Science & Sensibility

“Childbirth educators are crucial front-line professionals in providing information to women about their risks for medical complications related to pregnancy and birth, and postpartum depression is a common problem.” – Dr. Katherine L Wisner

Katherine L. Wisner, M.D., M.S., has been involved in clinical work and research since the mid-1980′s. Prior to her medical training, she achieved a Master’s Degree in Nutrition. Dr. Wisner did a pediatrics internship, is board-certified in both adult and child psychiatry, and completed a 3-year postdoctoral training program (NIAAA-funded) in epidemiology. Her major interest area is women’s health across the life cycle with a particular focus on childbearing. In January 2011, Dr. Wisner was chosen as the recipient of AMWA’s Women in Science Award for the year 2011. Dr. Wisner is a Norman and Helen Asher Professor of Psychiatry and Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine.

Most recently, Dr. Wisner and colleagues (2013) published the largest American study to date (N = 10,000) investigating the value of screening for depression in postpartum period (4 to 6 weeks) using the Edinburgh Postnatal Depression Scale (EPDS)¹. 

I know I speak for all in welcoming Dr. Wisner to Science and Sensibility.

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Walker Karraa: Congratulations to you and your colleagues on this most recent JAMA Psychiatry study. The findings have significant implications regarding the value of screening for postpartum mood and anxiety disorders. What role do you think childbirth education has in the area of perinatal mental health?

Dr. Wisner: Childbirth educators are crucial front-line professionals in providing information to women about their risks for medical complications related to pregnancy and birth, and postpartum depression is a common problem.  

WK: Should childbirth educators and doulas be trained to screen for PMADs? 

Dr. Wisner: My answer would be yes, but the controversy in the field is about routine screening – that women with depression can be identified, but getting them to mental health treatment if it exists outside the obstetrical care setting is difficult.  So the counterpoint is– why screen if we don’t have on-site, accessible, acceptable services for mental health?  My opinion is that we ought to work toward this model of integrated care rather than decide not to screen!   I certainly think childbirth educators and doulas can increase education and awareness and are often the first professionals that women call for help, so that group of women who want to and can access care can get the help they need.

WK: How could childbirth education organizations use this study to inform their practices and curriculum?

Dr. Wisner:The study provides evidence that the prevalence of depression is high both during and after pregnancy and evidence that screening is effective in identifying women with major mood disorders.  Women with psychiatric episodes certainly can be assured that they are not alone, which is a common belief of pregnant women and new mothers.  

WK: Due to the prevalence of self-harm ideation in postpartum period found in your study and other studies supporting this alarming rate, and the fact that suicide is the second leading cause of maternal death, how might childbirth education organizations and professionals address this critical problem?

Dr. Wisner:Screening with the EPDS, which has the item 10 self-harm assessment questions, and sensitive exploration of self-harm and suicidal ideation is the primary approach to suicide prevention.  It has to be identified before intervention can occur.  

WK: A remarkable finding in your study was the rate of bipolar disorder among women who had screened positive (10 or higher) on the EPDS. Additionally, among those with unipolar depression, there was high comorbidity for anxiety disorders. What are your thoughts as to how childbirth education might begin to help childbearing women unpack and understand the symptoms of anxiety in prenatal education?

Dr. Wisner: In our study we found that women with depression usually had an anxiety disorder that pre-dated the depressive episodes—this observation is true for women who are not childbearing as well.  Having anxiety or depression as a child or adolescent increases the risk for peripartum episodes.  There are excellent pamphlets and websites about perinatal depression (www.womensmentalhealth.org; www.postpartum.net) which can be used to frame a brief discussion and give to the patient for reference.  This also gives the message that talking about mental health before and during childbearing is an important topic, just like surgical births, anesthesia etc.    

WK: The data you have contributed to science are unsurpassed, yet early in your career many questioned whether postpartum depression was real, and doubted if you would be able to pursue a research career in postpartum mood disorders.

Dr. Wisner: Indeed!

WK: How did you persevere–and particularly in a male-dominated field?

Dr. Wisner: I got angry that so few data were available to drive care for pregnant and postpartum women and never let go of the importance of obtaining that information.  That motivation was coupled with a real joy in taking care of perinatal women and their beautiful babies!  

