Improving Maternal Depression Screening in the Neonatal Intensive Care Unit.

PURPOSE: To examine whether self-perceived benefits of mental health treatment differed between mothers of babies in the neonatal intensive care unit with and without a positive screen for depression based on their Edinburgh Postnatal Depression score. STUDY DESIGN AND METHODS: Mothers were recruited in person pre-COVID-19 pandemic, and via phone call and online advertisement during the pandemic. Mothers completed a 10-item depression scale and whether they believed they would benefit from mental health treatment. A chi-square test determined the difference in perceived benefit between mothers who screened positively for depression and those who did not. RESULTS: This secondary analysis included 205 mothers, with an average age of 29. Of the 68 mothers who screened positively for depression, 12 believed that would not benefit from mental health intervention. Of the 137 who screened negatively for depression, 18 believed they would benefit from mental health intervention. Mothers who screened negatively for depression were significantly less likely to believe they would benefit from mental health intervention. CLINICAL IMPLICATIONS: Depression screening scales offer guidance on which mothers to flag for follow-up, but neither on how a mother will respond nor how to effectively approach a mother about her mental health. Nurses can improve identification and follow-up of depressed mothers in the neonatal intensive care unit by asking mothers about their perceived need for mental health treatment.

Compassionate Care: Listening Visits Provided by Neonatal Intensive Care Unit Nurses.

PURPOSE: Although mothers of infants hospitalized in a neonatal intensive care unit (NICU) often experience clinically significant levels of depression symptoms, accessing mental-health treatment may be difficult. NICU mothers need emotional support that is conveniently delivered at the infant's point-of-care by a trusted professional who is knowledgeable about the medical and nursing care in the NICU. Listening Visits are an effective and accessible, nurse-delivered depression intervention, yet little is known about what mothers discuss during these sessions. This analysis of sessions recorded during the randomized controlled trial evaluation of Listening Visits in the NICU provides a glimpse into NICU mothers' concerns and experiences. STUDY DESIGN AND METHODS: This is a secondary, qualitative case analysis of the recorded Listening Visits sessions of four depressed NICU mothers as indicated by a score of 12 or above on the Edinburgh Postnatal Depression Scale. The mothers, who were all White, varied in their economic resources, educational level, availability of support, and infant illness severity. RESULTS: Mothers discussed similar concerns and experiences, often at analogous temporal points in the six Listening Visit sessions, as well as one common concern they voiced throughout: family and friends do not understand what it is like to have an infant in the NICU. CLINICAL IMPLICATIONS: For mildly to moderately depressed mothers of infants hospitalized in the NICU, Listening Visits provide a way for bedside nurses to deliver compassionate care by listening to mothers' concerns and experiences.

Over-the-Counter Pain Medication Use During Pregnancy.

PURPOSE: To examine over-the-counter pain medication use in pregnancy. STUDY DESIGN AND METHODS: Secondary analysis of a weighted surveillance survey using the 2019 Iowa Pregnancy Risk Assessment Monitoring System (PRAMS) data. A sample of 759 pregnant women of childbearing age from Iowa was weighted to represent 31,728 Iowa mothers. The weighted sample represents 80% non-Hispanic White mothers, with smaller percentages of Hispanic (10%) mothers and non-Hispanic Black (7%) mothers, consistent with the population of Iowa. Approximately two-thirds of women had commercial insurance (66%), some college or greater education (62%), and were from urban areas (59%). ANALYSIS: Descriptive statistics were calculated. Variables include over-the-counter pain reliever usage among all respondents and by race/ethnicity and education level. RESULTS: Seventy-six percent of women reported taking over-the-counter pain relievers during pregnancy. Of these, 71% reported taking acetaminophen, 11% reported taking ibuprofen, 8% aspirin, and 3% naproxen. Nearly 80% of non-Hispanic White mothers reported taking an over-the-counter pain reliever during pregnancy compared to just 64% of mothers reported as Hispanic. Iowa mothers with a college education or greater were more likely to report over-the-counter pain reliever use during pregnancy (84%) than their counterparts with a high school education or less (64%). CLINICAL IMPLICATIONS: Some medications may cause harm to the fetus if taken at specific time during pregnancy. Reinforcement of current pain medication education, including risks to fetus throughout pregnancy may be needed.

