A Review of Post-Partum Depression-Why is the Mom Sad!

Post-Partum Depression: History

The issue of post-partum depression is not a new one or a phenomenon observed in recent times. The history of postpartum depression (PPD) dates back far as the writings of Hippocrates, however, the symptoms of PPD were not recognized as a medical disorder until the 19th century. During the 19th century when women experienced depression, many did not divulge their symptoms and those who did were often diagnosed as “neurotic.” Women who sought help for their symptoms were often subjected to a variety of unusual treatments.

During the 1950s electroshock therapy was often the recommended treatment for a “neurotic” woman or they were occasional prescribed Valium. Women did not recognize their symptoms as those of depression, nor did they discuss their thoughts and fears regarding their symptoms. Their silence was most likely out of shame that others would think they were “neurotic” or insane.

PPD is significantly undertreated. Many women feel that sadness at what “ought” to be a joyful and a beautiful time is shameful. In order to confirm to the standards of society they put a lid on their feelings and suffer internally. Some women are influenced by society’s general stigma concerning mental health care. In addition, those women who do seek treatment often hesitate to take psychotropic medications when breastfeeding, despite substantial evidence of their relative safety [4]. In efforts to bring this issue to light many countries have had extensive health policy changes and many researchers in collaboration with primary care physicians have tried to find a clue to PPD [5]. Many health policies that adversely affect the woman’s health are to be held responsible for a lack of interest in PPD by many people who have the power to change the current scenario [6].

Post-Partum Depression and Maternal Care in US

In the United States, studies conducted by the CDC show that about 11-20% of women experience the symptoms of postnatal depression. This means that of the 4 million live births that occur every year, 600,000 of them develop postpartum depression. This is much more than the number of women diagnosed with breast cancer, cervical cancer, and stroke combined. When the studies are narrowed down to specific states, the rates even go higher [7].

A more recent report filed in the Morbidity and Mortality Weekly Report gave a more specific report in specific states. It showed that the overall prevalence rate is currently at 11.56%. There are huge disparities among states with some like Illinois having 8% and 20% for Arkansas [8].

Given the public health relevance of PPD, its well– characterized psychological risk factors, and the substantial barriers to care once women become ill, a focus on the prevention of PPD holds tremendous potential for clinical efficacy. In particular, prospective mothers are especially motivated for self-care [9] postpartum maternal health care is a neglected aspect of women’s health care. Missed

opportunities for enhancing the health care of postpartum women are a routine in primary health care clinics. Differing perceptions of maternal needs between nurses and new mothers also contribute to inadequate health care.

There are nearly 4 million live births every year in the United States. Nearly, 20% of these mothers will experience symptoms of major or minor depression during the first 3 months after delivery [10]. This makes depression the most common complication seen in the post-partum period surpassing both gestational diabetes (3-8)% and preterm birth (12.3%). There is huge lack of data and interest in maternal care and parameters that define how healthy a mother is after the childbirth. Therefore, collecting national data on postpartum maternal morbidity, reforming postpartum care policies, providing holistic and flexible maternal health care, encouraging family support and involvement in support groups, and initiating educational programs are recommended [11].

When we look at the post partum maternal care being given to mother in other countries we can see that USA is far behind and there is huge gap in the care. The national goals, surveillance and programs responding effectively to the health needs of postpartum women require relevant national health goals, surveillance systems, and programs of care. With regard to U.S. health goals, Healthy People 2010 objectives associated with maternity care focus on pregnancy and its immediate outcomes (U.S. Department of Health and Human Services, 2000a). Healthy People 2010 contains 467 objectives designed to serve as a framework for improving the health of all people in the United States during the first decade of the 21st century [12]. Although postpartum complications may be considered important, only postpartum depression was mentioned in Healthy People 2010, and its national goal was not established [13].

Public policy erects two barriers to adequate prevention and treatment of postpartum depression (PPD) in the United States:

(1) The lack of parity between insurance coverage for mental and physical illness decreases access to care.