WK: Do you think there is still an underlying doubt as to whether postpartum depression (or perinatal mood/anxiety disorders) is real?

Dr. Wisner: Not in academic medicine, and I have not heard anyone say this in about a decade (thankfully!). 

WK: What is your favorite part of the research? Data collection, analysis, or interpretation?

Dr. Wisner: Publishing findings that make a difference in women’s lives, and holding the babies. 

WK: What new trends do you see in research as hopeful signs of progress?  

Dr. Wisner:  The incredible number of young clinicians and investigators who are interested in perinatal mental health.  Also,  our field has been so accepting of interdisciplinary enrichment of research questions.  

WK: What advice would you share with women in research today? 

Dr. Wisner: Network with  your colleagues inside and outside your organization frequently, attend perinatal mental health meetings and don’t ever give up!  

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What are your thoughts regarding Dr. Wisner’s expert opinion?   How do you currently address postpartum depression and anxiety in your childbirth classes?  After reading this interview and taking at look at Dr. Wisner’s just published research, might you reconsider how you teach about this important topic or change your approach?  Let us know in the comments section below- Sharon Muza, Community Manager

More about Dr. Wisner

Dr. Wisner’s research has been NIMH funded since she completed her post-doctoral training in 1988. She served on NIMH grant review sections continuously from 1994 to the present. Dr. Wisner completed was a founding member of the NIMH Data Safety and Monitoring Board, and is only the second American to be elected President of the Marce International Society for the study of Childbearing Related Disorders.

Her major interest area is women’s health across the life cycle with a particular focus on childbearing. She is a pioneer in the development of strategies to distinguish the effects (during pregnancy) of mental illness from medications used to treat it (Wisner et al,JAMA 282:1264-1269, 1999; MHR01-60335, Antidepressant Use During Pregnancy).

In recognition of her work, she was a participant in activities related to the FDA Committee to Revise Drug Labeling in Pregnancy and Lactation, a committee member for the National Children’s Study (Stress in Pregnancy), a consultant to the CDC Safe Motherhood Initiative and the Agency for Healthcare Research and Quality Report Perinatal Depression: Prevalence, Screening Accuracy and Screening Outcomes.

Dr. Wisner was elected to membership in the American College of Neuropsychopharmacology in 2005. She received the Dr. Robert L. Thompson Award for Community Service from Healthy Start, Inc., of Pittsburgh in 2006 and the Pennsylvania Perinatal Partnership Service Award in 2007 from the State of Pennsylvania. 

Dr. Wisner was the first American psychiatrist to collect serum from mothers and their breastfed infants for antidepressant quantitation as a technique to monitor possible infant toxicity. She published the only two placebo-controlled randomized drug trials for the prevention of recurrent postpartum depression and showed that a serotonin selective reuptake inhibitor was efficacious.

References 

1.Wisner, K.L., Sit, D., McShea, M. C., Rizzo, D.M., Zoretich, R.A., Hughes, C.L., Eng, H.F., Luther, J.F., Wisneiweski, S. R., Costantino, M.L., Confer, A.L., Moses-Kolko, E.L., Famy, C. S., & Hanusa, B.H. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry, Published online March 13, 2013. Doi: 10.1001/jamapsychiatry.2013.87

 

Walker Karraa Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research Childbirth Education, depression, guest posts, Katherine L Wisner, maternal mental health, MD, PPMAD, PPMD, PTSD, Walker Karraa

By Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Recent press coverage of a British mother suffering from severe PMAD has made headlines and the topic is one that belongs in whatever childbirth class a woman chooses to take. – Sharon Muza, Community Manager.

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Safety regarding the use of a specific type of antidepressant medication, selective serotonin reuptake inhibitor (SSRI’s), is an important topic as maternal health care providers address the prevalence and negative effects of depression and other mood disorders in pregnancy and postpartum. Recently, the study The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) has garnered tremendous attention from media, researchers and childbirth professionals. I had the opportunity to ask the study’s authors and other experts about the dangers of discontinuation in a piece for Giving Birth With Confidence. From that article, we hear the overwhelming agreement; including two of the study’s authors, that sudden discontinuation of SSRI antidepressant medications in pregnancy is not advisable.