Creating affiliations, learning, and mindfulness for in vitro fertilization patients (CALM IVF): a clinical trial.

Objective: Determine if group psychoeducational support can improve in vitro fertilization (IVF) patients' quality of life (QoL). Design: Randomized controlled trial (NCT04048772). Setting: University-affiliated IVF clinic. Patients: Women (n = 76) and male partners undergoing initial autologous IVF cycle from August 2019, to December 2020. Interventions: Couples were assigned to groups based on projected oocyte retrieval date. Groups were randomly assigned to the control or intervention arm. Clinic closures because of the COVID-19 pandemic delayed treatment for a portion of participants. Groups were conducted in person before and virtually during the pandemic. Main Outcome Measures: The primary outcome was a change in fertility quality of life (FertiQoL) from baseline to 3 days after retrieval. Secondary outcomes were changes in depression (Patient Health Questionnaire 9), anxiety (Generalized Anxiety Disorder 7), resilience (Connor-Davidson Resilience scale), IVF knowledge scores, and the likelihood of return to treatment. Results: Knowledge scores among women in Creating Affiliations, Learning, and Mindfulness (CALM) for IVF groups significantly increased compared with control (mean difference 13.19 [3.53 - 22.84]) before the pandemic. During the pandemic, women in CALM IVF had significant improvement in the social FertiQoL score compared with controls (10.42 [1.79 - 19.04]). Compared with controls, male CALM IVF participants had significantly greater improvement in total FertiQoL (mean difference 6.68 [0.39 - 12.98]), treatment FertiQoL (8.26 [0.69 - 15.82]), and resilience (Connor-Davidson 1.13 [0.54 - 1.72]). Immediate return to care did not significantly differ between arms. Conclusions: For women undergoing IVF, group psychoeducational programs can improve IVF knowledge and social QoL during a pandemic. Participation in a group psychoeducational program can improve QoL and resilience in IVF dyad male partners. Clinical Trial Registration Number: Trial registration NCT04048772.

A Randomized Controlled Trial of Listening Visits for Mothers of Hospitalized Newborns.

BACKGROUND: Emotional distress is frequently experienced by mothers whose newborns are hospitalized in a neonatal intensive care unit (NICU). Among these women, there is a critical need for emotional support conveniently delivered at the newborn's point of care by a trusted and medically knowledgeable professional: a NICU nurse. One promising way to enhance in situ delivery of emotional care is to have a NICU nurse provide Listening Visits (LVs), a brief support intervention developed expressly for delivery by nurses to depressed postpartum women. OBJECTIVES: This trial assessed the feasibility of having NICU nurses deliver LVs to emotionally distressed mothers of hospitalized newborns and compared depression outcomes in a small sample of participants randomized to LVs or usual care (UC). METHODS: In this pilot randomized controlled trial, emotionally distressed mothers of hospitalized newborns were randomized to receive up to six LVs from a NICU nurse or UC from a NICU social worker. To assess change in depression symptoms, women were invited to complete the Inventory of Depression and Anxiety Symptoms-General Depression Scale at enrollment and 4 and 8 weeks post-enrollment. RESULTS: Depression symptoms declined over time for both groups, with no difference between the two groups. A post hoc analysis of reliable change found higher rates of improvement at the 4-week assessment among recipients of LVs than UC. DISCUSSION: NICU nurses successfully implemented LVs during this trial. Depression symptom scores did not significantly differ in the two groups posttreatment or at follow-up. Nevertheless, post hoc analyses indicated comparatively higher rates of clinical improvement immediately after LVs, suggesting the intervention can reduce maternal depression early on when women are most distressed.

Telehealth Listening Visits for emotionally distressed mothers of hospitalized newborns: Proof-of-concept.