(2) The current model of postpartum care fails to incorporate screening and follow‐up. Treatment for PPD falls into the insurance category of mental health. But many insurance companies either do not cover mental illness at all or provide coverage that is far below that for physical ailments. Because cost‐benefit analyses have shown the benefits of parity laws, legislation to achieve parity between mental and physical health insurance is crucial in addressing this problem [14].

Post-Partum Maternal Care in Other Countries

In the Netherlands, women with normal pregnancies can give birth at home or birth rooms, which are operated by midwives or general practitioners in a hospital. A continuous 1-week home care to mothers covered by insurance for normal birth is provided by kraamverzorgsters, who receive a 3-year training [11]. This postpartum home care includes care for children and mothers and housework services.

Despite home visits, mothers can also choose to stay in maternity centers for postpartum care. In Norway, maternity centers established near hospitals are hotel-like environments where new mothers, newborns, and their families can stay together for postpartum care. Likewise, in Taiwan, new mothers can choose to stay in private maternity centers where mothers and newborns are taken care of by nurses. A majority of Chinese mothers who choose to stay at home are cared for by their family members for about 1 month to prevent diseases and promote health. Parental leave is another policy that facilitates maternal and children’s health. In Sweden, new parents can take, at most, a 1-year leave at 80% of their salary. In Finland, women have the chance to take a 1-year maternal leave supported by a state grant.

Whether provided at home or a facility, postpartum care helps new mothers to recover from physical changes of pregnancy and to learn child-care skills [11]. The U.S. model of post‐partum care should follow the example of care provided in the United Kingdom where nurse‐midwives visit new mothers at home to check on their physical and emotional status. In one program that produced positive psychological health outcomes, midwifery visits were tailored to individual needs and extended to 10‐12 weeks postpartum. Encouraging developments in the United States include:

• An effective program that screens new mothers with signs of PPD and provides telephone follow‐up and rapid treatment referral
• proposed legislation to fund organizations working to reduce the incidence of PPD [14].

Contributing Factors and Their Assessment

Researchers are only at the beginning stages of discovering biological factors that may contribute to the etiology of postpartum depression, but there are numerous known psychological and social risk factors. Previous meta- analyses have identified fifteen: (1) lower social class, (2) life stressors during pregnancy, (3) complicated pregnancy/birth, (4) difficult relationship with family or partner, (5) lack of support from family or friends, (6) prior history of psychopathology (depression, anxiety), (7) chronic stressors postpartum (this can include problems with child care and difficult infant temperament), (8) unemployment/instability, (9) unplanned pregnancy, (10) ambivalence over becoming a pregnant, (11) poor relationship with own mother, (12) history of sexual abuse, (13) lack of a confidante, (14) bottle feeding, and (15) depression during pregnancy, with the last generally acknowledged to be the strongest predictor of PPD [9].

Young mothers who are looking for support usually fall behind schedule and are the most vulnerable. There can be many ways in which we can evaluate each of these factors and more research can be done on these to know the cause and effect [15]. Women who are not working, or those with lower occupational status are at greater risk for depression. Recent immigrants, particularly those who were not working or who had given birth to a second child, were also at higher risk Zelkowitz, et al. [16] Health system barriers included normalizing of symptoms, offering of unacceptable interventions, and disconnected care pathways [17].

These factors if studied individually can be of great help. If we can evaluate these one by one and the government works with women centered clinics to follow up on these issues we can be sure that we can handle PPD. Implementation of some ground rules and providing effective support to such centers is of vital importance. A mechanism of early detection linked to appropriate treatment and follow-up would be beneficial for the depressed woman, her family, and her infant. New strategies are required to identify women at highest risk or already suffering from depression Mandl KD, et al. [18] primary care providers should observe the mothers with a very keen eye if they are bringing a small baby frequently. It could be a mom’s cry for help. Although it is tempting to attribute postpartum depression to hormonal decline, several other factors may predispose women to this condition. Stressful life events, past episodes of depression (not necessarily related to childbearing), and a family history of mood disorders all recognized predictors of major depression in women, are also predictors of postpartum depression. The likelihood of postpartum depression does not appear to be related to a woman’s educational level, the sex of her infant, whether or not she breast-feeds, the mode of delivery, or whether or not the pregnancy was planned [19].