A week later, I learned about the tragic case of Felicia Boots, a 35 year old woman in the United Kingdom who, fearing she was harming her baby by taking SSRI’s and breastfeeding, suddenly stopped. Shortly after, she took the lives of her 14-month old and 10 week old children. A special editorial published by The Lancet (November 10, 2012), noted: “She had stopped her prescribed antidepressants because she was convinced that the drugs would harm her baby through her breastmilk and feared that her children would be taken away from her”(p. 1621). The authors went on to state: “A society in which women know that they will receive empathy, understanding, and help might be one in which women seek advice more readily, and accept appropriate treatments” (Lancet, 2012, p. 1621).

This is a vision shared by the guiding principles of maternity care–as childbirth professionals have always worked for a society where women know they will be cared for, understood, and have access to appropriate interventions. Unfortunately, we have failed to include mental health. How might the childbirth education community better address these issues? Asking experts is a place to start. What is uniquely helpful here is that the same questions were given to all participants—shedding light on one commonality: education.

Today’s article features Julia Frank, MD. Dr. Frank is a Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and Health Sciences, where she has been the Director of Medical Student Education in Psychiatry since 2000. A graduate of the Yale University School of Medicine and of the residency program in psychiatry at Yale, Dr. Frank is also the founder of `Five Trimesters Clinic, a service for women with mental health needs relating to pregnancy and childbirth. In this installment, Dr. Frank addresses how childbirth educators might address these complex issues.

WK: How might childbirth professionals integrate an understanding of postpartum psychosis (PP) and other perinatal mood disorders in classes? 

Dr. Frank: It is important to stress that the condition is rare but serious and treatment is generally quickly successful. Women with a family history of bipolar disorder or of postpartum psychosis in relatives should be told that they are at somewhat increased risk. Giving information in writing to them and their partners about what to look out for (especially profound sleeplessness and confusion) in the first couple of weeks postpartum might also be helpful.

WK: The recent Lancet editorial regarding the Felicia Boots tragedy stated: “Postnatal depression and, more broadly, perinatal mental health disorders, are among the least discussed, and most stigmatizing, mental health illnesses today” (p. 1621).   

How would you describe the stigma of perinatal mental health disorders and its impact?

Dr. Frank: I think the widespread publicity given to the sensational cases with terrible outcomes makes it hard for women to admit to any difficulty postpartum. The general public tends to conflate postpartum depression with psychosis. I have had women say to me “I don’t think I’m depressed, because I don’t want to hurt my baby”. We also overemphasize depression and neglect anxiety. I am not sure that is a factor of stigma, but it certainly contributes to under diagnosis.

Obstetricians and pediatricians may not recognize or discuss a postpartum psychiatric disorder for fear of offending the affected mother. Other aspects of stigma that apply to professionals are the belief that psychiatric disorders are overwhelmingly time consuming to address, that women who have them lack insight, that treatment is generally no better than passage of time.

WK: What do you see as the most significant barriers to treatment for women with perinatal mood and anxiety disorders (PMAD)? 

Dr. Frank: In the US, the disconnection between mental health care and medical care, written into our insurance systems, is a major barrier. Also, the way pediatricians are trained to deal only with the child, and not to assume any responsibility for the health of the mother, keeps them from screening appropriately. Obstetricians also maintain an overly narrow focus on the woman’s organs, and they tend to have very little contact with mothers after delivery, nor do most of them see mental health as within their sphere of interest or expertise. Fears of liability from the effects on the fetus of treating the mother are another barrier, especially in the US, where medical injury to an infant can bring astronomically high damage awards. This is a particular barrier to some psychiatrists being willing to initiate or maintain treatment related to pregnancy.

WK: How would you respond to media-based concerns regarding the safety of SSRI medication in pregnancy? 