Problem: Newborn admission to the neonatal intensive care unit (NICU) is stressful. Yet in clinical practice, at best, NICU mothers are screened for depression and if indicated, referred to a mental-health specialist. At worst, no action is taken. Listening Visits, an empirically supported nurse-delivered intervention addressing emotional distress, can be conveniently provided by a NICU nurse. Prompted by the need to minimize face-to-face contacts during the pandemic, the primary purpose of this small pilot trial was to assess the feasibility of having nurses provide Listening Visits to NICU mothers over Zoom. Secondarily, we assessed pre-to post-Listening Visits depression symptom scores as a preliminary evaluation of the effectiveness of this type of support. Materials and methods: Nine NICU mothers with mildly to moderately severe depression symptoms received up to six Listening Visits sessions from a NICU nurse via Zoom. Participants completed the Inventory Depression and Anxiety Symptoms-General Depression scale (IDAS-GD) at study entry and 4- and 8-weeks post enrollment. They completed the Client Satisfaction Questionnaire (CSQ) at the 8-week assessment. Results: Using an intent-to-treat approach, the effect of time from the mixed model analysis of IDAS-GD was statistically significant (F(2,26) = 10.50, p < 0.001), indicating improvement in IDAS-GD scores from baseline to follow-up. The average CSQ score was high (M = 29.0, SD = 3.3), with 75% of participants rating the quality of help they received as "excellent". Discussion: In this pilot trial, we learned it is feasible to provide Listening Visits over Zoom, that this mode of delivery is associated with a significant decrease in depression symptom scores, and that women value this approach. Clinical trial registration: [https://clinicaltrials.gov/], identifier [#201805961].

Race/ethnicity matching boosts enrollment of black participants in clinical trials.

BACKGROUND: Enrollment of a representative sample of racial or ethnic-minority participants can be challenging for researchers conducting clinical trials. One proposed solution is race/ethnicity matching (i.e., aligning the racial or ethnic identity of the trial recruiter with that of the desired participant), but in practice this idea has yielded mixed results. Nevertheless, the approach seems inherently strong, so we reevaluated this strategy in a secondary analysis. METHODS: Black participant enrollment was tracked during the screening phase of two clinical trials led by the same PI and conducted in the same setting: the NICU of a midwestern academic hospital in a predominantly White locale. In the first trial, the recruiter was a White neonatal nurse practitioner from the NICU. In the second trial, the recruiter was a Black research nurse. In this evaluation of race/ethnicity matching, the number of Black women who enrolled into the screening phase of the two trials was compared. RESULTS: The Black research nurse enrolled twice as many Black participants into the screening phase of a clinical trial compared to the White NICU neonatal nurse practitioner (12.24% & 6.1%, respectively). The 6.14 percentage-point difference in Black participant enrollment is significant using Fisher's exact test (p = 0.035). CONCLUSIONS: The key finding is that the Black recruiter enrolled a significantly greater number of Black participants than the White recruiter, suggesting that race/ethnicity matching is a viable strategy for increasing racial/ethnic minority participation in clinical studies.

Lessons Learned Recruiting and Retaining Pregnant and Postpartum Individuals in Digital Trials: Viewpoint.

In an increasingly connected world and in the midst of a global pandemic, digital trials offer numerous advantages over traditional trials that rely on physical study sites. Digital trials have the potential to improve access to research and clinical treatments for the most vulnerable and minoritized, including pregnant and postpartum individuals. However, digital trials are underutilized in maternal and child health research, and there is limited evidence to inform the design and conduct of digital trials. Our research collaborative, consisting of 5 research teams in the U.S. and Australia, aimed to address this gap. We collaborated to share lessons learned from our experiences recruiting and retaining pregnant and postpartum individuals in digital trials of social and behavioral interventions. We first discuss the promise of digital trials in improving participation in research during the perinatal period, as well as the unique challenges they pose. Second, we present lessons learned from 12 completed and ongoing digital trials that have used platforms such as Ovia, Facebook, and Instagram for recruitment. Our trials evaluated interventions for breastfeeding, prenatal and postpartum depression, insomnia, decision making, and chronic pain. We focus on challenges and lessons learned in 3 key areas: (1) rapid recruitment of large samples with a diversity of minoritized identities, (2) retention of study participants in longitudinal studies, and (3) prevention of fraudulent enrollment. We offer concrete strategies that we pilot-tested to address these challenges. Strategies presented in this commentary can be incorporated, as well as formally evaluated, in future studies.

