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Implications for practice and research
▪ Public health nurses (PHNs) can play a significant role in identifying and treating postpartum depression.
▪ The results obtained in this demonstration project suggest the need for a larger, randomised controlled trial.
This study focuses on postpartum depression, a problem that has lasting negative effects on children of affected mothers.1 The authors note that in Norway, postpartum mental health is inadequately addressed, thus postpartum depression is underidentified as well as undertreated. To improve the postpartum care provided by PHNs, the authors describe a programme in which standard care is reshaped to include a mental health perspective.
This study compares the frequency and severity of depressive symptoms and parenting stress among postpartum women in two convenience samples: (1) a municipality implementing standard PHN postpartum care (about 650 annual births) and (2) a municipality implementing an enhanced postpartum care model that emphasised mental health (about 1500 annual births).
Standard PHN care in Norway includes one home visit and subsequent well-baby clinic visits during the first postpartum year with no maternal mental health component. In the enhanced care municipality, PHNs participated in a 5-day workshop on postpartum mental health which included training on the delivery of a non-directive counselling intervention. PHNs then applied their training by (1) discussing postpartum mental health at the home visit, (2) providing a 20 min non-directive counselling session at the 6-week well-baby clinic visit (offering additional sessions to women judged to need further help) and (3) keeping alert to and openly discussing mental health issues with the mother throughout the first postpartum year.
Study participants, recruited by PHNs, included 441 and 1806 participants in the standard and enhanced care municipalities, respectively. Outcomes included assessments of depressive symptoms (Edinburgh Postnatal Depression Scale, EPDS) and parenting stress (Parenting Stress Index, PSI) at 6 weeks and at the 3-, 6- and 12-month postpartum visits.
The average EPDS score and the frequency of depression (EPDS score ≥10) were significantly lower at all time points for women in the enhanced care group, when compared with those from the standard care group. This artefact might reveal a shortcoming inherent to convenience sampling. Nevertheless, although the frequency of depression decreased in both groups, the change in EPDS scores was statistically significantly greater for women in the enhanced care group (6.9 vs 4.4 units). No statistically significant difference in parenting stress was observed between the two groups.
The emotional health of postpartum women has a significant impact on their children's well-being and is therefore a public health priority. Models of care, which incorporate PHNs, have significant potential to increase detection and treatment among postpartum women. This study has three notable strengths. First, it demonstrates that it is feasible to incorporate maternal mental healthcare into routine PHN postpartum care. The authors convinced PHNs to switch their emphasis from focusing on the physical well-being of the infant to an approach that included addressing mothers' mental health concerns and providing preventive counselling. This achievement should not be undervalued.
The second strength of the study is that it demonstrates the effective management of postpartum depression by PHNs. Among their patients with elevated EPDS scores (≥10), women in the enhanced care group evidenced a greater improvement compared with those in the standard care municipality. This result is consistent with earlier studies of non-directive counselling, also referred to as ‘Listening Visits’.2,–,6 The data underscore the effectiveness of depression treatment by PHNs. The third notable strength of the study is that, although previous studies showed Listening Visits are an effective treatment for postpartum depression, this is the first study to also provide even seemingly well women with one Listening Visit session. It is not possible, however, to draw conclusions about whether Listening Visits hold promise for preventing depression.
The methodological shortcomings of this study (eg, it relies on convenience sampling; the groups are not equivalent in terms of EPDS scores; the study lacks any measure of treatment adherence in the enhanced care setting) are reasonable for a preliminary report. Nevertheless, limiting the assessment to EPDS and PSI scores potentially misses other important programme outcomes, such as the link between maternal depression and increased use of health services.7Future studies should include a randomised research design with more sites, should assess prevention outcomes in a more sophisticated way and should more broadly assess outcomes (including a cost benefit and client satisfaction dimension). This would strengthen the claims of the results described here.
In summary, this study suggests it is feasible to ask PHNs to deliver mental healthcare. More importantly, the results suggest that nursing care can alleviate depressive symptoms among postpartum women. Additional research is needed before this model of care can be confidently implemented as evidence-based practice, particularly with regard to the effectiveness and cost-benefit value of the preventive programme component.
Competing interests None.