PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMS IN WOMEN: IMPLICATIONS FOR MATERNAL AND CHILD HEALTH NURSES

1. PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMS IN WOMEN: IMPLICATIONS FOR MATERNAL AND CHILD HEALTH NURSES JANE FISHER & KAREN WYNTER Jean Hailes Research Unit School of Public Health and Preventive Medicine Monash University

2. AUSTRALIA’S NATIONAL PERINATAL DEPRESSION INITIATIVE • Launched in 2009. • Objectives are to: “improve prevention and early detection of antenatal and postnatal depression and provide better support and treatment for expectant and new mothers experiencing depression”. (Austin et al., 2011)

3. AUSTRALIA’S NATIONAL PERINATAL DEPRESSION INITIATIVE In the first three years the main focus has been to: • Implement screening using the Edinburgh Postnatal Depression Scale during pregnancy and four to six weeks postpartum; • Train midwives, maternal, child and family health nurses, general practitioners and Aboriginal health workers in screening and first-line treatment; • Build referral pathways to care; • BUT, as yet little national focus on prevention.

4. PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMS Prevention strategies include: • Indicated: current symptoms; • Targeted: at risk of developing symptoms; • Universal: offered to all women (Mrazek et al, 1994; Lumley and Austin, 2001; Lumley et al 2004)

5. PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMS Universal prevention strategies: • Implemented in primary care; • Accessible and non stigmatising; • Provide a mental health promoting milieu; • Address potentially modifiable risk factors using evidence-informed approaches.

6. RISKS FOR POSTNATAL DEPRESSION Systematic reviews conclude: • past history of psychopathology, including depression during pregnancy; • coincidental adverse life events; • poor marital relationship; • low social support. (Scottish Intercollegiate Guidelines for Postnatal Depression and Puerperal Psychosis, 2001)

7. RISK FOR POSTNATAL DEPRESSION Less consistent evidence for: • unintended or unwelcome pregnancy; • longer time to conception; • operative childbirth; • not breastfeeding; • personal coping style; • unemployment; (Scottish Intercollegiate Guidelines for Postnatal Depression and Puerperal Psychosis, 2001)

8. PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMS Prediction of maternal psychological functioning • Antenatal prediction of postnatal depression through screening during pregnancy? • Low positive predictive values; • No test met criteria for routine use antenatally. (Austin and Lumley, 2003; Austin 2003)

9. UNIVERSAL ANTENATAL INTERVENTIONS TO REDUCE PND Universal antenatal interventions to prevent postpartum mood disturbance: • Additional antenatal classes, including men with practical key messages (Gordon et al, 1960; Midmer et al, 1995); • Continuous ante- to postnatal midwife care (Shields et al, 1997; Waldenstrom et al, 1999, Biro et al, 1999); • Information about depression, help seeking and recovery (Hayes et al, 2001). (Austin 2003; Austin 2004)

10. UNIVERSAL POSTNATAL INTERVENTIONS TO ‘REDUCE DEPRESSION’ Seven universal trials of postnatal interventions: • Postnatal hospital stay • Debriefing(Priest et al, 2003); • Midwife listening(Lavender et al, 1998); • Changes to postnatal care: • Earlier postnatal visit to a GP (Gunn et al, 1998); • 10 X 3 hour home visits of increased practical and emotional support (Morrell et al, 2000); • Information pack ± invitation to new mothers group (Reid, 2002); • Enhanced postnatal care by trained home visitors(MacArthur et al, 2002); • Enhanced postnatal care and community education (Small et al, 2007). (Austin, Lumley and Mitchell, 2004)

11. PREVENTION OF POSTNATAL MENTAL HEALTH PROBLEMS: Why were most interventions unsuccessful? Methodologically robust studies, so the findings are perplexing: • Aimed to reduce depression, rather than anxiety, which is prevalent and problematic; • Did notdistinguish between newonset or recurrent conditions; • Modifiable or non-modifiable risk factors? • Addressed low social support by providing increased professional support;

12. NEGLECTED BUT POTENTIALLY MODIFIABLE RISK FACTORS Infant behaviour: • Prolonged crying; • Resistance to soothing; • Dysregulated sleeping and feeding; • Irritability; (Fisher, Feekery and Rowe-Murray, 2002; Fisher, Rowe and Feekery, 2004)

13. NEGLECTED BUT POTENTIALLY MODIFIABLE RISK FACTORS Partner behaviours: • Being unavailable through long hours in employment and independent leisure; • Rigid gender stereotypes about the division of labour; • Limited participation in unpaid workload of infant care and household tasks; • Lack of sensitive emotional support; • Criticism and coercive control; (Fisher, Feekery and Rowe-Murray, 2002)

14. NEGLECTED BUT POTENTIALLY MODIFIABLE RISK FACTORS Occupational fatigue: • Increased, but unrecognised, workload of infant care and household tasks; • Frequently interrupted sleep; • Insufficient sleep; Contributes to: • Irritability, poor concentration, reduced functional efficiency.

