Maternal Depression

Maternal depression is a condition characterized by intense feelings of sadness, anxiety or despair after childbirth that interfere with a mother’s ability to function and that do not resolve (1).  Women may experience depressive symptoms for the first time during pregnancy, within days of childbirth or up to 12 months following birth. Others may have a history of depression and be at increased risk (up to 50%) for recurrent depression associated with pregnancy. Maternal depression encompasses the entire life continuum from before, during and following pregnancy. 

Prevalence
Maternal depression is a national public health issue affecting approximately one out of every four women over their lifetime. Maternal depression affects approximately 12% of pregnant women with rates doubling for low-income mothers, particularly among teen mothers (2-4).

Impacts on the Infant and Mother
There is increasing evidence that maternal depression has a negative impact on infant emotional, cognitive and behavioral development. The profound consequences of maternal depression on maternal and child health include maternal self-neglect, poor nutrition and sleeping patterns, refusal of prenatal care, domestic violence, drug and alcohol abuse, child neglect and abuse, low coping skills, high levels of stress and anxiety, inability to bond and care for one's baby, reduced parenting skills, and sub-optimal child development. Maternal depression is related to increased risk for low birthweight and preterm birth, likely as a result of the factors already mentioned.

Treatment
Maternal depression can be readily identified and effectively treated. Early intervention is essential, as the degree of risk to children appears related to the length of the mother's depression. However, for the most part, neither obstetric nor pediatric providers routinely assess for depression before, during or after pregnancy. Therefore, a carefully planned approach to screening, treatment and follow-up for maternal depression before, during and after pregnancy is an important factor in the promotion of healthy development among children and their mothers.

References
1. "Psychosocial risk factors: Perinatal screening and intervention." ACOG Committee Opinion No. 343. Obstet Gynecol 2006; 108-469-77.
2 .O’Hara MW, Swain AM. "Rates and risk of postpartum depression –a meta-analysis." International Review of Psychiatry 1996; 8:37-54.
3. Hobfoll SE, Ritter C, Lavin J, Hulsizer MR, Cameron RP. "Depression prevalence and incidence among inner-city pregnant and postpartum women." J Consult Clin Psychol 1995; June; 63(3):445-53.
4. Panzarine S. Slater E, Sharps P. "Coping, social support, and depressive symptoms in adolescent mothers." J Adolescent Health 1995; 17:113-119.

Practice guidelines from the American College of Obstetrics and Gynecology (ACOG)

  • Perform psychosocial screening at least once each trimester to increase the likelihood of detecting important issues and reducing risk for poor birth outcomes.
  • Have a well developed referral network that can address patients that have a positive screen for maternal depression.
  • Consider psychosocial risk factors in discharge planning post delivery. Considerations should be heightened for mothers with risk factors already present prior to delivery. These include:
 
  • barriers to care
  • unstable housing
  •  
  • communication barriers
  • poor nutrition
  •  
  • substance abuse/use
  • safety
  •  
  • stress
  • intimate partner violence
    • Clinical practices in screening for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis and implementation of treatment, and are followed up with a referral.

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    The MacArthur Foundation Initiative on Depression and Primary Care Toolkit:This is a depression toolkit created by the MacArthur Foundation’s Initiative on Depression and Primary Care to assist primary care physicians with education about perinatal depression. The toolkit provides an overview of the Patient Healthcare Questionnaire (PHQ-9) and how to use this in screening for maternal depression. The toolkit also assists providers with how to manage depressed clients and monitor their progress 
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    The Care Model for Prenatal Care: this is a model created by Dr. Wagner at the Institute for Healthcare Innovation originally developed for chronic disease but adapted for perinatal care. The model promotes a comprehensive look at systems that impact health.

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    What is a PDSA? PDSA stands for Plan Do Study Act - an abbreviated way of developing a way to testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).

    Plan Do Study Act worksheet: This is a worksheet that allows quality improvement teams to test any change made within their practice. The words Plan Do Study Act are shorthand to represent the various steps in the process in documenting the change that has been made by the team in the work setting.

    Sample Maternal Depression PDSA: Here is an example of a PDSA worksheet and how it is used to track progress on implementing any change

    Depression Clinical Pathways: Here is the clinical pathway for Maternal Depression and specifically demonstrates how to make an informed decision relating to the PHQ-9 form.

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    University of Washington School of Nursing: The University Of Washington School Of Nursing has a great resource on Maternal Depression. The site has several training modules pertaining to maternal depression and includes slide presentations and even video clips.

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