The pediatrician who finds a mother bringing in her infant for frequent visits to the emergency department or to the office should closely examine the motivation for the visits, and consider screening for depressive symptoms. Specific evaluation of mothers by health care providers who recognize these signature patterns of service use may reduce unnecessary health care use and facilitate early diagnosis and treatment of postpartum depression, improving outcomes for women and their families Mandl KD, et al. [18] Apart from questions about psychiatric history, a psychosocial history in early pregnancy including stressful life events, native language and employment status could help the health professionals to identify women at risk for recurrent or sustained depression during pregnancy and the year after giving birth [20].

The Edinburgh Post Natal Depression Scale (EPDS) is a very useful tool. This questionnaire is a very complete guide to ask mothers the relevant questions and in a short duration a primary care provider can assess the mental wellbeing of the mother. Using this we can examine the effects of the mother’s sense of well-being on the child’s growth and development and explore risk factors for low spirits in the post-partum period [21]. The EPDS was found to have satisfactory sensitivity and specificity, and was also sensitive to change in the severity of depression over time. The scale can be completed in about 5 minutes and has a simple method of scoring [22].

Strategies to Address the Issue

One of the feasible options to reduce the number of women who are faced by the dilemma of PPD would be a good support system [23]. Other activities that a mother can include in her life would be stress management and increasing activity levels to prevent or lessen depressive symptoms [24]. The family support is very much needed and can help with stress management.

Apart from the families and friends a good working environment where a preference is given to handle the issues of the employees is also a much needed change. The work culture of US does not give a lot of leverage to women who have just delivered. The official paid maternity leave is only 6 weeks. It is the least amount of time compared to all developed countries like European countries. It is also important that new mothers receive work-related support. Length of maternity leave and number of work hours are both significantly related to new mothers’ postpartum mental health [25]. It appears that taking a longer maternity leave and limiting work hours during the postpartum period may have positive health consequences for mothers with infants.

Job-related stress indicates a need for work policies and benefits that provide flexibility and support for employed women who give birth. With more than one half of women returning to the work force after having a baby, the development of work-related support systems is especially critical. Considerable associations between early returns to work and children’s outcomes are found suggesting causal relationships between early returns to work and reductions in breastfeeding and immunizations, as well as increases in externalizing behavior (mental health problems that include depression and psychosis) problems. There is a strong chance for mothers who return to work full‐time within 12 weeks of giving birth to have the negative symptoms [26].

Time for a Work Culture Change

Rapid changes in the modern work environment, including the proliferation of computer technology and the United States transitioning from a manufacturing-based economy to a service-based one, have led to longer work hours, more shift work, and greater job complexity. Modifications that help mothers feel less stressed about keeping pace with workload demands and maintain better work–life balance bode well for recovery. For instance, allowing new mothers to work day shifts rather than night shifts helps them establish regular feeding and sleep–wake routines with newborns and optimize their own sleeping patterns as well. Also, many child care programs will not enroll children who are not toilet trained—meaning that women with infants have fewer options for child care, especially if they lack a partner or family members to help provide support. Permitting flexible schedules or teleworking can be especially helpful in such situations. Only 12% of U.S. private companies offer paid parental leave, and there is a misperception that only large tech outfits and Fortune 500 companies can afford to do so. However, many businesses may be able to extend this privilege without breaking their bottom line. A recent analysis of the state-mandated paid leave programs in New Jersey and California found that paid leave financed by payroll deductions are relatively inexpensive, costing individual employees approximately $30 a year-less than $1 a week. The states have also reported that the programs tended to have either a positive effect or no impact whatsoever on outcomes such as profitability, performance, productivity, turnover, and employee morale. Despite any lingering reluctance, some businesses may be forced to contemplate paid maternity leave in the near future: although only four states currently have such legislation (California, New Jersey, Rhode Island, and New York), 18 are reviewing their laws in consideration of adopting similar mandates.

