Maternal issues in mental health pose huge obstacles for communities around the world. The birth of a child causes the role and duty of a woman to shift unexpectedly and intensely. The most prevalent psychological disorder after delivery is postpartum depression (PPD), a debilitating mental disorder that can disrupt mother activity and negatively influence children's cognitive, psychological and behavioural growth (Hahn-Holbrook et al, 2018). PPD typically develops around 4–6 weeks following birth, and signs involve depressive mood, lack of enthusiasm or satisfaction in activities, disruption of sleep, disturbance of appetite, lack of energy, sense of worthlessness or remorse, decreased focus, irritability, anxiety, and suicidal thoughts (O'Hara and Wisner, 2014; Werner, 2015). The worldwide cumulative prevalence of PPD was 17.7% (95% confidence interval: 16.6%–18.8%), with substantial nationwide variability (Hahn-Holbrook et al, 2018). PPD prevalence was varying in Asia between 3.5%–63.3% (Abdollahi, 2011); however, in Indonesia, incidence of PPD was 2.32% of women after childbirth (Idaiani, 2012).
Untreated PPD implies a negative effect on both children and mothers. The mother will find it difficult to self-adjust to her new role, while the child is at risk of being sick and stunted easily because the mother does not want to breastfeed (Pope and Mazmanian, 2016). Mothers with PPD have needs in the process of transition, both physically and mentally, and so different clinical measures are required to help them improve the optimum level of health. A variety of studies have been undertaken to prevent the incidence of PPD, including research into health intervention or prevention strategies. However, current studies, especially in Indonesia, have mostly only investigated single actions and then assessed the efficacy of the action taken. There is no research that integrates various interventions in the prevention of PPD into the literature review, especially for studies in Indonesia. The goal of this systematic review was to gain an understanding of the interventions of Indonesian health professionals; physicians, nurses and midwives to avoid and resolve PPD. This systemic analysis also helps synthesise empirically study, so that different approaches can be established to prevent and cure PPD, and obtain an overview of instrument performance to assess PPD.
Methods
The review method in this literature review was informed by systematic review methodology (Khan et al, 2003). The studies in this review had to meet following criteria: participants were women in postpartum period or third trimester of pregnancy, the focus was interventions or techniques to prevent PPD, study design was a quasi-experiment design with control group or pre-post-test design, and using a valid instrument to assess risk of PPD such as Edinburgh Postnatal Depression Scale (EPDS). This review focused on Indonesian studies.
The electronic databases were Google Scholar and Indonesian database (Kandaga and Sinta) as the majority of Indonesian studies published in those data bases. The articles that were included in this review were full-text articles, published from 2008–2017). The keywords were bilingual: Indonesia and English, including postpartum women—Ibu masa nifas, nursing interventions—tindakan perawatan, prevention—pencegahan, and depression—depresi. The articles were evaluated using the JBI critical appraisal tool. The literature summarised in a table that described the study characteristic, statistical methods, and the effect of interventions. The final step was interpreting the study findings, criticising the risk of study bias and providing recommendations.
Results
A total of 189 articles were retrieved. After screening the variables, 14 articles met the type of nursing intervention criteria, and 11 articles were full-text. The next phase of screening was to check the content duplication, finally 10 articles were included in the analysis.
The summary of the articles' characteristics are described in Table 1. According to the eight articles, the research took place in five out of 34 provinces in Indonesia, and were mostly conducted in the central Java province (n=6). A quasi-experiment was chosen as research method in all of the researches, while most of the sample were postpartum mothers, there were two participants that were classified as third-trimester pregnant women. Counselling (n=7) is the method chosen by the majority of the researchers in this review to prevent postpartum blues, followed by music therapy (n=2) and aroma therapy (n=1). The authors applied different methods of counselling, including psychoeducation, individual consultation and group discussions. They developed a counselling programme that provides consultation sessions approximately 3–10 times group and individual sessions. Several participants involved the woman's family, peers, or partner in the counselling processes. For the music therapy, listening to classical music by Mozart was chosen by participants in two articles (Manurung et al, 2011; Permatasari et al, 2015) within this literature review. Respondents listened to the music using earphones for 15–20 minutes during pregnancy and postpartum period. The last method was aromatherapy (Sari and Mulia, 2018), where lemon grass oil (more specifically Citronella oil) was used in this study. The instrument to measure the effectiveness of these interventions to prevent PPD were the EPDS, Beck Depression Inventory-II (BDI) and Zung's Self-rated Anxiety Scale (ZSAS).
Discussion
This section addresses the efficacy of each of the approaches described in this literature review. The 10 articles used in this study identified three approaches that were successful in preventing PPD, namely counselling, music therapy and aromatherapy. This literature review found that therapy was the most commonly used method of prevention of PPD (Husen et al, 2017; Murwati and Suroso, 2017; Muyassaroh et al, 2017). The data analysis showed that therapy was successful in avoiding PPD. Counseling was administered during pregnancy and the postpartum period. During pregnancy, it was done during the third trimester as part of pregnancy planning for birth (Husen et al, 2017; Sari and Wardani, 2017; Winarni et al, 2017).
