Implementing Patient-Centered Trauma-Informed Care for the Perinatal Nurse.

Adverse childhood experiences and trauma significantly impact physical and mental health. Increased maternal perinatal depression/anxiety, preterm labor, and low birth weight, as well as infant morbidity and mortality, are some examples of the impact of trauma on perinatal health. Trauma-informed care begins with knowledge about trauma, the ability to recognize signs of a trauma response, responding to patients effectively, and resisting retraumatization. As holistic providers, perinatal nurses can create safe care environments, establish collaborative patient relationships based on trust, demonstrate compassion, offer patients options when possible to support patient autonomy, and provide resources for trauma survivors. This can prevent or reduce the negative impact of trauma and improve the health and well-being of infants, mothers, and future generations. This clinical article outlines key strategies for implementation of patient-centered trauma-informed perinatal nursing care.

Public health nurse delivered group cognitive behavioral therapy (CBT) for postpartum depression: A pilot study.

OBJECTIVES: Although postpartum depression (PPD) affects 1 in 5 women, just 15% receive treatment. Cognitive Behavioural Therapy (CBT) is a first-line treatment for PPD. The objective of this pilot study was to determine the feasibility and acceptability of public health nurse (PHN)-delivered group CBT for PPD and to determine preliminary estimates of effect. DESIGN: A pre-posttest design was used. Participants provided data before and after the CBT groups. SAMPLE: Seven women who were over the age of 18 and had given birth in the past year participated. MEASUREMENTS: Feasibility and acceptability focused on PHN training, recruitment, retention, and adherence to the intervention. Participants provided data on depression, worry, health care utilization and mother-infant relations. Women and their partners reported on infant temperament. INTERVENTION: Participants attended a 9-week CBT group delivered by two PHNs. RESULTS: The PHN training, CBT intervention and our study protocol were found to be feasible and acceptable to participants. Reductions were seen in depression and worry. The number of health care visits decreased; mother-infant relations improved. CONCLUSIONS: These findings highlight the feasibility of PHN-delivered group CBT for PPD and suggest that it could reduce the burden of PPD on women and their children.

Treating postpartum depression with brexanolone.

The FDA has approved brexanolone specifically for treatment of adults with postpartum depression (PPD). Administered I.V., it can relieve severe signs and symptoms of PPD within days rather than weeks. This article discusses the benefits and risks of brexanolone as a treatment for PPD, including nursing considerations and patient teaching.

Technology-assisted nursing for postpartum support: A randomized controlled trial.

AIM: To determine if an electronic nursing intervention during the first 6 months postpartum was effective in improving mood and decreasing stress. BACKGROUND: Unmet needs postpartum can have a negative impact on mood and parenting stress. Technology-assisted nursing care may provide needed support and reduce risk. DESIGN: Randomized controlled trial (RCT) with three conditions. METHODS: Enrollment began on 11 May 2017. Participants were randomized into one of three groups after completion of the baseline survey. Intervention I participants received standardized electronic messages four times/week for 6 months postpartum. Intervention II participants additionally received the option for nurse contact. Depression and parenting stress as measured using the Edinburgh Postnatal Depression Scale (EPDS) and Parenting Stress Index-Short form (PSI-SF) was obtained at 3 weeks, 3 months and 6 months postpartum and results compared with a usual care group. Patient satisfaction and nursing factors were measured. RESULTS: Significantly higher satisfaction scores were found in both intervention groups as compared with control, but there were no significant changes in EPDS or PSI-SF. CONCLUSION: The interventions were perceived as helpful and not burdensome. Better nurse-sensitive outcome measures are needed to adequately assess effectiveness. IMPACT: Postpartum women report unmet needs for support and education. The interventions were perceived as being helpful but did not significantly reduce depressive symptoms or parenting stress. Nurses can use this research to inform development of innovative approaches to support postpartum women. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02843022.

Postpartum depression symptoms among Syrian refugee women living in Jordan.