Dr. Frank: There is no pregnancy without risk, and the risks of not treating a serious psychiatric disorder are as important to consider as the risks associated with treatment.  When we bypass maternal suffering out of concern for the safety of a fetus, we are making a misguided moral judgment that privileges “innocent” life over life as lived. The risks of these drugs are important and should be weighed carefully, but it has taken literally decades and the review of the experience of tens of thousands of women to identify the risks. Absolute and percentage risks remain acceptable, when weighed against the known benefits of taking medication when necessary. Over fifty percent of pregnant women take something during pregnancy, and treating a mood disorder is as important as treating a UTI, or diabetes, or heartburn or any of the conditions that are typically addressed.

WK: What are your thoughts regarding discontinuation of medication in pregnancy? 

Dr. Frank: Depends on the medication, the woman’s history, and the illness being treated. Certainly, discontinuing a medication should not be an automatic response to a woman becoming pregnant.

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice? 

Dr. Frank: Widespread education in the use of efficient screening methods, particularly the PHQ 9 or the Edinburgh Postnatal Depression Scale would be a first step.  Educators  also need to develop routines for referring women to mental health services—the postpartum depression self-help  community , embodied in organizations like Postpartum Support International, is pretty well organized and can help bridge the gap between screening and referral . Ideally, these organizations could reach out to women postpartum, rather than waiting for them to come in. Routine phone calls two and four weeks after delivery, providing encouragement for everyone while also identifying and facilitating referrals for women in difficulty, might be quite effective in both preventing and intervening in postpartum mood problems. This is an area that merits systematic study. Finally, organizations that include mothers themselves might consider urging women who have been identified and treated to write thank you notes to the health care providers who contributed to them getting help. I think this would counter the fears that providers have about giving and offense and doing harm.

Conclusion

Dr. Frank contributes to the broadening conversation regarding how childbirth educators might better address perinatal mental health. How do her suggestions resonate with your practice? In what ways could you use her information?  Will you consider adding this information to your classes and new mother contact? And how could your certifying or professional organization become a source of support and education?

The second post in this series, scheduled for Thursday, features Nancy Byatt, D.O., MBA–Assistant Professor of Psychiatry and Obstetrics & Gynecology;  Psychiatrist, Psychosomatic Medicine and Women’s Mental Health UMass Medical School/UMass Memorial Medical Center.

References

Domar, A. D., Moragianni, V. A., Ryley, D.A., & Urato, A.C. (2012). The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Human Reproduction, Vol.0(0) pp. 1–12 doi:10.1093/humrep/des383

Bringing postnatal depression out of the shadows The Lancet – 10 November 2012 (Vol. 380, Issue 9854, Page 1621 ) doi: 10.1016/S0140-6736(12)61929-1

Other Resources: 

Department of Health and Human Services: Depression During and After Pregnancy: A Resource for Women, Their Families, & Friends

The Organization of Teratology Information Services (OTIS), (866) 626-6847

 

 

Walker Karraa Babies, Breastfeeding, Childbirth Education, Depression, Giving Birth with Confidence, Guest Posts, Infant Attachment, Maternal Mental Health, Maternity Care, News about Pregnancy, Perinatal Mood Disorders, Postpartum Depression, Prenatal Illness, Research antenatal mood disorder screening, Childbirth Education, guest posts, Julie Frank, MD, mental illness, PMAD, postpartum, postpartum depression, PPMD, prenatal depression, prenatal depression screening, screening for postpartum depression, Walker Karraa

By Penny Simkin, PT, CCE, CD(DONA)

In a two part series examining the recent research that stated that natural childbirth is a major cause of  Posttraumatic Stress Disorder,  our guest bloggers, Penny Simkin and Dr. David White, look at how the media may be sensationalizing the topic and reviews the published article to help understand more about what the research revealed.  Enjoy this blog post and the second part on Tuesday, August 21 to gain great insight into the statements made by the researchers. – SM

It has happened again. Yet another study of a hot topic in maternity care – this time, “natural childbirth,” which the authors define as “childbirth without an analgesia or without an epidural” – has been picked up by online and print media, and passed on to their audiences, with twists sensationalizing the material and adding fuel to the belief that natural childbirth is traumatic. Such articles bear provocative titles or subtitles, such as “Natural Births a Major Cause of PTSD”; “Having a Baby Like Being in a Terror Attack”; and “Is Natural Birth Connected with Post-Traumatic Stress in New Moms?”  Additionally, social media sites have begun discussing these frightening reports, most of which do not accurately present the study findings.

