produce dried capsules of the placental tissue. Placenta encapsulation is believed to provide many benefits to women postpartum; including improved lactation, improved mood and prevention of postnatal depression (Colls and Fannin, 2013). The placenta is a rich source of iron, Vitamin B6 and corticotrophin-releasing hormone; which are believed to assist in the prevention of postnatal depression. The rich supply of iron in the placenta is believed to result in improved energy levels and a reduction in fatigue; thus improving mood and reducing incidence of postnatal depression (Beacock, 2012). One of the main motivators for women participating in placentophagy is to improve mood and prevent postnatal depression; with 40% of women reporting improvement in mood and 75% reporting high satisfaction with the overall experience of placentophagy (Selander et al, 2013).
The reported effects of placentophagy and placental encapsulation are based on subjective anecdotal evidence. There is a lack of recent evidence-based findings to support the practice of placentophagy. As well as concerns regarding limited evidence on efficacy, there are also many concerns and criticisms regarding placentophagy practices; and it is argued that placentophagy is unsafe, abhorrent and even a form of cannibalism (Beacock, 2012). Furthermore, there are concerns regarding blood-borne infections and communicable diseases from ingestion of the maternal placenta. Therefore, it is important that midwives are aware of conflicting views regarding placentophagy and any risks involved. Midwives have an important role in supporting women's informed choices and providing holistic care; midwives should acknowledge that for some women the placenta is a significant symbol of spirituality and the pregnancy and birth.
Recommendations for practice
Midwives are often the first point of contact for new mothers and therefore play an important role in the screening, management and prevention of postnatal depression. A large proportion of women use their midwife as their main support for discussing emotional and psychological issues. Midwives facilitate a trusting relationship, which is often found to enhance honesty and disclosure—integral to effectively identifying women at risk of postnatal depression (Schetter and Tanner, 2012). In establishing a rapport, it is also recommended that midwives strive to facilitate continuity of care, when available; to enhance trust and communication between the midwife and the woman (Morton, 2014).
Midwives provide education regarding the risk factors, symptoms and preventive interventions associated with postnatal depression; which increase a woman's knowledge and effectively empower the woman in seeking assistance in the prevention of postnatal depression. Increasing awareness and education are vital to reduce the associated stigma surrounding postnatal depression, and the midwife can ensure thorough antenatal assessment, history-taking and clinical assessment in conjunction with administering screening tools for the identification of potential risk factors or symptoms of depressive conditions. It is also imperative that midwives have cultural awareness and modify interventions where necessary to ensure sensitivity.
Conclusion
Postnatal depression is a serious debilitating condition that affects up to one in four childbearing women. It is considered a significant public health issue due to the associated long-term adverse health effects on the woman, her child, her family and the broader community. Early screening and early intervention are necessary for the prevention of postnatal depression, and midwives can assess for positive or potential risk factors, and attempt to eliminate or reduce these where possible. Midwives should strive to provide woman-centred care and use interventions that enhance social support; including involvement of partner and family and provide information on a variety of preventive interventions and encourage woman to make informed choices.
In regards to preventive interventions there is limited evidence-based information regarding the efficacy of omega-3 supplements, physical activity and placentophagy practices. However, there is promising evidence regarding the efficacy of antidepressant therapy, increased social support, and technological-based psychological interventions in the prevention of postnatal depression. The midwife can ensure unbiased information is provided to the woman regarding alternative non evidence-based interventions; and promote informed decision-making. It is vital that midwives acknowledge their role as public health educators and ensure the provision of holistic woman-centred care that meets physical, social and psychological needs. Midwives endeavour to promote psychological health and wellbeing of childbearing women to promote optimal health outcomes for the woman, her child and her family. Therefore, midwives need to make psychological health and wellbeing a priority of antenatal care and strive towards the prevention of postnatal depressive conditions of all child bearing women.
Key Points
- Postnatal depression affects 1 in 4 women
- Depression has debilitating outcomes on women's well-being
- Intervention is an integral aspect of the midwifery role
- Placentophagy is associated with improved mood and reduced incidence of postnatal depression
- Screening for postnatal depression is not universal; however, it can be valuable assessment tool for midwives