The Lived Experience of Pain and Depression Symptoms during Pregnancy.

BACKGROUND: Depressive symptoms and pain are prevalent during pregnancy. Untreated pain and depressive symptoms occurring together may have a negative effect on maternal and newborn outcomes, yet little is known about women's experiences with pain and depressive symptoms during pregnancy. The purpose of this study is to describe the lived experience of depressive symptoms and pain occurring in women during the third trimester of pregnancy. METHODS: A descriptive phenomenological study was conducted. Women during postpartum were recruited from a previous cross-sectional study of women in their third trimester that evaluated the relationship between pain, depression, and quality of life. Twenty-four women entered their responses into an online secure research Web site. These data were analyzed using Colaizzi's method of descriptive phenomenological analysis. RESULTS: Four themes that described the essence of women's experiences with both pain and depressive symptoms were identified. They were pregnancy: feeling minimized, unheard and overwhelmed; attempting or trying but not treated: living with pain and pain interference; pain, sleep loss, and suffering; and pain and depressive symptoms: helpless, hopeless, and suffering. CLINICAL IMPLICATIONS: If a woman presents with pain, additional nursing assessments of her sleep and emotional state may be needed. Likewise, a positive depression symptom screening suggests the need for a more in-depth exploration of pain, pain interference, poor sleep, and mental health symptoms. Because the women perceive their pregnancy as minimized, nurses may need to assist in setting realistic expectations and encouraging social support. Nurses listening to women describing these conditions may be essential in promoting the women's wellbeing.

Perceived Racial Discrimination and Depressed Mood in Perinatal Women: An Extension of the Domain Specific Stress Index.

PURPOSE: The negative impact of stress on the mental health of perinatal women is well-established. Prior research using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) confirms three distinct stress domains: financial, relationship, and trauma. In 2013, an item assessing perceived racial discrimination was added to the Iowa PRAMS. Using the first phase of available data, we examine whether perceived racial discrimination represents an independent stress domain and assess its association with postpartum depressed mood. METHODS: A principal component analysis of the Iowa PRAMS data (2013-2015: N = 2,805) evaluated stress and perceived racial discrimination. Logistic regression examined the effect of racial discrimination on postpartum depressed mood. RESULTS: In Iowa, 4.4% of respondents perceived racial discrimination, with higher rates among non-Hispanic Black women and Hispanic women. The principal component analysis identified five stress domains: financial, relational, traumatic, emotional, and displacement. Perceived racial discrimination did not load onto any of these domains, suggesting that it represents an independent stress component. Logistic regression indicated that those who experienced perceived racial discrimination were twice as likely to have experienced depressed mood. CONCLUSIONS: Racism, in the form of perceived racial discrimination among pregnant women, is a unique domain of stress that is significantly associated with an increased risk for depressed postpartum mood. Decreasing discrimination's effects on perinatal mental health could begin with ensuring respectful and compassionate health care during pregnancy and the postpartum period.

Pathways from pain to physical and mental health-related quality of life during the third trimester of pregnancy: an exploratory mediation analysis.

AIMS AND OBJECTIVES: To understand how pain affects physical and mental health-related quality of life during the third trimester of pregnancy. BACKGROUND: Poor health-related quality of life during pregnancy is associated with adverse maternal foetal health outcomes such as increased risk of low-birth-weight neonates. Poor health-related quality of life is linked to pain, pain interference and anxiety in the general adult population. However, we do not know how pain, pain interference (i.e., interference of pain with patient function), and anxiety are interrelated during the third trimester of pregnancy. METHODS: This exploratory cross-sectional study followed STROBE guidelines. A mobile educational and tracking pregnancy application was used to obtain a racially/ethnically diverse convenience sample of 141 third trimester pregnant women from the U. S. In this sample, 58.2% of women had commercial health insurance, 68.8% were Caucasian, 86.5% were younger than 35 years, and 85.1% had a partner. Women completed demographics, Edinburgh Postnatal Depression Scale and the Brief Pain Inventory on REDCap. Path analysis was used to investigate a model for the relationships among pain intensity, pain interference, anxiety and physical and mental health-related quality of life. RESULTS: Pain intensity affected health-related quality of life indirectly by increasing pain interference, which in turn, decreased both physical and mental health-related quality of life. In addition, pain interference also increased anxiety, which in turn worsened mental health-related quality of life, but not physical health-related quality of life. CONCLUSIONS: Treating perinatal pain may improve health-related quality of life by decreasing pain interference and anxiety. RELEVANCE TO CLINICAL PRACTICE: Nurses should assess for pain interference and anxiety in women experiencing moderate to severe pain during the third trimester of pregnancy. With this knowledge, nurses may advocate for women in receiving effective treatment for their conditions and improvements in their physical and mental health-related quality of life.