The study causing the stir is “Postpartum Post-Traumatic Stress Disorder symptoms:  The Uninvited Birth Companion” (1), which was published in the Israel Medical Association Journal in June, 2012 but was picked up and disseminated widely only in early August. There are two major problems with this study:

1. The misinformation and selective reporting by the media (it was attention from the media that led to my seeking the original paper to confirm the accuracy of the media statements; and
2. The quality of the study itself (from design to interpretation of the findings to its validity).

In today’s blog post (part one of a two part series on this research article,) I will try to clarify some of the misinformation published in the media and analyze the harm done by these reports.  In part two, to be published on Science & Sensibility next Tuesday, David White, MD, masterfully analyzes deficiencies with the study itself.

At the beginning of the study, 102 women (a convenience sample) volunteered to participate in two surveys – one given within the first two to four days after birth and another at one month after birth. 89 subjects completed both surveys and were included in the results. The purposes of the surveys were to detect the prevalence of Posttraumatic Stress Disorder(PTSD,) and to identify associated risk factors before, during, and after birth. Because of the small sample size inconsistency in both reported numbers and terminology, and other factors (to be discussed in Part Two), any conclusions should be viewed with skepticism about the study’s external validity and applicability beyond the group studied.

And yet, despite these issues, the big media push has thrust this study into the limelight, giving it much more visibility and influence than it deserves. Most of the media accounts that I have read emphasize the finding that natural childbirth (meaning vaginal birth without pain medications) was the major cause of PTSD. In this study, there was an extremely high rate of cesarean birth (53%). Another finding reported by the media was that being accompanied during labor had no impact on the rate of PTSD. Neither of these findings was accompanied by statistical evidence.  These and other findings of the Israeli study are contrary to those of numerous other studies and reviews of satisfaction with childbirth, PTSD after childbirth, and the role of pain vs suffering during labor (2-4). Close examination of the details of the Israeli study design and reporting is called for, even though the damage has already been done by the media. Please see Part Two of this blog on Tuesday for this careful analysis.

Participants were questioned about the prevalence of PTSD symptoms after birth, and also about the presence of pre-pregnancy, intrapartum, and postpartum factors that are known to be associated with post-birth PTSD. Natural birth was highlighted by the media because of the report that 80% of the 7 women who developed PTSD (5 women) did not receive pain medication. In fact, many media reports state that these women either chose or opted for natural childbirth without pain relief. On careful inspection of the original paper, nowhere does it state that the women chose natural birth, but rather that “… fewer women who developed PTSD symptoms received an epidural and there was a great incidence of PTSD symptoms in women who did not receive an epidural.” It is possible that an epidural was not available to the women (which could be traumatizing if they had wished to have one).

Furthermore, these women had numerous other factors that are associated with PTSD. Before accepting natural birth as the major cause of PTSD after childbirth, please check the table below for these other factors, which were as prevalent, or nearly so, as lack of pain relief as a cause of PTSD. As you can see, for example, 80 percent of the women with PTSD also had discomfort with being undressed; previous mental health problems in previous pregnancy or postpartum; and complications, emotional crises, and high fear of childbirth in their current pregnancy.  All these factors have been reported in many studies to be instrumental in the development of PTSD (2-4).

Selected PTSD Risk Factors (with large differences in incidence between the two groups)