Actions Taken by the Government

The main problem arises when we do not give enough importance to a very sensitive issue. We know the stakeholders in this issue, we know what are the probable implications and consequences and yet we are not doing enough in this regard??.

The constellation of health policy hierarchy is different in every country; however there is usually a “top of the pyramid.” If policy is mandated from that peak, be it the legislature or the executive branch, the likelihood increases that the largest number of citizens will benefit. We can examine the progress of the government of United States as the following yearly steps taken in the right direction.

Mothers Act and the ACA – What has Happened Since 2010?

When the  U.S.  Patient Protection and Affordable Care Act passed in 2010, the MOTHERS Act was included in the text of the bill. The adoption of the Patient Protection and Affordable Care Act (ACA), Section 2952: Support, Education, and Research for Postpartum Depression mandated ongoing research to better understand the frequency and course of postpartum depression, address  differences in treatment needs among racial and ethnic groups, and develop culturally competent evidence-based treatment approaches (U.S. Department of Labor, 2012). However, Congress has not appropriated funds to carry out the activities authorized in these provisions.

Step in the Right Direction

The Mothers Act was historically significant, introducing language of postpartum depression into the federal legislative record, and it garnered support and interest across the US and across political parties. However, none of the provisions of the Act were  activated with funding. Subsequent legislative action has been state-based, until the introduction of the Bringing Depression Out of the Shadows Act in 2015. Although there are no US federal policies that require screening of new mothers for postpartum depression, at least 12 states have adopted either state  legislation, developed awareness campaigns, or convened tasks forces. States that require screening include New Jersey (Findings, Declarations Relative to Postpartum Depression,  2006), Illinois (Perinatal Mental Health Disorders Prevention and Treatment Act, 2008),  and West Virginia (Uniform Maternal Screening Act, 2009). Other states require education  about postpartum depression including Texas (Relating to Information Provided to Parents  of Newborn Children, 2005), Virginia (Certain Information Required for Maternity  Patients, 2003), Minnesota (Postpartum Depression Education and Information, 2015), and Oregon (Relating to Perinatal Mental Health Disorders and Declaring an Emergency,  2011). Washington has passed statewide awareness campaigns, and California, Michigan, and Oregon have postpartum depression awareness months.  Maine, Maryland, Massachusetts, and Oregon have appointed perinatal depression task forces [30].

Guidelines by American College of Obstetricians and Gynecologists

According to the guidelines laid down by the American college of Obstetricians and Gynecologists (ACOG) there are a number of things that can be ensured to keep a mother safe and emotionally healthy during the post-partum period. In 2018, the ACOG said “In redefining the Postpartum health care program, a post-partum Visit Task Force revised the American College of Obstetricians and Gynecologists’ Committee Opinion on postpartum care (Committee Opinion No. 732, Optimizing Postpartum Care) to reflect the importance of the “fourth trimester” period. Instead of a single visit, the new Committee Opinion recommends that services and support should be tailored to each woman’s individual needs. It is recommended that all women have contact with their health care providers within the first 3 weeks of the postpartum period. This initial assessment should be followed up with individualized ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth. The Committee Opinion also highlights the importance of health care providers counseling women who have experienced pregnancy complications, as well as women who may have chronic conditions, to receive timely follow- up care with their obstetrician–gynecologists or primary care providers.”