Listening Visits for maternal depression: a meta-analysis.

Listening Visits are a non-directive counseling intervention delivered by nurses to depressed postpartum women. In 2007, Listening Visits were listed as a recommended treatment in British national guidelines. They were removed from the guideline update, due to the small effect size drawn from a meta-analysis of five clinical trials with depressed and non-depressed postpartum women. The purpose of this meta-analysis is to provide an estimate of the true population effect of Listening Visits as a treatment for maternal depression compared to control conditions. A meta-analytic review was conducted of studies published before October 2020. Inclusion criteria required that the study was a pragmatic or randomized trial of Listening Visits delivered by non-mental health specialists to mothers with elevated symptoms of maternal depression. Post-treatment depression rates for the treatment and control groups were extracted from eligible studies. Six studies met eligibility criteria which included 703 participants. Analyses of observed effect sizes corrected for study artifacts revealed an estimate of 0.66 (95% CI: 0.32, 0.99) with high heterogeneity (Q = 17.95, p = 0.003, I2 = 72.14). After removing outliers and addressing heterogeneity across observed effect sizes, the meta-analytic estimate across four methodologically similar studies and 651 participants was 0.43 (95% CI: 0.24, 0.62). The moderate effect size for Listening Visits, considered together with the advantages afforded by how, where, and who provides this treatment, supports Listening Visits as a first-line intervention in a stepped care approach for mothers with mild to moderately severe depression symptoms.

Maternal depression and breastfeeding in home visitation.

BACKGROUND: Home visitation is a popular mechanism for supporting parents and their young children. Breastfeeding is often promoted by home visitors due to its health benefits. However, maternal depression may interfere with breastfeeding. Thus, home visitors may be attempting to encourage health-promoting behaviors like breastfeeding, but maternal depression may interfere with engagement in those behaviors. METHOD: The data for this study were provided by the Des Moines Healthy Start and the Empowerment Family Support Project (DMHSP). We analyzed the relation between depression and breastfeeding for 364 women. RESULTS: First, rates of elevated depression scores in this sample of women (8.7%-21.4% of women) were lower than rates of elevated depression scores reported in other studies of women enrolled in home visitation (30%-50% of women). Second, rates of breastfeeding at 3 months postpartum in this sample (56% of women) were higher than rates of breastfeeding reported in the general population (51% of women). Third, Non-Hispanic White women were significantly less likely to breastfeed compared to other racial groups. Fourth, average Edinburgh Postnatal Depression Scale (EPDS) scores during the first 3 months postpartum, but not during pregnancy, were predictive of likelihood to breastfeed at 3 months postpartum, even after accounting for demographic characteristics. CONCLUSION: Addressing maternal depression during the early postpartum period may increase the likelihood of engaging in breastfeeding.

Pain and Depression Symptoms During the Third Trimester of Pregnancy.

