Postpartum Depression: Women’s Perspectives of their Support Needs

1. Postpartum Depression: Women’s Perspectives of their Support Needs N. Letourneau PhD RN L. Duffett-Leger MN(C) RN

2. Co-Investigators M. Stewart PhD C.-L.Dennis PhD RN K. Hegadoren PhD RN C. Rinaldi PhD CPsych J. Stoppard PhD CPsych

3. Overview • Background • Study Description • Research Findings • Next Steps

4. 1. Background

5. Causes of PPD Hormonal Changes • Dopamine sensitivity • Thyroid Dysfunction Negative Life Events • Marital conflict, lack of support from friends, family or partner, social isolation

6. persistent negative mood anxiety irritability sleep disturbance lack of energy lack of enthusiasm feelings of worthlessness loss of pleasure poor appetite inability to cope with daily activities (e.g. look after child) poor concentration poor memory suicidal ideation unreasonable fears What is PPD?

7. Duration and Function • Symptoms lasting longer than 1 week • Symptoms affect functional ability to look after self or child

8. Who is affected? • Depression following childbirth affects up to 25% of new mothers. • PPD has serious implications for: • women’s health • family functioning • health and development of children.

9. When? • PPD symptoms begin within first 12 weeks after birth. Duration depends on the time taken to access treatment. • 50% of women remain clinically depressed at 6 months postpartum. • 25% of untreated women remain clinically depressed for over a year after the birth of their child.

10. Need for the Study • 50% of women decline support from a professional even when it is available. • 50% of women with PPD decline medication. • Available health services may not be sufficient to meet women’s needs.

11. Need for the Study • For many, medication is insufficient to fully address PPD symptoms. • Multiple causes of PPD suggests multiple interventions are needed. • Current research has not addressed women’s perspectives of their needs and preferences for support interventions.

12. 1. Study Description

13. Research Questions For women with PPD, what are their: • Support needs • Available resources • Barriers to accessing resources • Preferences for support interventions

14. Research Design Multi-site exploratory, descriptive study conducted in Edmonton, Alberta (urban) and New Brunswick (rural).

15. Sample & Setting • Eligible mothers >18 years of age, had a baby and experienced PPD within the past 24 months for >1 week • Mothers at both sites (AB= 24, NB= 18) participated in individual interviews • Group interviews were conducted with mothers (AB= 5, NB= 6) and service providers (AB= 14, NB= 18)

16. Description of Sample

17. Description of Sample

18. 2. Findings

19. Findings • 71% reported symptoms of depression in the last 2 weeks • 64% of the women reported a difficult pregnancy/ delivery • 83% of sought professional help for PPD from service providers (i.e., public health services).

20. PPD Symptoms

21. Provincial Differences

22. Provincial Differences

23. Support Needs Women identified a number of support needs in 3 distinct categories: • Instrumental • Emotional/Affirmational • Informational

24. Support Needs Instrumental In-home Spousal “A new mom coming to help me, to show me how easy it is to take a baby out; to go out with the car seat, to show me how to breastfeed in a mall, or just to be more mobile”. (PPD_3) “He fully supported me. I think [pause] the only reason I think he couldn’t have helped me more is he wasn’t sure how to”. (PPD_16)

25. Support Needs Instrumental Family/Friends “My Mother-in-law helped my situation… Just having someone here all the time, who you could just say it’s O.K.…and she would take the baby and you wouldn’t have to worry about it” (PPD_1)

26. Support Needs Emotional/Affirmational “Getting somebody to talk with, and getting the validation, and getting the understanding, getting a sense of we’re here to help”. (PPD_12)

27. Support Needs Informational Knowledge for self (baby care, normal child development, PPD) “As I tell everybody, you know that thing that comes out after the baby is a placenta, not a manual. We don’t know any more than they do, but we’re expected to.” (AB Group Interview)

28. Support Needs Informational Knowledge for others (understanding & identification of PPD) “I want them [husbands] to go to a class that’s called ‘What the Hell’s Wrong With My Wife?’ [laughter] Explain it to them. Because they have no idea. They just see all of a sudden, their wife is different”. (AB Group Interview) “You know, you have to take counseling to get married, well in my religion anyways, there’s marriage preparation courses, where are the children preparation courses? Where do they tell you to prepare for no rest, the conflicts between husband and wife?” (PPD_33).