Postpartum depression (PPD) is recognized as a common maternal health problem, but few studies have investigated the postpartum mental health of refugee women. In this cross-sectional study, we investigated the prevalence of PPD symptoms and associated factors among Syrian refugee women living in north Jordan. Women (N = 365) were recruited from four health care centers in Ramtha and Jarash, cities in northern Jordan. Participants completed a demographic data form, the Edinburgh Postnatal Depression Scale (EPDS), and the Maternal Social Support Scale at 6-8 weeks postpartum. Half (49.6%; n = 181) of the Syrian refugee women scored >12 on the EPDS. PPD symptoms were significantly associated with low social support, low monthly income, and recent immigration (less than 2 years). There is a high level of PPD symptoms among Syrian refugee women, many of whom are living in poverty and with limited social support. The results highlight the need for immediate action by governments to support childbearing refugee women with early screening for psychosocial risk and respond to women's physical and mental health, and social needs through interservice collaboration. Social support programs would meet an important need for these women, as would ongoing assessment by health professionals and early intervention for women who screen positive for PPD.

There is more to perinatal mental health care than depression: Public health nurses reported engagement and competence in perinatal mental health care.

AIMS AND OBJECTIVES: To explore public health nurses' engagement, competence and education needs in relation to perinatal mental health care in Ireland. BACKGROUND: It is estimated that 15%-25% of women will experience a mental health problem during or postpregnancy, either as a new problem or a reoccurrence of a pre-existing problem. Public health nurses, or their equivalent, are ideally positioned to support women's mental health and improve health outcomes for the woman and baby, yet little is known about their role and engagement with mental health issues, other than with postnatal depression. The objectives of the study were to identify public health nurses' knowledge, skills and current practices in perinatal mental health and establish their education needs. DESIGN: The research used a descriptive design. METHOD: A total of 186 public health nurses completed an anonymous, online survey, designed by the research team. RESULTS: While public health nurses are positive about their role in supporting women's mental health, they lack the knowledge and skills to address all aspects of mental health, including opening a discussion with women on more sensitive or complex issues, such as trauma and psychosis and providing information to women. Those who received education reported statistically significant higher knowledge and confidence scores than those without. CONCLUSION: Public health nurses lack the knowledge and skills required to provide comprehensive perinatal mental health care to women. Future education programmes need to move beyond postnatal depression and address the range of mental health problems that may impact on women in the perinatal period. RELEVANCE TO CLINICAL PRACTICE: Without knowledge and skill among nurses in all aspects of perinatal mental health, women with significant mental health needs may be left to cope alone and lack the necessary prompt evidence-based interventions and supports.

Postnatal psychosocial assessment and clinical decision-making, a descriptive study.

AIMS AND OBJECTIVES: To describe experienced child and family health nurses' clinical decision-making during a postnatal psychosocial assessment. BACKGROUND: Maternal emotional well-being in the postnatal year optimises parenting and promotes infant development. Psychosocial assessment potentially enables early intervention and reduces the risk of a mental disorder occurring during this time of change. Assessment accuracy and the interventions used are determined by the standard of nursing decision-making. DESIGN: A qualitative methodology was employed to explore decision-making behaviour when conducting a postnatal psychosocial assessment. METHODS: This study was conducted in an Australian early parenting organisation. Twelve experienced child and family health nurses were interviewed. A detailed description of a postnatal psychosocial assessment process was obtained using a critical incident technique. Template analysis was used to determine the information domains the nurses accessed, and content analysis was used to determine the nurses' thinking strategies, to make clinical decisions from this assessment. RESULTS: The nurses described 24 domains of information and used 17 thinking strategies, in a variety of combinations. The four information domains most commonly used were parenting, assessment tools, women-determined issues and sleep. The seven thinking strategies most commonly used were searching for information, forming relationships between the information, recognising a pattern, drawing a conclusion, setting priorities, providing explanations for the information and judging the value of the information. CONCLUSION: The variety and complexity of the clinical decision-making involved in postnatal psychosocial assessment confirm that the nurses use information appropriately and within their scope of nursing practice. The standard of clinical decision-making determines the results of the assessment and the optimal access to care. RELEVANCE TO CLINICAL PRACTICE: Knowledge of the information domains and the decision-making strategies that experienced nurses use for psychosocial assessment potentially improves practice by providing a framework for education and mentoring.

Cumulative trauma and partner conflict predict post-traumatic stress disorder in postpartum African-American women.

