Left untreated, postpartum depression (PPD) is not only harmful to a mother, but can lead to long-term detrimental effects for an infant and family as well. The key to optimal care is early identification and treatment, and it takes a team effort to identify women in need of mental health support after giving birth. MEDNAX-affiliated neonatologist Rebecca Mischel, MD, and her co-authors agree. They published findings of their quality improvement initiative in a recent edition of Neonatal Network called Postpartum Mood Disorders Screening in the NICU.
There are numerous ways that fetal and infant development may suffer as a result of a mother’s PPD, including changes in stress hormone levels in mother and baby, disturbed interactions and decreased care. After birth, a mother experiencing signs of depression may be less likely to engage with her baby both physically and emotionally. These changes in touch and insufficient positive interactions and response behaviors impede an infant’s developing sense of security and wellbeing. A child who does not receive these care-based connections may face higher rates of poor attachment and other psychological problems, and is at an increased risk of disturbed sleep and impaired growth, which can persist into adulthood. Maternal PPD affects the whole family – up to 50% of partners of a woman with PPD also experience mood disorders during the time before and after birth.
Identifying the problem
Screening for PPD is an essential part of obstetrics and pediatrics, including neonatology. Data from the World Health Organization and the Centers for Disease Control and Prevention place PPD rates at 10%-19%. The American Psychology Association cites one in seven women will suffer from more than “baby blues.”
The physical and emotional strains of pregnancy and birth are hard on a woman’s body and mind, and some mood and behavior changes are common during and after pregnancy. However, postpartum depression is diagnosed when the behavioral symptoms worsen, strongly affect a mother’s life and last for more than two weeks. A woman does not need to exhibit all signs of PPD to have the condition. The level of severity ranges from patient to patient, but all symptoms must be taken seriously. PPD commonly develops following childbirth, but similar symptoms may also occur during pregnancy or within a year after giving birth.
Finding solutions
A multi-disciplinary health-care team at Randall Children's Hospital in Oregon partnered with the Oregon Chapter of the American Academy of Pediatrics (Oregon Pediatric Society) and START (screening tools and referral training) on a statewide quality improvement initiative to screen and refer mothers for PPD. The team at Randall Children’s Hospital considers PPD screening and referral critical to promoting family health and long-term infant/child and family wellbeing.
This quality-improvement project focused on providing PPD education to all NICU staff and physicians, and identifying and training a team of PPD screeners, which included lactation consultants, NICU nurses and the NICU case manger. They developed and used an algorithm for referring all moms to community resources, and when needed, to additional experts. The project also applied a process for hardwiring documentation of maternal PPD screen and referral information into the infant’s discharge summary to support outpatient longer-term follow-up.
Screenings were based on the Edinburgh Postnatal Depression Scale with self-harm as a specific concern. Patients were provided information on available mental health services and self-care. Challenges of bringing maternal PPD screening into the NICU milieu included providing sufficient staff coverage to screen and refer all moms, revising the electronic medical record to allow documentation of screening and referrals, and the hardwire inclusion of maternal PPD status in the infant’s NICU discharge summary. Patient barriers included language and cultural stigma.
Why this matters
Instituted in 2013, the program reached 90% of mothers whose infants were hospitalized for at least two weeks and up to four months at Randall Children’s Hospital. More than 20% of mothers screened positive for PPD, which is higher than the 10-19% rate cited by most resources for the general population.
This data highlights the importance of screening and referring women for PPD to support identification and treatment. The team at Randall Children’s Hospital is working to expand the psychological services they provide for women and families whose infants are hospitalized in the NICU and to the greater community to increase recognition and resources for this serious but treatable condition.
Start a similar process at your practice
The team at Randall Children’s Hospital NICU encourages other clinicians to consider the value of PPD screening and referral. To learn more about the process trial at Randall Children's Hospital, contact:
Rebecca Mischel, MD, Neonatologist, North West Newborn Specialists, an affiliate of MEDNAX, Randall Children’s Hospital NICU.
Resources
Perinatal Depression Screening: Tools for Obstetrician-Gynecologists