Pregnancy is a time of emotional changes. During pregnancy and postpartum, women are often assumed to be happy as they await the birth of their baby and become new mothers. However, some women during pregnancy and up to a year after giving birth are at risk for developing postpartum depression (PPD). Interaction with maternity care providers often ends shortly after birth, increasing the likelihood that PPD is not identified (Beck & Gable, 2000). Pediatric well-child visits (WCVs) provide an opportunity to conduct screening for PPD for new mothers (Chaudron, Szilagyi, Campbell, Mounts, & McInerny, 2007 ; Liberto, 2012). The pediatric WCV offers an opportunity to assess mothers who are more likely to attend their child's appointment for medical care versus their own (Feinberg et al., 2006). Current guidelines for pediatric WCVs recommend that a child be seen at 3 to 5 days; 1 month; 2, 4, 6, 9, and 12 months during the first year of life (American Academy of Pediatrics Committee on Practice and Ambulatory Medicine/Bright Futures Periodicity Schedule Workgroup, 2014). During these times, pediatric providers can assess family environments and address issues pertinent to the mother and the infant's wellbeing (American Academy of Pediatrics Committee on Child Abuse and Neglect, 1998).
The American Academy of Pediatrics and The Agency for Healthcare Research and Quality (AHRQ) strongly encourage screening mothers at the 1-, 2-, 4-, and 6-month WCVs, yet not all pediatric practices are doing so. The 1-, 2-, 4-, and 6-month WCVs are potential peak times for maternal depression, which can be easily integrated into pediatric visits (AHRQ, 2015). When conducting PPD screenings in the pediatric setting, it is important to consider: a) feasibility and barriers of screening within this setting; b) current recommendations for frequency of screening during the first postpartum year; and c) integrity with which recommendations are followed within current clinical practice.
Postpartum Depression Definition and Duration
Postpartum depression is defined as a major depressive disorder with an onset during pregnancy or after birth up to 4 weeks postpartum (American Psychiatric Association, 2013). However, onset of maternal depression symptoms can either start or continue within this first 12-month period occurring at variable time frames (Gavin et al., 2005). To accurately detect maternal PPD, screening should extend beyond the first 4 weeks postpartum (Gaynes et al., 2005). This extension coincides with evidence-based recommendations and accounts for the variance of prevalence and onset seen with PPD.
Effects of Postpartum Depression
Postpartum depression can affect both mothers and their infants. Field (2010) summarized the notable effects of PPD in the literature over the last decade that included increased disruptions in infant temperament, maternal–infant interactions, duration of breastfeeding, and engagement in caregiver activities that promote infant safety and maintain health (Field, 2010).
Feasibility and Barriers to Screening for Postpartum Depression
Feasibility. Universal screening for maternal PPD at each WCV is not mandated. Primary care physicians, obstetricians, and pediatricians have been reported to be inconsistent in their practice of screening; with reports of universal PPD screening to be less than 50% (Seehusen, Baldwin, Runkle, & Clark, 2005 ; Wiley, Burke, Gill, & Law, 2004). Screening tools can aid in detection rates of maternal depression, and increase feasibility of screening (Castañón & Pinto, 2008). Freeman et al. (2005) found screening for PPD at WCV is feasible and interdisciplinary collaboration may enhance screening rates.
Barriers. Noted barriers that impede follow-up for identified cases of PPD include inadequate time, limited opportunity for follow-up, difficulty with the referral process, and the inability to provide screening and treatment within the same facility (Trude & Stoddard, 2003). Inadequate training and time for counseling along with impairments in knowledge about diagnostic criteria and treatment were noted provider barriers (Olson et al., 2002). Providers' confidence level in diagnosing and managing the overall care for at-risk mother can also be a barrier (Olson et al., 2002).