29. Support Resources Mothers in New Brunswick and Alberta identified the need for both informal and formal supports.

30. Informal Resources • Self • Partner • Family and friends

31. Informal Resources Self “I have learned through this that you have to be your own advocate and you have to trust in yourself because, if you don’t, nobody else will fight for you” (PPD_35). Partner “I’d just sit there and get right quiet and I’d look like I was going to start bawling at any minute and he’d just come over and give me a hug and make me feel better” PPD_36).

32. Informal Resources Family “One time I was feeding the baby in the kitchen and I just said- I have to go. So I called my mom and I said- mom I need you to come over with the kids and I have to go. I need to get some help. But just talking to my mom made me feel better” (PPD_38). Friends “And I have a friend who lives in the building. I go talk to her. If I’m stressed out and just need a minute to get out, I just go and see her for a few minutes and then I come back” (PPD_36).

33. Formal Resources • Medical/mental health providers • Mom’s Groups, Breastfeeding Support Groups • In-home support • Telephone Support Lines • Church/Spiritual Support

34. Formal Resources Medical/Mental Health Providers “The nurse was incredible [public health]. She talked to me, and she would phone and check on me, and if I was down she showed up. So she was really good. And my physician listened when I said ‘No pills’”(PPD_7). “I had a psychiatrist that was involved with my first pregnancy, and I got reacquainted with her due to the state of depression that set in during pregnancy. She helped me monitor things and keep them in a proper light as opposed to letting things get blown out of proportion like they sometimes do.(PPD_35).

35. Formal Resources Mom’s groups “I’ve been meeting new moms, and that was the big thing, because I don’t have any friends that really have any kids, so just to meet some new moms was good” (PPD_15). In-home support “They [name of program] will come and watch your other kid, or if you have a pile of dishes, they’ll do dishes. If you need vacuuming, they’ll do that. If you want to, they’ll just sit down and talk with you and have a coffee (PPD_16).

36. Formal Supports Telephone Support Lines “The Mother-Baby Hotline. The twenty-four hour hotline, that really helped” (PPD_33). Spiritual Support “I think in the spiritual sense, they’re very supportive. Like, they can’t help you personally, but they say they will pray for you, and if you need help, by all means, just ask. But I never asked them. It’s just support in a spiritual sense” (PPD_21).

37. Barriers to Support Mothers with PPD identified themselves as the most common barrier to accessing support “You know deep down inside that you really do need this, and you really do want it, but what comes out of your mouth is, ‘No, I don’t need any help’ even though inside, you’re screaming, and saying, ‘Yes, for God’s sake, help me.’ ” (AB Group Interview)

38. Barriers to Support • Self: shame/stigma/denial/fear •  energy to make appointments, leave house, seek help • Family & friends minimizing symptoms • Fear of taking anti-depressants (while breastfeeding) • Lack of services or services do not meet needs • Financial constraints • Early maternal discharge • Inconsistent messages & difficulty developing rapport with service providers.

39. Barriers to Support Self “It was just my being worried about what people were going to think if I felt that way. And I didn’t want to be given any kind of prescription drugs for how I was feeling. Looking back now, I know that I should have opened up way earlier” (PPD_31). “I didn’t want to seem like a bad mom. My overriding fear was that somebody would think that I was being terrible and take (babies name)” (PPD_32). “And I think when you have suffered from depression before you always think that you are the one that can’t handle situations like others can. And so there is a certain stigma about that. Obviously the word depression. I didn’t want to be labeled that” (PPD_42)

40. Barriers to Support No Energy “The thought of going out of my house... to dress that baby up and go out in public? No, I couldn’t even think about it. No. Because that was just one more thing to have to do” (PPD_33). Finances “More finances would have helped me to go to the psychologist. That definitely stopped me from getting as much help as I needed.” (PPD_31).