Make Sure Employees Know their Rights

Not all working mothers are aware of the rights afforded them by the U.S. Equal Employment Opportunity Commission (EEOC). According to the EEOC (2008), companies with more than 15 employees are required to comply with the

1978 Pregnancy Discrimination Act and the Americans with Disabilities Act (ADA). Under these, employers must make the same allowances, such as extended unpaid leave or workplace accommodations, to women with pregnancy- related disabilities as they do to employees with other ADA- covered disabilities. Reassure working mothers that they cannot be terminated, demoted, or denied promotion for experiencing a peripartum or postpartum mental illness (EEOC v. The Lash Group, Inc., 2014). Education about the terms of the Family Medical Leave Act should extend to all employees, not just pregnant women, and should include the length of time covered (up to 12 weeks unpaid) and eligibility (i.e., an employee must have worked for the company for 1 year and at least 1,250 hours within a year).

Comparisons and Conclusions

In conclusion to the discussion, it can be stated that to achieve all our health goals we need to give importance to the women’s health. When we say women’s health we are talking about all aspects of health that include the physical as well as mental health specially in vulnerable times of a woman’s life. Public health for 2020 (HEALTHY PEOPLE 2020) and beyond should continue to stretch beyond traditional health sectors. Doing so will require reinvigorated public health leadership that engages nontraditional partners to create healthier choices that are easier for all people to make and adapt their lives according to the goals [31].

This clearly shows the need to assess for both depression and anxiety in new and expectant parents, and the term ‘postnatal mood disorder’ (PMD), accurately reflects significant adjustment disorders for the new parents specifically the new mother. More research is required to understand the problem but in the meantime the health systems should be improved to give support to mothers suffering from PPD [19].

Results from clinical trials on depressed new mothers found that both psychosocial (e.g., peer support, non‐directive counseling) and psychological (e.g., cognitive behavioral therapy and interpersonal psychotherapy) interventions appear to be effective in reducing symptoms of postpartum depression [32]. Studies have shown that counseling done by health visitors through a systematic program has ample benefits for pregnant women who are anxious or mothers who are showing symptoms of non- psychotic depression [33]. More funds should be allocated to achieve these goals and priority should be given in finding a way to help women suffering from this debilitating condition.

Another important practical example comes from the state of Minnesota. The states establish and administer their own Medicaid programs and determine the type, duration, amount and scope of services. A mandatory benefit under Medicaid is Early and Periodic Screening, Diagnostic and Treatment Service (EPSDT), which covers visits commonly, referred to as well child checks. This program also includes Child & Teen checkups (C&TC”s). In 2010, the staff within the Minnesota Health Department began including maternal depression screening as a recommended but not required screening for visits from birth till 12 months [34]. The providers who actually performed this screening said that this practice actually made it easier for them to look for mothers with post-partum depression and utilize the time available in clinic in talking about the treatment. If we can implement this model to our health care programs all over US we can actually see a change. Many health models from the European countries also suggest that home visits by the health workers and nurses might actually help in helping a woman with non-psychotic post-partum depression. Women who are pregnant or have given birth should be given maternity leaves that are paid beyond the regular 6 weeks leave. Research has found an association between longer maternity leave and a lowered risk of PPD, with women taking less than 6 months of leave being at an increased risk for the disorder [35]. Findings suggest employed women experience problems in wellbeing at approximately seven months postpartum. Variables associated with improved health include: longer maternity leaves, fewer prenatal mental health symptoms, fewer concurrent physical symptoms, more sleep, increased social support, increased job satisfaction, less physical exertion on the job, fewer infant symptoms, and less difficulty arranging child care [36]. Work places should have child friendly areas with nursing stations and in house day care centers so that women feel stress free. State and the Government should give more funds to research centers and women centered clinics. In the end, we can sum up our discussion with a hope for a better future and a good health care system.

“Whether you are a patient, a provider, a business, a health plan, or a taxpayer, it is in our common interest to build a healthcare system that delivers better care, spends healthcare dollars more wisely and results in healthier people. Today’s announcement is about improving the quality of care we receive when we are sick, while at the same time spending our healthcare dollars more wisely.” HHS Secretary Sylvia Burwell on the organization’s goal to shift 50 percent of payments to value-based models by 2018.