Postnatal Depression and Social Exclusion.
What is Post Natal Depression ?
Postnatal depression is a discrete clinical entity which appears to have a number of different aetiological factors. It does not appear to be greatly influenced by geography (Affonso et al 2000), or culture (Oates et al, 2004). A typical rate for detection of postnatal depression is quoted as about 13% of postnatal women (O’Hara et al 1996). It classically arises during the first three months post partum but the spread of onset is wide. (Cooper & Murray 1995)
One of the prime factors is considered to be the sudden postnatal drop in progesterone levels in the post partum days. (Nappi et al 2001) The placenta is responsible for the vast majority of circulating progesterone during pregnancy and it’s delivery is effectively responsible for the precipitate drop in levels post partum.
There may also be other related hormonal changes including the fluctuations in prolactin levels (Hendrick et al 1998) and falling oestrogen and cortisol levels. (Halari et al. 2004)
Symptoms can initially include irritability, tearfulness, insomnia, hypochondriasis, headache and impairment of concentration. There is a maximal incidence of these symptoms on about the fifth post partum day and these can progress to frank depressive symptoms over a variable period. (Ramsay et al 1995). There are various tools that can be used to measure the degree of depression and these include the Edinburgh postnatal depression scale,(Cox et al 1987), The Stein scale for maternity blues, (Stein 1980) and the Beck depression rating inventory. (Beck et al 1961)
Key issues affecting vulnerable patients
There have been a number of studies that look at the effectiveness of treatment of postnatal depression. One of the most recent publications (Dennis 2005) provides a meta-analysis of the factors which influence the outcome in the condition. The author concluded that the only strategy that was shown to have “a clear preventative effect” was intensive post-partum support from the healthcare professionals involved in the case. Curiously, this was found to be more effective than similar regimes which included an ante-natal component as well.
The morbidity associated with postnatal depression has a number of potential consequences not only for the mother, but also the child and the rest of the family as well. (Oakley et al 1996)
One of the most significant is the fact that one episode of postnatal depression is the greatest predictor (or risk factor) for another episode after subsequent pregnancies. The children are likely to have difficulties because of possible problems with bonding and the mother’s possible negative perceptions of the behaviour of the children. (Cooper & Murray 1997)
Some studies have shown that mothers with postnatal depression have derived beneficial help from social support during pregnancy. (Ray et al 2000). It would therefore appear that the key issues in this area are identification of the predictive factors that make postnatal depression more likely and then the provision of prompt supportive measures if those factors are established.
Local resources for support
Apart from the more “traditional “ resources of the primary healthcare team of the General Practice the Midwife and the Health Visitor, some centres have tried experiments with postnatal support worker provision (Morrell 2000). This particular study found that the patients found an high level of satisfaction with the service – but no more so than with the services provided by the rest of the primary healthcare team. Analysis of the results showed that the postnatal support worker helped to achieve higher levels of breast feeding, but had little impact on the severity or frequency of postnatal depression.
One significant factor that was found, however, was that support from a partner was a significant positive factor in preventing severe postnatal depression.
Several recent studies have shown that healthcare professionals often fail to spot the signs of postnatal depression. (Bick et al 1995). Making the diagnosis is obviously the prerequisite of establishing a treatment regime so it is clearly vital for all healthcare professionals to be on their guard for warning signs – sleep disturbance, irritability, mood swings and irrationality. (Ramsay et al 1995)
Reflection and reflective practice is a vital part of effective nursing. (Gibbs 1998) . Each healthcare professional should ideally reflect upon their management of each individual case to decide whether they were communicating optimally with the patient and that they were fully receptive to all that was on the patient’s agenda. Communication is a two-way modality.
Bulman (et al.2004) points to the need to understand, at a deeper level, just what it is the message that the patient is taking away from any interaction. Communication is therefore vital in the strategy to empower and educate the vulnerable patient.
Role of midwife and Health Visitor
The new mother is often at the centre of an emotional rollercoaster. The sudden culmination of nine months of expectation results (frequently) in a flurry of support from healthcare professionals and family, which then rapidly evaporates and the mother is left to deal with the new situation which is frequently stressful. (Kitzman et al 1997)
The midwife can obviously help by preparing the ground in the antenatal period and offering support in the immediate postnatal period. (Dennis 2005). The health visitor is probably better placed to be aware of any developing warning signals that postnatal depression is developing, as they are likely to be in contact with the patient during the “high risk period”. (Cooper & Murray 1995).
It has been suggested that encouragement of the mother to attend the health visitor clinic rather than to have home visits is a positive way of encouraging social inclusion. (Seeley et al 1996)
Studies which have looked at the cost-effectiveness of using community postnatal support service workers have shown no benefit over the more traditional midwife and Health Visitor support. (Morrell et al 2000)
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