AIM AND OBJECTIVE: To describe relationships between cumulative trauma, partner conflict and post-traumatic stress in African-American postpartum women. BACKGROUND: Cumulative trauma exposure estimates for women in the USA range from 51-69%. During pregnancy, most trauma research has focused on physical injury to the mother. Post-traumatic stress disorder (PTSD) is associated with trauma and more prevalent in African-American women than women of other groups. Knowledge about both the rate and impact of cumulative trauma on pregnancy may contribute to our understanding of women seeking prenatal care, and disparities in infant morbidity and mortality. DESIGN: This retrospective, correlational, cross-sectional study took place on postpartum units of two Detroit hospitals. Participants were 150 African-American women aged between 18-45 who had given birth. METHODS: Mothers completed the Cumulative Trauma Scale, Conflict Tactics Scale, Clinician Administered Post-traumatic Stress Scale, Edinburgh Postnatal Depression Scale and a Demographic Data form. Descriptive statistics, correlations and multiple regressions were used for data analysis. RESULTS: All participants reported at least one traumatic event in their lifetime. Cumulative trauma and partner conflict predicted PTSD, with the trauma of a life-threatening event for a loved one reported by 60% of the sample. Nearly, one-fourth of the women screened were at risk for PTSD. Increased cumulative trauma, increased partner conflict and lower level of education were related to higher rates of PTSD symptoms. CONCLUSION: Both cumulative trauma and partner conflict in the past year predict PTSD. Reasoning was used most often for partner conflict resolution. RELEVANCE TO CLINICAL PRACTICE: The results of this study offer additional knowledge regarding relationships between cumulative trauma, partner conflict and PTSD in African-American women. Healthcare providers need to be sensitive to patient life-threatening events, personal failures, abuse and other types of trauma. Current evidence supports the need to assess for post-traumatic stress symptoms during pregnancy.

An Exploration of Parenting Stress in Immigrant and Taiwanese Mothers.

To assess parenting stress and major difficulties experienced in early motherhood among immigrant and Taiwanese women in Pingtung, southern Taiwan. A comparative, descriptive, cohort study of parenting stress and maternal psychological health, using the Child Care Stress Checklist and Edinburgh Postpartum Depression Scale. A purposive sample of 26 foreign-born Vietnamese and 162 Taiwanese mothers were surveyed at 6 weeks' postpartum. Both groups of mothers experienced similar parenting difficulties including the establishment of a regular sleeping schedule for the infant, consoling a crying infant, awareness of infant's needs, conflict with family members, and difficulties managing household chores. Curtailment of social activities was reported more often by Taiwanese mothers, whereas inaccessibility to other experienced mothers and poor maternal-infant bonding were experienced more by immigrant mothers. There were significant differences between groups, with high levels of child care stress and postpartum depression symptoms reported more often by immigrant mothers. Nurses-midwives and community child health nurses need to be sensitive to the particular difficulties and stresses of parenting in mothers from different backgrounds and provide effective interventions and support activities.

Postnatal Depression: Don't reinvent the wheel.

Poor mental health accounts for 23% of all ill health in the UK, with the cost of treating it expected to double in the next 20 years. In addition, postnatal depression (PND) in both mothers and fathers can have a detrimental long-term impact on a child's cognitive, social and behavioural development. This paper discusses the development process of an innovative evidence-based resource which involved professional expertise and parent involvement. This unique resource helps to recognise PND in both mothers and fathers and will support health visitors in making a real impact in improving outcomes for children and families.

The effect of educational intervention on prevention of postpartum depression: an application of health locus of control.

AIMS AND OBJECTIVES: To assess the effectiveness of application of health locus of control in pregnant women for prevention of postpartum depression in Iran. BACKGROUND: Nearly 10-15% of women suffer postnatal depression by the end of the second week after delivery, which creates problems in caring for the child that may affect child's future learning and concentration. DESIGN: Pre-post experimental design. METHODS: Two hundred and thirty volunteer women were randomly divided into experimental and control groups. The data collection tools included a demographic questionnaire, the Multidimensional Health Locus of Control Scale and the Edinburg Depression Scale. Based on the associations found in the pretest, intervention programme was planned and carried out in the focused group discussion method. Data were collected after the end of scheduled sessions, immediately and one month later. The data were analysed with SPSS-16 using statistical methods including anova, chi-square test, Student's t-test and paired t-test. RESULTS: Chance health locus of control significantly reduced and internal health locus of control significantly increased, immediately after intervention. Also, a month after intervention, a significant difference was observed between the two groups in reducing postpartum depression. CONCLUSIONS: The planned participatory intervention led to empowerment and increased awareness and internalisation of health control beliefs and less tendency towards external health control beliefs, especially chance, improvement in general health leading to improved psychological health for prevention of postpartum depression in mothers. RELEVANCE TO CLINICAL PRACTICE: Clinicians might assess chance and internal health locus of control to identify the women at risk of developing depression during their pregnancy and to develop prevention and treatment plans.