Study Aims and Purpose
There are three primary aims for this study: a) determine the prevalence of PPD among new mothers who score in the at-risk range, defined by a score of ≥10 on the EPDS, when they are screened at each of the 2, 4, and 6 months in an urban outpatient pediatric WCVs, b) determine presence of visit-specific content including medical record documentation of suicide assessment, homicide and attachment assessment, discussion of treatment options, referral information, support, and PPD education for mother identified to be at-risk when screened during their child's 2-, 4-, and 6-month WCV, and c) examine feasibility factors including accuracy of EPDS scoring, provider notification, rate of EPDS completion, and clinical team reports related to acceptability, comfort level, and implementation of PPD screening at the 6-month WCV.
The aims address gaps and practice concerns. If women are reporting depressive symptoms throughout the first 6 months after birth, then practice should reflect screening at intervals consistent with recommendations. Feasibility conducting screening as recommended should be assessed. There is very little evidence exploring the visit content completed for at-risk women identified based on their EPDS score within the pediatric setting. If screenings are being completed, it is essential the content reviewed with the at-risk women is examined in order to establish consistencies. If screening for PPD creates complications for pediatric physicians, physician assistants, and nurse practitioners, then alternative venues should be examined.
Participants and Setting
A Midwestern urban pediatric outpatient clinic served as the study site. Inclusion criteria: postpartum women who were not pregnant by self-report, able to read and understand English, age 19 or older, and attending the 6-month WCV for their infant. All WCVs were defined as visits that occurred 6 months from the child's date of birth plus or minus 14 days. Any 6-month visit not scheduled as a WCV (e.g., sick child visit) was excluded. Institutional review board approval was obtained. Postpartum women deemed eligible were identified by members of the clinical team who were knowledgeable of the study protocol. The study was explained to potential participants after which written informed consent was obtained. Consent was implied by submission of the feasibility survey by the clinical team. The clinical team consisted of physicians, nurse practitioners, physician assistants, nurses, and medical assistants.
This was a prospective cohort study design during which new mothers were screened for PPD using the EPDS at their child's 6-month WCV. Scores from the postpartum mothers' previous 2-month WCV and 4-month WCV, which were routinely done by the clinical team, were also collected from the electronic health record. Feasibility factors and clinical team feedback about adding the additional 6-month time frame into the pediatric setting were assessed using the data collected and survey responses of the clinical team.
Edinburgh Postnatal Depression Scale. The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item screening tool that was developed by Cox et al. (1987), specifically for use in postpartum women. The EPDS has been reported to be effective in identifying PPD, and has demonstrated moderate psychometric properties (Austin & Lumley, 2003 ; Boyd, Le, & Somberg, 2005 ; Gjerdingen & Yawn, 2007 ; Hanusa, Scholle, Haskett, Spadaro, & Wisner, 2008).
Clinical Team Survey. The survey was an investigator-developed 10-item questionnaire specifically for use in this study to evaluate items associated with feasibility including acceptability, comfort level, and implementation effort involved in adding the additional 6-month screening time to current practice. See Table 1.
For eligible mothers who agreed to participate in the study during their child's 6-month WCV, the following steps were initiated: a) consent was obtained, b) the EPDS was given to the mother to complete and then returned to a member of the clinical team, c) the team member scored the EPDS, d) if score was ≥10, the team member was asked to flag the score in the electronic health record that served to inform the pediatric provider of the score, and e) the provider was then asked to discuss the EPDS score results and document visit details. Once complete, the following data were extracted from the medical record: 1) Accuracy of score; 2) Notification of at-risk score being provided to pediatric provider; and 3) In at-risk mothers (EPDS score ≥10), documentation details on content including suicide, homicide safety, attachment, treatment options, referral information, presence of support, and PPD education.
During the course of the study, at 1 and 2 months, checkpoints were conducted to ensure compliance with the approved protocol. If discrepancies were noted, education was provided to the clinical team. All data were deidentified and password protected. Any paper documentation was kept in a secure locked cabinet. The clinical team survey was emailed to the team 1 month after the start of the study and was completed through survey monkey.
Analyses included descriptive statistics and hypothesis generation. Each statistical test was conducted at p = .05 level. Descriptive statistics were used for each of the demographic, intervention, and outcome variables. Summary scores were calculated for the EPDS and the feasibility questionnaire questions 1 to 7. Feasibility questions 8 to 10 were analyzed with qualitative methods.