There were several methods of counselling, however, Murwati and Suroso's (2017) approach, Cognitive Behaviour Therapy (CBT), has been used to prevent PPD successfully (p<0.014). CBT is a process linked to psychotherapy that helps to turn cognitive attitudes into constructive behaviour. The therapist discusses the main concerns of the client, with both working together to create a roadmap for target improvements and goals (Diaz, 2012). Another method of treatment that was successful in the prevention of PPD was psychoeducation. The EPDS score decreased after the implementation of this method from 15 to 13. CBT is part of psychotherapy that seeks to turn cognitive activity and behaviour into positive behaviour (Girsang and Novalina, 2015). Psychoeducation is an intervention for individual, family and group that focuses in educating participants about live challenges, helping participant to develop support system from family or social sources, and developing positive coping in problem solving (Bäuml et al, 2006). The application of the psychoeducation method increased in midwifery practices (Lara et al, 2010; Hutton and Hall, 2013; Fenwick et al, 2015).
Midwives have a broad role to play in healthcare, including educators and counsellors. The therapy approaches used in this study would be of interest to midwives as an alternate approach for counseling services. At antenatal appointments, midwives usually discuss how women feel during their pregnancy and offer advice on giving birth and what to expect during the postpartum period (Haines et al, 2012). Women then decide on the basis of their desires and capabilities.
Out of the 10 articles, two applied music therapy as a method in preventing PPD (Manurung et al, 2011; Permatasari et al, 2015). Both studies used music by Mozart, which was approved as a music that had an influence on human physiology (Manurung et al, 2011; Permatasari et al, 2015). The music therapy had a disparity between the intervention group and control group. The intervention group had a 1.8-fold risk of PPD, while the control group had a 5.6-fold risk (Manurung et al, 2011). Manurung et al's (2011) findings were in line with Permatasari et al's (2015) who also played music composed by Mozart to women during the postpartum period. Apriyanti (2011) also identified the importance of music in maternity care; music is an audio analgesic or relaxant that decreases tension and pain by altering the patient's perception of pain. In addition, women with PPD had characteristics such as anxiety, difficulty in concentration, insomnia and hopelessness. Music therapy can help women heal from their psychological issues by calming their minds and stabilising their moods and behaviours.
Indonesia is a multicultural country with a large amount of traditional music. Thus, midwives should lead the way in exploring traditional music that may be beneficial for the wellbeing of the patient. Previous research in Indonesia evaluated the effect of traditional music on disease recovery (Komariyah, 2016). However, there is limited study of traditional music practice in midwifery, particularly in Indonesia. Indonesian traditional music and the association with midwifery interventions need to be discussed.
Sari and Mulia (2018) found that aromatherapy was effective in preventing PPD. Aromatherapy used in this study was Citronella oil which had a relaxing effect on the woman. The scent activates the sensory receptor of the nose, which is then transmitted to the brain that regulates memories and emotions. The receptor also sends information to the hypothalamus, which regulates the temperature and tension of the body. Another effect of using Citronella oil is a healthy tonic for the neurosystem, anti-compulsive, and has benefited patients with neurological disorders such as anxiety, dizziness, Alzheimer's and Parkinson's disease. This oil is also beneficial for body relaxation, bath therapy, reducing symptoms of depression and fatigue, and stimulating blood circulation (Sumiartha, 2012). PPD symptoms reduced following the use of Citronella oil aromatherapy. This aromatherapy has an antidepressant that helps to relieve anxieties, fears and anxieties, so blood supply and the respiratory system become regular.
Conclusion
The results of this literature review have provided insight into the efficacy of many non-pharmacologyical approaches in preventing PPD. However, none of the approaches concer ned Indonesian culture and natural resources. Therefore, other methods involving Indonesian resources need to be developed. Indonesian health professionals will also be able to apply these new approaches effectively in Indonesia. These results may be an alternative midwifery intervention in maternity cases, taking into account that this study only focused on Indonesian studies. However, the results of the study may be generalised to other developing countries because they may share similar characteristics, such as economic and socio-cultural.
Key points
- Untreated postpartum depression (PPD) implies a negative effect on both children and mothers
- Counselling, music therapy and aromatherapy were successful in preventing PPD
- The research methods used, ie Edinburgh Postnatal Depression Scale and Zung Self-Rate Anxiety Scale, were effective in measuring the risk of PPD
CPD reflective questions
- What alternative therapy could be used to prevent postpartum depression (PPD)?
- What are suitable tools to identify risk of PPD?
- Could traditional music be used as an alternative therapy and why?