Mental health literacy and postpartum depression: a qualitative description of views of lower income women.

The purpose of this study is to understand mental health literacy (MHL) (Jorm, 2000) in lower income women postpartum and share participant experiences of recognizing and seeking help for depressive symptoms. Focus group textual data were received from 25 participants who completed a weight and psychosocial health longitudinal study. Iterative content data analysis using Jorm's framework provided thematic understandings descriptive of MHL. Women recognized behavioral changes indicating mental distress, but fears prevented them from seeking help, and some resorted to risky behaviors. This framework could guide providers to identify women who may benefit from early intervention for postpartum depressive symptoms.

Theoretical approaches to maternal-infant interaction: which approach best discriminates between mothers with and without postpartum depression?

OBJECTIVE: The purpose of this study was to determine which of the four common approaches to coding maternal-infant interaction best discriminates between mothers with and without postpartum depression. METHODS: After extensive training, four research assistants coded 83 three minute videotapes of maternal infant interaction at 12month postpartum visits. Four theoretical approaches to coding (Maternal Behavior Q-Sort, the Dyadic Mini Code, Ainsworth Maternal Sensitivity Scale, and the Child-Caregiver Mutual Regulation Scale) were used. Twelve month data were chosen to allow the maximum possible exposure of the infant to maternal depression during the first postpartum year. The videotapes were created in a laboratory with standard procedures. Inter-rater reliabilities for each coding method ranged from .7 to .9. The coders were blind to depression status of the mother. RESULTS: Twenty-seven of the women had major depressive disorder during the 12month postpartum period. Receiver operating characteristics analysis indicated that none of the four methods of analyzing maternal infant interaction discriminated between mothers with and without major depressive disorder. CONCLUSION: Limitations of the study include the cross-sectional design and the low number of women with major depressive disorder. Further analysis should include data from videotapes at earlier postpartum time periods, and alternative coding approaches should be considered. Nurses should continue to examine culturally appropriate ways in which new mothers can be supported in how to best nurture their babies.

A qualitative meta-synthesis and theory of postpartum depression.

To synthesize existing qualitative literature on the first-hand experiences of women suffering from postpartum depression (PPD), to uncover potential common themes, a meta-synthesis of 12 qualitative studies using Noblit and Hare's 7-phase model of meta-ethnography was used. Four themes were discovered: crushed maternal role expectation, going into hiding, loss of sense of self, intense feelings of vulnerability, plus practical life concerns. A preliminary theory of PPD as a 4-step process is proposed, based on the relationships between the themes in this meta-synthesis. This 4-step process is compared and contrasted with Cheryl Tatano Beck's 4-stage theory of PPD "Teetering on the Edge". This meta-synthesis and theory offers a significant contribution to the literature in helping identify PPD distinctly from depression outside of the postpartum period, and deserves further study.

Postpartum depression: perceptions of a diverse sample of low-income women.

Postpartum depression (PPD) continues to significantly impact women and their families during the perinatal period. Consequences of untreated PPD in the mother may lead to impaired mother-infant bonding, recurring psychiatric illness, and fewer positive parenting behaviors. North Carolina participates in the Pregnancy Risk Assessment Monitoring System (PRAMS) survey and has the second highest self-reported rate of postpartum depressive symptoms at 19.0%. The full study used both quantitative and qualitative methods. The qualitative approach, an interpretive Heideggerian perspective, elicited the postpartum clients' perceptions of risk factors, how those perceptions affected the pregnancy experience, and how self-efficacy played a role in their perceived ability to make healthy choices. The sample was comprised of 60 pregnant women between the ages of 18 and 40. Four themes were found: (1) Feeling joy and apprehension at once, (2) Depression is something you think about (3) Rearranging your thinking, and (4) Garnering support. The women in this study believed that support was an indispensable tool in dealing with feelings of sadness and depression. Critical aspects of becoming involved in their pregnancy included changing their expectations and knowing how to detect and seek help when depressive symptoms occurred.

Postpartum depression: risks, protective factors, and the couple's relationship.