Six-Month Screening. From November of 2016 through April of 2017, 65 potential participants were eligible for the study. Of these, 65, 6 declined to be screened. Sixteen mothers were inadvertently not screened, resulting in a final sample of 43 postpartum women. Average age of participants was 28.2 years (SD 6.25). There were 15 visits in which an at-risk EPDS score was present, four during the 2-month WCV, five at the 4-month WCV, and six during the 6-month WCV.
Two of the six mothers who were identified with a positive EPDS at 6 months did not have a positive score at either the 2- or 4-month WCV. The remaining four mothers had an at-risk EPDS score at the 4-month WCV, and three of these four mothers had an at-risk score at the 2-month WCV as well; one of the four participants was not screened at the 2-month WCV. In the six postpartum women who were positive at the 6-month WCV, four were directed to meet with a patient care coordinator (PCC), a licensed clinical social worker, by the pediatric provider. In the remaining two, one at-risk score was not detected until the mother had left the office, she never returned the PCC phone call to follow-up.
There were no referrals made by the pediatric provider beyond referring the patient to the clinic PCC. Documentation of a referral plan was present during the interaction with provider or PCC for mothers with a positive screen in four out of the six visits. The referral plan included contact information for the healthcare provider with whom the mother was planning to see for the care of her PPD. One participant declined a referral, two were planning to meet with a mental healthcare provider, and another was meeting with their PCP. In the remaining two participants with a positive score, one mother did not follow up with the PCC nor any other provider based on the information available, and one met with a provider/PCC but had no documentation related to the referral plan.
Prevalence rate of positive EPDS scores for the 6-month WCV was consistent with the anticipated prevalence rates at 14% (O'Hara & Swain, 1996). Prevalence rate for the 2-month WCV was 10% and 12.5% for 4-month WCV. Of note, if the postpartum women were positive at one of the 2-, 4-, or 6-month WCV screening times, it appeared the mother may have a positive score at one of the other screening intervals. See Table 2 for information on prevalence, incidence, and documentation rates of PPD. The visit content documented for each of the positive EPDS visits varied greatly. Only 47% of the visits included documentation on suicidal content. Documentation of assessment of attachment and homicide were present in 33.3% and 40% of visits. Documentation of support was present in 67% of visits. Treatment options and PPD education were documented in 87% of visits. See Table 3 for documentation of completion of content discussed during the visit with the provider.
Staff Survey. Eleven clinical team surveys were received, resulting in a response rate of 42.3%. For data analysis, two questions were recoded to reflect the instrument questions having the same directional meaning. In two of the surveys, there were missing responses for question # 6 on the survey. See Table 4. For questions 8 to 10, qualitative responses that reflect factors important to the staff included, “Making sure the questionnaires are presented to the mother in a timely fashion and not forgotten at the outset of the visit,” “Having good referral sources for moms who screen positive,” “Is it going to benefit our families or is it going to be more paperwork for nothing,” and “Assessing past results in reference to current results.”
Screening mothers at more than one time frame may be beneficial to identify if PPD risk persists. Nine percent of the mothers declined to be screened and 27% were unable to be screened due to obstacles in clinical team member availability during the time of participant presentation. These data suggest need to further explore a mother's acceptability to being screened and obstacles for the clinical team that impede their ability to screen. When team members were asked for feedback on these missed opportunities, the answer most commonly provided was lack of time. Yet, in the survey, results indicate over half of the respondents would disagree or strongly disagree implementing the 6-month EPDS was time consuming.
The PCC seemed to play a pivotal role in supporting the pediatric providers and following up with mothers who were at-risk. Even if the pediatric provider did not indicate knowledge of the EPDS score within their progress note, the PCC was still notified if there was an at-risk mother and followed up with these mothers accordingly. Olin et al. (2017) found critical supports are needed in the pediatric setting to improve timely access for PPD treatment. Having a PCC seemed to create a safety mechanism that ensured someone would follow-up with each of the at-risk mothers even if the system in place did not work according to plan. Using a PCC may be a way to provide the critical support needed for PPD screening within the pediatric setting.
