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Q How do women experience routine screening by health visitors (HVs) using the Edinburgh Postnatal Depression Scale (EPDS)?
DESIGN
Indepth interviews.
SETTING
22 general practices in Oxford, UK.
PARTICIPANTS
39 women (mean age 34 y) were selected based on their registered general practice, EPDS scores at 8 weeks and 8 months, and whether listening visits were recorded (a proxy measure for postnatal depression). Exclusion criteria were inadequate English, age <16 years, learning disability, or infant death.
METHODS
Women were interviewed at 11–19 months after delivery and asked about how they felt in the first 3 months after the birth and about completing the EPDS. Screening was judged “acceptable” if women gave positive or neutral responses to questions about the EPDS. Interviews were tape recorded, transcribed verbatim, and analysed using constant comparison. Data saturation was achieved.
MAIN FINDINGS
21 women (54%) found screening for postnatal depression unacceptable. 3 themes explained this. (1) Women with negative views of screening found the process of screening to be simplistic and preferred open questions or an opportunity to talk. Women felt ill prepared for screening, were anxious about the consequences, and were reluctant to answer questions honestly. 13 women (33%) felt the baby clinic was an inappropriate place to complete the EPDS, citing reasons of stress and inadequate time and privacy. Most preferred screening at home. One third of women received little feedback from HVs and felt dissatisfied. Even non-depressed women felt distress, yet “normal” EPDS results prevented discussions about troublesome symptoms. (2) To some women, the EPDS seemed like a personal intrusion, which was pointless and frustrating. They attributed their distress to their social situation rather than illness. The women saw no medical solution to their distress and therefore resented intrusive questions from health professionals. (3) Stigma. Many felt that postnatal depression was stigmatising, and they did not want to admit to it. This reluctance was related to their image of a good mother. Some covered up their feelings to avoid being “found out” (and risk “losing” their baby) and lied deliberately on the questionnaire. Regardless of their emotional state, women felt threatened by a questionnaire to “diagnose” this stigmatising illness.
CONCLUSIONS
Over half of the participants found routine screening with the Edinburgh Postnatal Depression Scale to be unacceptable. Unacceptability was explained by the inadequacy of the screening process, the intrusiveness of the questions, and the stigma of postnatal depression. Women preferred talking about how they felt rather than completing a questionnaire, and many admitted to giving unreliable responses.
Commentary
Screening for postnatal depression has become established practice in the UK, and the EPDS is a commonly used screening tool. The study by Shakespeare et al is the first direct exploration of women’s experiences of being screened for postnatal depression.
Slightly less than half the sample found screening acceptable, but the study focused on the 53% who were judged to have found screening an unacceptable experience. It would have been illuminating to know what all participants felt about screening, but the authors report that those who found it acceptable had little to say about their experiences. However, the feelings and opinions of those who did not find it acceptable are important because they provide useful information about service delivery. Central to these women’s experiences appears to be the desire for a more human experience, one that involves the health visitor spending time establishing a relationship with the woman to facilitate disclosure of the postnatal experience. The choice of setting was also perceived to contribute to acceptability of the experience. Attention to these details, as well as adequate information about the purpose of the EPDS, could result in the EPDS more accurately reflecting women’s mental health.
Of great concern is the disclosure that some women deliberately provided socially desirable responses to the EPDS rather than revealing their interior truths. This finding is consistent with another study that identified discrepancies between EPDS scores and women’s self reported feelings of depression.1 The behaviour appears to be related to the stigma of a positive screening result and the potential effects of a diagnosis of postnatal depression. Such a diagnosis is perceived as a threat to the family.
The findings of the study by Shakespeare et al reinforce that not all women find routine screening acceptable and that the relationship with the HV appears to be of vital importance to accurate screening for postnatal depression.
Footnotes
For correspondence: Dr J Shakespeare, Summertown Health Centre, Oxford, UK. judyshake-speare.demon.co.uk
Sources of funding: National Health System and the Scientific Foundation Board of the Royal College of General Practitioners.