15. CHANGE IN MATERNAL DEPRESSION (EPDS) * p<.0001

16. CHANGE IN INFANT CRYING AND FUSSING * p <.001

17. IMPLEMENTATION OF PREVENTION STRATEGIES Successful implementation of universal prevention strategies requires: • Detailed understanding of the views of primary care providers; • Consultation with primary care providers about content; • Identification of barriers to implementation; • Identification of learning needs.

18. ONLINE SURVEY OF PRIMARY MATERNAL AND CHILD HEALTH PRACTITIONERS Aims: • What are primary care practitioners’ views, experiences, current practices in relation to postnatal mental health problems? • What are their specific views about potentially modifiable risk factors for postnatal mental health problems? • What are their views about adaptations to practice to include new strategies to prevent postnatal mental health problems? • What learning needs do they identify?

19. SURVEY

20. RESPONDENTS Overall response rate = 343/1051=32.6%

21. RESPONDENTS

22. WHAT CONTRIBUTES TO MENTAL HEALTH PROBLEMS IN PARENTS? In your experience, what are the three main contributing factors to mental health problems in parents of infants in your area?  

23. WHAT CONTRIBUTES TO UNSETTLED INFANT BEHAVIOUR? We know that parents often seek help with a baby who is unsettled (for example, sleeps poorly, cries inconsolably, is difficult to feed, is difficult to manage). In your experience, what contributes to unsettled infant behaviour?

24. ADVICE REGARDING FREQUENT OVERNIGHT WAKING Please imagine that a mother/caregiver presents with a concern regarding her 6 – month old infant, of age-appropriate weight, who wakes every few hours overnight and/or is difficult to settle. She is distressed about this. Please could you tell us briefly what advice you would give her. • MCH nurses have a consistent view that comprehensive assessment of and responses to women’s mental health are integral to MCH services.

25. ADVICE REGARDING FREQUENT OVERNIGHT WAKING • most (213) would “discuss settling strategies”, but • many (125) did specify what approach to settling would be taken; • among the the rest, 25 different approaches were described e.g.: Controlled comforting Wrap the infant Controlled crying Do not wrap the infant Let the infant cry Patting the cot Camping out Do NOT let the infant cry Stretcher method Co-sleeping

26. ADVICE REGARDING FREQUENT OVERNIGHT WAKING • In the absence of clear and specific clinical practice guidelines, nurse are currently offering very varied advice to parents • No agreement amongst respondents about what sleep patterns are “normal” for 6 month old infants, or whether / where to refer parents for help with sleep and settling problems.

27. ASKING ABOUT OCCUPATION How do you ask a woman about her occupation? Included because: • increased, but unrecognised, workload of infant care and household tasks; • rigid gender stereotypes about the division of labour are a common problem for parents in adjusting to new roles; • primary care practitioners can be agents of social change; • gender-informed language is part of establishing a mental health promoting milieu.

28. ASKING ABOUT OCCUPATION • Many MCH nurses use language that names and values this unpaid work • Some encourage women not to describe their current occupations as ‘not working’ or being ‘just a mother’. I ask her what she does in 'paid employment.' If she says that she is 'only a mother' as many do, I tell her that she is doing the most important job that there is. • However, some still ask about “work”. Do you work normally?

29. INCLUSION OF FATHERS IN FTP GROUPS • Most MCH nurses indicated that fathers are welcome to attend. • Only 12% reported that fathers are specifically invited. • Specific group activities implemented to increase fathers’ participation have not been well attended. • Current content of FTP groups: • 45% include partner relationships • 85% include “A settled baby: what does it mean?” • We've tried fathers groups in our area....no interest

30. WILLINGNESS TO MAKE CHANGES TO FTP PROGRAMS

31. WILLINGNESS TO MAKE CHANGES TO FTP PROGRAMS • Less than 1% of MCH nurses indicated that FTP group sessions are currently offered on a Saturday morning. • Almost 75% acknowledged that offering programs only in conventional office hours was a barrier that prevents fathers from participating.

32. IMPLICATIONS • MCH nurses recognise that in addition to their role in the identification and treatment of current symptoms, they have a role in promotion of mental health and prevention of mental health problems; • MCH nurses identified the following potential risks for postnatal mental health problems: • new parents’ lack of relevant knowledge and skills to respond to unsettled infant behaviours; and • lack of support / the quality of the intimate partner relationship.

33. IMPLICATIONS • MCH nurses have diverse views about ways to respond to parents seeking assistance with unsettled infant behaviours. This would be assisted by evidence-informed clinical practice guidance. • They are interested in future professional development about the prevention of postnatal mental health problems in primary care.

34. ACKNOWLEDGMENTS • Victorian Department of Education and Early Childhood Development • Anne Colahan • Karene Fairbairn • Jennifer Carr • Municipal Association of Victoria • Helen Rowe • Jean Hailes Women’s Research Unit: • Heather Rowe • Joanna Burns • Evaluation Solutions Pty Ltd