Given the variation in documentation of topical content, it is important to examine this further. Screening tools provide assistance in identification of PPD and open the lines of communication related to PPD in nonpsychiatric settings, but screening alone does not dictate what additional elements are necessary for assessment after a mother is identified to be at-risk (Chaudron et al., 2007). In a person who is identified to be at risk for depression, it seems reasonable and, in certain settings, expected that a clinician assess for the presence of suicide; however, documentation that this took place was found in less than half of the identified cases. Perhaps this relates back to the providers' confidence in going beyond screening for the presence of PPD. Asking directly about suicide does not cause a mother to attempt/complete suicide but it does involve a provider's comfort level in directly assessing for its presence.
It could be argued that homicide assessment toward the infant, attachment to the infant, and the presence of support to care for the infant should be assessed for each at-risk mother as well because these areas are linked to maternal depression mood disorders (Liggan, 2000). An infant's wellbeing can be affected by the presence of risk for direct harm, insecure attachment, and lack of maternal support. In mothers who are identified to be at-risk, it is essential appropriate content aspects are assessed on a regular and consistent basis to implement interventions when necessary. Screening without a clear and consistent content assessment likely puts mothers and their infants at risk. For screening to be effective for those identified with depression, there needs to be a system in place to ensure adequate follow-up for those at-risk (AHRQ, 2015). Developing decisive pathways for at-risk PPD mothers may help to improve the assessment of these content areas and our chances of reducing the negative consequences that can result for both the mother and her infant.
Strengths and Limitations
This study used a reliable and valid screening tool, the EPDS, which has been used in comparable outpatient settings. The clinical team was familiar with the EPDS and the proposed protocol, which was similar to their current standard of practice. Checkpoints were built into the study to ensure accuracy and consistency in the devised protocol.
Preliminary data were obtained from a small, convenience sample limiting the generalizability of the findings. There was no randomization in the study design. Conducting the study in a pediatric setting, where the child was the patient of interest, not the mother, created limitations in the maternal data available in the electronic health record. It would have been beneficial to examine maternal characteristics such as current breastfeeding practices, use of birth control, number of children, and so on, which increased likelihood for EPDS at-risk score. The clinical team survey was not piloted prior to use and two of the respondents did not answer all of the questions.
Clinical Implications for Nursing
Mothers who are identified to be at-risk for PPD should be assessed for suicidal ideation. Without thorough PPD assessment, providers are unable to comprehend the complexity of maternal PPD, limiting the clinician action that is initiated. Care management of PPD should incorporate a systematic risk assessment (Olin et al., 2017). If mothers are not assessed for specific factors, it is unlikely necessary interventions will be implemented, limiting the benefit of screening. Pediatric providers have a unique opportunity to improve infant health by ensuring their parents are healthy as well. However, this creates the need to have clear guidelines or protocols that include the sequence of events expected for clinicians to follow when mothers are identified to be at-risk. Identifying at-risk postpartum women is just one part of identifying and managing PPD. Even when mothers are identified to be at-risk, they still may not follow up with psychiatric services for PPD treatment (Clavenna et al., 2017). It is imperative once mothers are identified to be at-risk, the sequence of events following the screening is consistent and accounts for the variability seen in treatment.
Suggetsed Clinical Implications
- Screening for maternal PPD at time frames that coincide recommended guidelines appears feasible within the ambulatory pediatric setting.
- Postpartum mothers who are identified to be at-risk for PPD should be asked about thoughts of suicide.
- When screening for maternal PPD, a protocol should be devised that outlines clear steps that are completed by clinical staff for at-risk mothers.
- Protocols used for identification and assessment of maternal PPD should evaluate potential risk factors both for mothers and their infants.
- A PCC or licensed social worker who is designated to meet with mothers identified to be at-risk may be a way to improve consistency in assessment of at-risk mother within the pediatric setting.
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