Existing before the study pregnancy	P Value	PTSD (n=7)	No PTSD (n=82)
Psychiatric or psychological treatment	P=0.157	60% (n=4)	29.8% (n=24)
Body image (uncomfortable in undressed state)	P=0.014	80% (n=4)	27.7% (n= 22)
Existing in previous pregnancies
Traumatic birth experience	p=0.012	60% (n=4)	15.5% (n= 12)
Sadness, blues, or anxiety during or after pregnancy	p=0.038	80% (n=4)	33% (n= 26)
Existing in current pregnancy
Complications during	p= 0.016	80% (n=4)	28.6% (n=25)
Emotional crises during	p= 0.06	80% (n=4)	23.8% (n=21)
High fear of childbirth	p= 0.021	80% (n=4)	30% (n= 27)
Delivery
“A significantly smaller number of women who developed PTSD received analgesia during delivery compared to the control group” *	p=0.000	No numbers or % given	No numbers  or % given
Mothers’ Feelings in Labor & Birth			No PTSD (n=80)
Felt danger to their life or health	p=0.001	71.4% (n=5)	20.7% (n=17)
Mild discomfort with undressed state	p=0.029p=0.029	57.1% (n=4)	87.7% (n= 70)
Major discomfort with undressed state		42.9% (n=3)	12.3% (n= 10)
Support during labor
No relationship between PTSD and being accompanied by someone or the extent of support received. No numbers or percentages were given.

*  This statement was all that was given to support “evidence” of natural birth as a cause for PTSD.

In spite of the flaws of this study, the authors offered some valuable conclusions, pointing out “the importance of inquiring about previous pregnancy and birthing experiences and the need to identify at-risk populations and increase awareness of the disorder.” Despite the shortcomings of their study, this advice is on target, as has been confirmed over and over again in the literature on traumatic birth.

In conclusion, this study was given much more publicity than it deserves, and as such has done more harm than good in understanding PTSD after childbirth. Our lesson: Recognize that many media outlets look for sensational and shocking material to attract readers, and will manufacture it if it doesn’t exist. Go to the source and think for yourself.

As educators and  birth professionals, how do you deal with students, clients and patients sharing what they read in the media, that may have been sensationalized?  What is your response?  Have you had to field questions about this recent study?  How do you respond?  Did you come to your own conclusions about this study?  Please come back on Tuesday to read a wonderful review of this research by Dr. David White and continue the discussion. – SM

Resources:

1. Polachek I, Harari L H, Baum M, Strous RD, (2012) Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion. Israel Medical Association Journal 14: 347-353

2. Alcorn K L,  O’Donovan A, Patrick J C, Creedy D and Devilly G J. (2010). A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. Psychological Medicine, 40, pp 1849-1859 doi:10.1017/S0033291709992224

3. Alder J, Breitinger G, Granado C, Fornaro I, et al. 2011. Antenatal psychobiological predictors of psychological response to childbirth. Journal of the American Psychiatric Nurses Association 17(6): 417-425. doi: 10.1177/1078390311426454

4. Simkin P, Hull K. 2011 Pain, Suffering and Trauma in the Perinatal Period. Journal of Perinatal Education 20(3): 166-175.

For more information visit the PATTCh Resource Guide.

About Penny Simkin

Penny Simkin is a physical therapist, childbirth educator, doula, and birth counselor. She is author or co-author of many books and articles on maternity related topics for both professionals and the public. She is a co-founder of DONA International, and of PATTCh (Prevention and Treatment of Traumatic Childbirth), and is also a member of the Editorial Board of the journal, Birth.

Penny Simkin Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Social Media, Uncategorized Childbirth Education, David White MD, guest post, media, mental health, PATTCh, Penny Simkin, postpartum, postpartum depression, postpartum mood disorders, Posttraumatic Stress Syndrome, PPMD, PTSD

This is a post by Science & Sensibility’s regular contributor, Walker Karraa, MFA, MA, CD(DONA)

The recently published study, “Reducing Postpartum Depressive Symptoms Among Black and Latina Mothers: A Randomized Controlled Trial” (Howell et al., 2012) has garnered attention among birth and perinatal mental health professionals.  The intention of this post is to (a) present the evidence given in the study; and (b) encourage community discussion, exploration, and solution-driven strategies for childbirth education practices that address postpartum depressive symptoms in communities of color.

Study Breakdown: Objectives and Rationale

The objective of the randomized controlled study was to “estimate the effectiveness of a behavioral educational intervention to reduce postpartum depressive symptoms among minority mothers” (p. 942).