This study examined pregnancy risk for developing, and protective factors for preventing, Postpartum Depression (PPD). The object of this study was to (a) examine previously identified pregnancy stressors to learn which stressors put women more at risk for PPD and (b) to identify possible buffers for women who are at risk for developing PPD. A secondary data set was used for two analyses. Women were invited to participate in the study while still in the hospital, within 24-48 hours after delivery of a singleton, term (≥37 weeks) live-born infant. The data were collected in four large urban hospitals in Utah from 2005-2007. A total of 1,568 women participated in the study. Women who report experiencing less stress in their couple relationship are less likely to report PPD symptoms even when they have a personal history of depression and or PPD. The results of these analyses illustrate that a couple's relationship, depending on the stress level experienced in the relationship, can be both a risk and protective factor for pregnant women.

Depression screening on a maternity unit: a mixed-methods evaluation of nurses' views and implementation strategies.

Postpartum women often suffer clinically significant depressive symptoms, a problem addressed by nurse-delivered screening programs. In the past, success of these identification programs was measured in terms of screening rates; however, merely evaluating the screening rate does little to inform how to implement depression screening in clinical practice. This article describes the experiences of nurses in implementing depression screening on a maternity unit. We evaluate the practice qualitatively, by asking nurses to describe their screening strategies and their views about implementation, as well as quantitatively by assessing their screening rates and the number of women identified. Utilizing a framework of program evaluation, 20 maternity unit nurses completed qualitative assessments investigating their day-to-day experiences with this practice. To include the perspectives of nurses that declined to participate in qualitative assessments, 14 additional maternity unit nurses completed a brief survey assessing their views. We also assessed screening rates, defined as the number of women screened divided by the number eligible for screening. Maternity unit nurses viewed depression screening positively and were able to screen patients in relatively few steps, which they implemented using strategies they had developed themselves. Despite nurses' ongoing concern about finding time to screen, they achieved high screening rates and, with one exception, indicated they would opt to continue voluntarily. Depression screening on the maternity unit is feasible and embraced by attending nurses. The clinical strategies used to implement screening are extensively described and provide a basis for implementation in other settings that serve perinatal women.

Screening for symptoms of postpartum traumatic stress in a sample of mothers with preterm infants.

There are no established screening criteria to help identify mothers of premature infants who are at risk for symptoms of emotional distress. The current study, using data obtained from recruitment and screening in preparation for a randomized controlled trial, aimed to identify potential risk factors associated with symptoms of depression, anxiety and posttraumatic stress in a sample of mothers with premature infants hospitalized in a neonatal intensive care unit. One hundred, thirty-five mothers of preterm infants born at 26-34 weeks of gestation completed three self-report measures: the Stanford Acute Stress Reaction Questionnaire, the Beck Depression Inventory (2nd ed.), and the Beck Anxiety Inventory to determine their eligibility for inclusion in a treatment intervention study based on clinical cut-off scores for each measure. Maternal sociodemographic measures, including race, ethnicity, age, maternal pregnancy history, and measures of infant medical severity were not helpful in differentiating mothers who screened positive on one or more of the measures from those who screened negative. Programs to screen parents of premature infants for the presence of symptoms of posttraumatic stress, anxiety, and depression will need to adopt universal screening rather than profiling of potential high risk parents based on their sociodemographic characteristics or measures of their infant's medical severity.

Delivery of CBT to treat postnatal depression: health visitors' perceptions.

The most extensively researched form of psychotherapy over the last 10 years, cognitive behavioural therapy (CBT), has recently been promoted in health visiting practice. Health visitors, frontline practitioners for the majority of women with postnatal depression (PND), stand between the use of antidepressants for PND on the one hand where compliance is not good and the potential to offer a practical alternative using cognitive behavioural techniques on the other. The aim of this study was to examine how health visitors understand the concept of CBT and envisage its implementation in practice with regard to the treatment and management of PND. A qualitative research methodology using a phenomenological approach was adopted to analyse transcripts from two semi-structured focus group interviews with nine health visitors about their work with PND and CBT. The findings demonstrated that health visitors do not want to be known as 'frontline' professionals in the delivery of CBT to treat PND as this would imply 'counsellor'--a diversion from their professional identity and unique role. However, they wanted to be equipped with more than just introductory basic assessment and treatment techniques in CBT to deliver a pragmatic, psycho-educational approach to PND in four to eight home sessions.