PURPOSE: To assess the association between depression symptoms and pain characteristics, including pain intensity, location, and effectiveness of pain management strategies, among women in their third trimester of pregnancy. DESIGN: Descriptive, exploratory cross-sectional study. SETTING: Mobile health pregnancy application (app). PARTICIPANTS: A convenience sample of women in their third trimester of pregnancy from across the United States. METHODS: Women completed demographic questionnaires, the Brief Pain Inventory, and Edinburgh Postnatal Depression Scale (EPDS) through an online Web site. RESULTS: N = 132 women participated. The sample was demographically diverse. . Women ranged in age from 18 to 39 years (M 28.1 ± SD 5.2). Most women were Caucasian (68%), with smaller percentages of Hispanic (12%) and African American (11%) women. Most had commercial insurance (59%) and a partner (85%). Of the 132 women, 79.6% reported moderate-to-severe pain. Approximately 93% experienced back and pelvic pain, whereas 27% experienced moderate-to-severe depression symptoms. Bivariate and linear regression analyses revealed that higher EPDS depression scores were associated with higher levels of pain (p < .01). Other variables significantly associated with higher EPDS scores were White race (p = .04), marital status (p = .05), and headache (p < .01). CLINICAL IMPLICATIONS: In the third trimester of pregnancy, pain affects more than two-thirds of women and may occur with and without depression symptoms. Although the value of universal depression screening during pregnancy is widely recognized, our findings suggest clinical outcomes for pregnant women would improve with a standardized, multidimensional screen for both pain and depression symptoms. Nurses are ideally positioned to assess and advocate for the combined treatment of pain and depression.

Use and Misuse of Opioid Pain Medications by Pregnant and Nonpregnant Women.

BACKGROUND: The use and misuse of opioid pain medication is a public health problem that has extended to pregnant women. Assessing both the use and misuse of opioid pain medication had been limited. AIMS: The aim of the present study was to disseminate data from a national sample of pregnant and nonpregnant women, tracking the rate and predictors of opioid use and misuse. METHODS: In 2015 the National Survey on Drug Use and Health expanded the assessment of opioid pain reliever use and misuse. Here, a secondary analysis of 2 years of National Survey on Drug Use and Health expanded data assesses the use and misuse of opioids in pregnant and nonpregnant women ranging in age from 18 to 44 years (N = 46,229). RESULTS: Opioid medication use was reported by 31.89% of pregnant women and 38.87% of nonpregnant women. Race and pregnancy status were associated with risk, with pregnancy being protective and White women having significantly higher risk. CONCLUSIONS: The high rates of use and misuse of opioids in pregnant women underscores a critical need for screening for opioid use and misuse, particularly among White women. Pregnancy provides a unique window of opportunity to educate, screen, and provide treatment.

Using the EPDS to Identify Anxiety in Mothers of Infants on the Neonatal Intensive Care Unit.

Despite the prevalence of postpartum depression and anxiety, current screening recommendations are limited to depression symptoms. Screening using the Edinburgh Postnatal Depression Scale-Anxiety subscale (EPDS-A) may enhance ability to detect distress in postpartum women. We aimed to replicate the EPDS-A in 200 mothers with infants hospitalized in the neonatal intensive care unit (NICU) and examine its incremental utility in identifying emotional distress. Presence of the EPDS-A was identified using exploratory factor analysis. Women experiencing elevated anxiety were identified using a previously established cutoff score. Results replicated the EPDS-A for the first time in mothers with infants hospitalized in the NICU. In all, 21.9% of these women had elevated anxiety symptoms and nearly one quarter of them would have been missed in routine depression screening. Use of the EPDS-A, in addition to the total EPDS score, is a promising approach to identifying anxious women in need of further evaluation, treatment, or support.

Using mobile health applications for the rapid recruitment of perinatal women.

This article describes how two research teams recruited participants using a mobile application for pregnant women. In both studies, a study description appeared on the home screen of a pregnancy application. Interested women were directed to a secure research website to enroll. Enrollment goals were rapidly exceeded. Both studies enrolled participants from across the USA. Demographic diversity was achieved by one study. Mobile health applications are innovative venues for recruiting research participants.

Brokering the Evidence-Practice Gap: A Strategy for Moving Evidence Into Clinical Practice.

Moving novel, evidence-based interventions into broad community use is challenging. This column describes how a midlevel public health administrator acted in the role of broker to link university-based researchers with maternal health clinical staff to successfully implement an innovative, evidence-based maternal depression treatment. Program evaluation assessed adoption, implementation, reach, and effectiveness. In reflecting on this partnership, the broker provided critical elements of access, credibility, and accountability. A partnership between service providers and research teams provides one strategy to disseminate evidence-based practices among those served by public-health programs.