The rationale for the study itself included the current quantitative data demonstrating the public health problems presented by the high prevalence of postpartum depressive symptoms in American women, and the subsequent negative effects of depressive symptoms on maternal quality of life, mother-infant attachment, and the impact of those symptoms on the social, cognitive, and emotional development of children (cited studies: Gaynes et al., 2005; Howell, Mora, Horowitz, & Leventhal, 2005; Martin et al., 2006; Zayas, Cunningham, McKee, & Jankowski, 2002). Most relevantly, rationale for a study examining African American and Latina mothers specifically was based in evidence of three previous studies that have demonstrated “the burden of postpartum depressive symptoms is especially high in low-income black and Latina women” (p. 942; cited studies: Das, Olfson, McCurtis, & Weissman, 2006; Howell et al., 2005; Lewis-Fernandez, Das, Alfonso, Weisman, & Olfson, 2005).

In this study, Howell, et al., (2012) offered that the rationale for generating a behavioral educational intervention was also rooted in previous research findings that “situational factors such as postpartum physical symptoms, overload from daily demands, and poor social support play a major role in the generation of depressive symptoms” (p. 942, cited studies: Howell et al., 2005; Howell, Mora, DiBonaventura, & Levanthal, 2009; Howell, Mora, & Levanthal, 2006).

 Methods: How Did They Do the Study?

• Recruitment: 540 self-identified black and Latina mothers recruited to participate during their postpartum hospital stay at a “large tertiary inner-city hospital located in East Harlem in New York City” (p. 943). Inclusion criteria included participants who self-identified as black or Latina, 18 years or older, with neonates weighing 2,500g or higher, with 5-minute Apgar score of >7.
• Randomization: Randomization of groups occurred through approved procedure of computerized randomization of participant number. Research coordinators were blinded to the assignment of the study arm of those who would receive the intervention and the control arm that received enhanced usual protocol.

 Intervention: What did they do?

For the group assigned to the intervention, the following 2 steps were taken:

Step 1:

“The in-hospital component of the intervention involved a 15-minute review of an educational pamphlet and partner summary sheet by the mother with a Masters-trained bilingual social worker” (Howell, et al., 2012, p. 943)

 What was in the pamphlet?

“The pamphlet represented each potential trigger of depressive symptoms as a “normal” aspect of the postpartum experience and provided specific suggestions for management. For example, the prevalence of moderate or heavy vaginal bleeding immediately postpartum was depicted by eight of 10 female silhouettes colored red; only one of 10 was red 3 months postdelivery. Simple “to do” statements (rest; use pads) were listed between the two rows of figures.  A separate page was dedicated to social support and ‘helpful organizations’ were listed” (Howell, et al., 2012, p. 943).

 What was the “partner summary sheet”?

The partner summary sheet spelled out the typical pattern of experience for mothers postpartum, i.e., it was designed to “normalize” the feelings and behaviors experienced and enacted by most mothers postpartum and stressed the importance of social support for the patient. The social worker reviewed the patient education pamphlet and partner summary sheet with the patient during her postpartum hospital stay and answered questions (Howell, et al., 2012, p. 943).

 Step 2:

A phone call 2 weeks post-delivery by a social worker was placed to each mother in the intervention group to assess symptoms, symptom management skills, and to review the “to-do” lists in the pamphlets.

 Results: What Did They Find?

The authors compared the group of mothers who did not receive the intervention to the intervention group and published the following results:

• Positive depression screens were less common among the intervention group compared with the non-intervention group at 3 weeks (8.8% compared with 15.3%, P=.03), 3 months (8.4% compared with 13.24%, P=.09), and 6 months (8.9% compared with 13.7%, P=.11).
• Analysis for up to 6 months follow-up demonstrated that:

“Mothers in the intervention group were less likely to screen positive for depression compared with enhanced usual care (odds ratio 0.67, 95% confidence interval 0.47-0.97)” (Howell, et al., 2012, p. 948).

Implications

Here the authors noted that implications were that behavioral education could address and modify risk factors that have been shown to correlate with postpartum depressive symptoms. Increasing mothers’ knowledge about triggers, and the “to-do” list of management of those triggers, followed by the phone contact with trained social worker provided an intervention that demonstrated significance in reduced postpartum symptomatology for this study.  Authors noted that implementing visual modalities in educational materials assisted mothers’ understanding of the triggers, and the range of “normal” symptoms that could be addressed with behavioral strategies, and re-examined in a timeframe of normalcy.

