This report was triggered by a video entitled ‘The Baby Blues’ (BBC 1995) which was part of an enquiry-based-learning module. The focus of the enquiry will be on the midwife’s role in identifying the psychological factors that put women at risk of developing postnatal depression highlighting strategies such as ‘primary prevention’ and ‘early intervention’ (Austin 2003) to improve outcomes in mortality, morbidity and encourage positive mother-baby relationships.
The transition from womanhood to motherhood is a ‘rite of passage’ (Van Gennep 1909, 1969) and can contribute to personal growth and be wonderful, but it can also be a time that can predispose women to mental disorders. Barnes (2002) describes the transition to parenthood as an ‘experience of crisis proportion’. Affective disorders can range from mild transitory ‘blues’ through to severe postnatal depression, puerperal mania, and psychosis (Brockington 1996).
The Department of Health (DOH 2002) takes the view that maternal mortality due to mental illness around pregnancy and childbirth has the ‘potential’ to be ‘prevented’, by identifying mothers at risk during the antenatal period (DOH 2002). This poses the question; what can midwives do antenatally to identify risk factors and prepare woman for the adaptation to motherhood, thereby minimising the risk of them developing postnatal depression.
Community midwives are well placed (Carson 2001) to carry out risk assessments throughout the antenatal period referring to other health professionals such as General Practitioners (GP), Health Visitors (HV), Community Mental Health Team (CMHT), and Obstetric Consultants when specialised input is required. At present, there are no valid screening tools for antenatal depression (Austin ; Lumley 2003) but that should not stop midwives from developing effective interpersonal relationships with women and their partners using good communication and observational skills to assess women’s mental health during antenatal visits.
NICE (2003) guidelines recommend between seven and ten antenatal appointments depending on parity for routine pregnancy care, this is a minimum recommendation. Should the women’s status indicate that further visits are necessary the midwife can arrange for extra appointments as required? Dennis and Creedy (2004) in a recent systematic review note that by managing ‘risk factors’ it maybe possible to assist in the prevention of postnatal depression, however, they also noted that psychosocial interventions antenatally did not reduce the incidence of PND.
Contrary to popular belief, pregnancy does not protect a woman from becoming depressed (Kahn et al 2001), an article in the Harvard Mental Health Letter (2002), reported that the lack of recognition of antenatal depression could be due to the misconception that pregnancy protects against mood disorders. Both these statements are contradicted in the recent Maternity Services (DOH 2004) document, which refers to a ‘reduction of serious mental illness during pregnancy’, Opposing views in the literature draw attention to the paucity of valid research into perinatal mental ill health.
In 1990, Nicolson identified that despite the development of preventative programmes, most treatment initiatives are reactive. Various studies are now focusing on the pro-active approach to dealing with mental illness during pregnancy and the postnatal period. Ross et al (2004) acknowledge that following two decades of research, affective disorders are worthy of investigation during the perinatal period. Evans et al (2001) have identified that a higher percentage of women experience more depressive symptoms during pregnancy than postnatally, while Austin (2004) suggests that postnatal depression could be a ‘continuum of distresses’ with its onset in the antenatal period.
In a study by Larsson et al (2004), forty-six percent of women with antenatal depressive symptoms had depression postnatally. Some women, who fear the stigma of mental illness (SIGN 2002), suppress the signs and symptoms of non-psychotic depression and anxiety, the result of which if they remain undiagnosed, and receive no help can result in self-harm and violent suicide both during pregnancy and postnatally.
According to Brockington (2004) the term ‘postnatal depression’ (PND) is a lay term that has been useful in reducing the stigma attached to mental illness, which means that women have found it a more socially acceptable condition to seek help for. Nevertheless, deaths from mental illness are actually the leading cause of maternal death (Lewis 2001). The Confidential Enquiry into Maternal Deaths recommends that a relatively simple procedure should be instituted in every antenatal clinic to identify women at risk of postnatal psychiatric illness and/or self-harm (Drife 1998, Lewis 2001).
This could prove to be problematical for midwives as NICE guidelines (2003) state that pregnant women should not be offered antenatal education interventions to reduce perinatal or postnatal depression, as these interventions have not been shown to be effective. Conversely key recommendations presented in Mainstreaming Gender and Women’s Mental Health (DOH 2003) make it clear that services should consider staff training needs particularly for midwives and health visitors, furthermore, information related to mental health in pregnancy and how to access help should be available to all women. A point reiterated in The National Service Framework (DH 2004). It would be difficult for midwives to broach the subject of mental illness and identify women at risk; without offering some form of information related to mental health issues.
Women who have a family history or have had major depression in the past have a higher risk of becoming depressed in pregnancy and developing a postnatal psychiatric illness which affects approximately 10 to 13% (O’Hara ; Swain1996) of all mothers. Puerperal psychosis affects 2: 1000 women (Lewis 2001) and usually occurs early in the puerperium. Non-psychotic postnatal depression has a peak onset of 4 – 6 weeks. Detection not ‘diagnosis’ is aided by use of the Edinburgh Postnatal Depression Scale (EPDS, Cox et al 1989); the Health Visitor will complete an EPDS with all women between 4 – 6 weeks postpartum and again between 3 – 4 months. Baby blues, which occurs 3 – 5 days postpartum, usually resolves spontaneously, it is considered a normal physiological response (Strass 2002), and affects up to 80% of all mothers (Ussher 2004).
The literature suggests that postnatal depression is a normal response to a life event (Murray et al 1995, Paykel 2002). Many researchers argue that there is little to distinguish PND from depression occurring at other times (O’Hara and Zekoski 1988; Watson et al. 1984; Whiffen 1991, 1992; Whiffen and Gotlib 1993 cited by Hagen 1999), with Nicolson (1990) describing it as parallel to a ‘grief reaction’ and part of a normal postnatal profile.