41. Barriers to Support Services “ I wish there would have been more support groups. Because I didn’t have anybody that I could say, “Hey, you went through the same thing I did. Well, how do I get through this?” I had nobody around to really talk to about that” (PPD_36). “Well, lack of resources. There is nothing in my face saying- if you are depressed call this number. I mean, it’s non-existent… and just my own need to do it all like a good little mother, good little wife. And not breastfeeding… Yeah, all the groups it seemed that were for breastfeeding mothers or abusive mothers or mothers that didn’t have money, you know what I mean”. (PPD_41).

42. Preferences for Support Women described several preferences for: • One-on-one support; • Group support; and, • Greater public awareness about PPD

43. One-on-One Support Instrumental and informational support “It’s that initial stage… you come and you take some control here. You say, ‘You don’t look good. Go to bed. I’m here, I’m handling this. Don’t even get up. Just go to bed. We’re here.’… You want a mom, but not your mom.” (AB Group Interview) “Like teaching the mother- and this sounds so simple but it is necessary- teaching the mother to enjoy the child’s toes. Teaching the mother how to interact with the baby and how to coo and how to talk to the baby, and that the baby knows you and loves you right away and knows your voice. Some mothers may not know that. Teaching how to deal with stress so that you are not freaking out at the baby because sometimes you are crying and yelling” (PPD_41).

44. One-on-One Support Emotional and affirmational support “Once you’ve got your routines down and you know how to change a diaper, you know how to bathe the baby, you know how to get the meals on time, you know how to you’re on top of that game, then you need the mental working-out, then you need the counseling” (AB Group Interview) “I think to be able to approach it with compassion and to develop a rapport; you need to see the same person over and over again.” (AB Group Interview)

45. Group Support Members would include mothers with similar symptoms and those who have recovered. “I would want to talk to someone…I have a group right now. We meet, there’s four women, we meet every week. And I would want to talk to someone who has already been through postpartum depression, who doesn’t pretend that it’s perfect, that it’s just a natural, earthy, wonderful experience. Someone who’s very real, that I could talk to about the real side” (PPD_33). “Shared experience is good. Like if they are going through a similar experience or they are having similar problems…. I just took a lot of comfort when someone would say- oh I had a terrible time and that was so terrible- just hearing other people’s stories. I don’t know why but you take such great comfort in that- I guess it’s because you don’t feel alone. You know, you don’t feel like you are crazy (PPD_38).

46. Group Support Group would provide a safe place where mother’s feelings are validated. “For me, I would have had to start in a group, ‘cause there’s safety in that, and kind of the admission that I’m not okay, that there’s a safety in the group. And then maybe, if you get, like, a mentor person, and then you go with one-on-one, once you’ve established kind of that safety”. (AB Group)

47. Group Support Group would provide an avenue for mothers to socialize with other mothers in similar situations. “I need a group where I can feel like there’s a safe place to say ‘This isn’t the greatest time of my life’, and I won’t be judged. And just getting some support around, and also just getting some support that you are a good mom, and that your baby does feel loved, even though you’re not, like, jumping up and down for joy. [pause] And that it will get better”. (PPD_12)

48. Group Support Most women felt the group should be facilitated by a professional or paraprofessional with group facilitation skills and experience with PPD. “I think someone that has definitely been through postpartum depression would be best to facilitate something like that because they’d have their own experiences that they could relate with you. Then you’d understand that, ok, they do understand where I’m coming from” (PPD_31).

49. Preferences for Support Public Awareness • Women identified a need for increased public awareness of PPD. • If better understood/less stigmatized, it would be easier for the mothers and their loved ones to recognize the symptoms and get help.

50. Public Awareness “I think people in general need to be more aware. Some people might not see it until their partner or their friend or their sister or somebody says, ‘You’re not yourself.’ Other people around you need to know, ‘Okay, this is a possibility and these are the things you look for and this is what you can do.” (PPD_41)