 Limitations

The authors noted that limitations included potential lack of generalizability, as the study took place in one site; they suggested future research in multiple settings would be indicated.

Food for Thought

How does the study inspire ways in which you might most effectively address postpartum symptoms, their triggers, and education with your clients? What are some ways you might use this information in your childbirth education classes?

And lastly, perhaps deeper still, can we truly engage this topic without discussing the role of racism plays in creating barriers to treatment, stigma, and lack of access to care for women of color? What are the steps childbirth and doula organizations can take toward addressing this issue? I would suggest position papers on perinatal mental health and racial disparities would be first line action items for organizations to implement publicly. Outreach to public health and mental health professionals from the organizational level, would further support birth professionals to gain the knowledge and tools needed to acknowledge and address these issues, and become active participants in substantive social change for the future of childbearing women. How many of our organizations are listed in educational pamphlets on postpartum depression as “helpful organizations”?

Walker Karraa, MFA, MA, CD(DONA)

Walker is currently the President of PATTCh, a not for profit founded by Penny Simkin and Phyllis Klaus–dedicated to the Prevention and Treatment of Traumatic Childbirth. Walker is a doctoral candidate at Institute of Transpersonal Psychology, a certified birth doula, writer, and maternal mental health advocate.  She holds an MA degree in Clinical Psychology from Antioch University Seattle, and a BA and MFA degree in dance from UCLA.  Walker is a contributor to the Lamaze sites, www.givingbirthwithconfidence.org and www.scienceandsensibility.org.  She lives in Sherman Oaks, California with her husband, and two children.

References

Das, A., Olfson, M., McCurtis, H., & Weissman, M. (2006). Depression in African Americans: Breaking barriers to detection and treatment. Journal of Family Practice, 55, 30-39.

Gaynes, B., Gavin, N., Meltzer-Brody, S., Swinson, T., Gartlehner, G., Brody, S., & Miller, W. (Ed.). (2005). Perinatal depression: Prevalence, screening accuracy, and screening outcomes (Summary, evidence report/technology assessment No. 119). Rockville, MD: Agency for Healthcare Research and Quality.

Howell, E. A., Balbierz, A., Wang, J., Parides, M., Zlotnick, C., & Leventhal, H. (2012). Reducing postpartum depressive symptoms among Black and Latina mothers: a randomized controlled trial. Obstetrics & Gynecology, 119(5), 942-949. doi:10.1097/AOG.0b013e318250ba48

Howell, E. A., Mora, P. A., Horowitz, C. R., & Leventhal, H. (2005). Racial and ethnic differences in factors associated with early postpartum depressive symptoms. Obstetrics & Gynecology, 105, 1442-1450.

Howell, E., Mora, P., Chassin, M., & Levanthal, H. (2010). Lack of preparation, physical health after childbirth, and early postpartum depressive symptoms. Journal of Women’s Health (Larchmont), 19, 703-708.

Howell, E., Mora, P., DiBonaventura, M., & Levanthal, H. (2009). Modifiable factors associated with changes in postpartum depressive symptoms. Archives of Women’s Mental Health, 12, 113-120.

Howell, E., Mora, P., & Levanthal, H. (2006). Correlates of early postpartum depressive symptoms. J Maternal Child Health, 10, 149-157.

Lewis-Fernandez, R., Das, A., Alfonso, C., Weisman, M., & Olfson, M. (2005). Depression in US Hispanics: Diagnostic and management considerations in family practice. Journal of American Board of Family Practice, 18, 282-296.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2006). Births: final data for 2004. National Vital Statistical Report, 55, 1-101.

Zayas, L., Cunningham, M., McKee, M., & Jankowski, K. (2002). Depression and negative life events among pregnant African-American and Hispanic women. Women’s Health Issues, 12, 16-22.

 

Walker Karraa Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Walker Karraa Childbirth Education, postpartum, postpartum depression, postpartum mood disorders, PPD, PPMD, Walker Karraa, women of color