Running head: EFFECTIVENESS OF POSTPARTUM DEPRESSION SCREENING

Effectiveness of Postpartum Depression Screening

Dani Woodley
Western Washington University

Running head: EFFECTIVENESS OF POSTPARTUM DEPRESSION SCREENING

EFFECTIVENESS OF POSTPARTUM DEPRESSION SCREENING

Effectiveness of Postpartum Depression Screening

Pregnancy and childbirth, in many instances, are a joyous occasion for many
women. Bringing home your precious bundle of joy from the hospital leaves parents
feeling overjoyed, anxious, terrified, excited, exhausted, and mostly curious over what
the future will bring to their new little family. As a new mother, I fell through the cracks
when it came to my postpartum experience, and nobody discussed postpartum depression
with me. I got the general statement to call my doctor if I had thoughts about hurting my
baby; however, who believes themselves to be capable of this? Postpartum depression is
not always on the forefront of a new mothers mind. The instances of postpartum
depression are on the rise, and we must examine this issue. Mandated screening for post
partum depression, as standard care, will decrease the instances and/or severity of PPD in
new mothers by helping women understand the concept, symptoms and risks of PPD,
identify resources available to them, and help increase the mother-infant bond.
While searching for articles to support this thesis I focused on research that used
well-known screening tools that demonstrated effectiveness as it relates to post partum
depression. The exploration of research helped discover articles that encompassed risk
factors for new mothers that connect life stressors to the degree of post partum
depression. Since the majority of research supports using a screening tool in the post
partum period, it was interesting to find an article that supports a point of view opposite
of the others. The journey of finding articles to support my thesis guided my thoughts and
strengthened my belief that screening for PPD must be improved.
Recognizing Post Partum Depression
To begin, one must first understand what postpartum depression entails.
Rosenfield (2007) defines postpartum depression (PPD) as the most common psychiatric

EFFECTIVENESS OF POSTPARTUM DEPRESSION SCREENING

condition experienced by women during the first year after the birth of a child (as cited
in Youash et al., 2013, p. 489). PPD can be seen immediately after giving birth; however,
it is most common to be diagnosed and observe symptoms arising within 4-6 weeks
postpartum. Unfortunately, this also is the generalized time in which postpartum care
tends to be tapering off, when these women are at there most vulnerable.
Having the ability and effective resources to screen and identify women for PPD
is critical in reducing the severity and prevalence of this condition. Many new mothers, or
those in the post partum period, may not have been screened for PPD. These women may
need help but are too afraid or ashamed to ask. A 2009 national survey of obstetriciangynecologist fellows found that only 37% reported using a validated screening instrument
to detect depression in their patients (Farr, Denk, Dahms, & Dietz, 2014, p. 657). Farr et
al. (2014) focused their research on New Jersey and the rates of prenatal education and
screening, at hospital delivery, for postpartum depression. New Jersey is the first state to
mandate that all women in the postnatal period be screened for PPD. The law states that:
prenatal care providers shall provide education to women about postpartum
depression to increase detection and treatment of the disorder. Additionally, the
law specifies physicians, nurse midwives, and other licensed healthcare
professionals providing postnatal care to women shall screen new mothers for
postpartum depression symptoms prior to discharge from the birthing facility and
at the first few postnatal check-up visits. (Farr et al., 2014, p. 657).

The New Jersey Postpartum Depression Task Force recommended using the
EPDS and the Pregnancy Risk Assessment Monitoring System (PRAMS) to evaluate the
degree of postpartum depression in the mothers, and to analyze whether their prenatal

EFFECTIVENESS OF POSTPARTUM DEPRESSION SCREENING

care provider discussed postpartum depression with them post delivery. Farr et al. (2014),
found that 89.6% of the 2012 women in their study were screened for depression at
hospital delivery, and of those women 87.1% screened negative at both delivery and
postpartum, 3.9% screened positive at delivery and negative postpartum, 7.4% screened
negative at delivery and positive postpartum, and 1.6% screened positive at both time
points. What is incredibly important to point out is that of the 94.5% of women who
screened negative on EPDS at delivery, 7.8% reported depressive symptoms postpartum
(Farr et al., 2014, p. 659). This illustrates that even though the screening has happened,
women still may fall through the cracks or bend the truth in their evaluations.
Schaar & Hall (2013) conducted research that entailed a nurse-led initiative to
implement routine screening for postpartum depression using the EPDS. It is their belief
that screening for postpartum depression as standard care would enhance recognition of
this potentially devastating illness (Schaar & Hall, 2013). Throughout their research,
they consistently found that PPD screening is limited and not standard care in the
postpartum period. As a screening tool, the EPDS has been found to be beneficial, used
without cost, reliable, and valid, but routine screening and/or use of this tool continue to
not be the standard by obstetricians nationwide. The question remains as to why this
screening isnt happening routinely, when PPD is so prevalent in postpartum mothers,
and the author illustrates this with the following:
Nurses are well positioned to play a critical role in postpartum depression
education and screening. This is evident in a statewide study involving Iowa
nurses showing that almost 97% either strongly agreed or agreed that nursedelivered postpartum depression screening was a good idea.. Arndt, Beck,

EFFECTIVENESS OF POSTPARTUM DEPRESSION SCREENING

OHara, and Segre (2010) found that a study of 691 postpartum women show that
more than 90% of the women overwhelmingly supported nurse-delivered
postpartum depression screening and counseling (as cited in Schaar & Hall, 2013,
p. 313).
Since prior research hasnt been able to truly link PPD to identifiable risk factors, having
postpartum screening available to all women, in the postnatal period, will help women
understand what PPD encompasses and where to get help.
Risk Factors
Youash et al. (2013) complains that there was limited research conducted on the
relationship between health information levels and their influence on PPD as measured
by the Edinburgh Postnatal Depression Scale (EPDS) scores. EPDS is a common
screening tool that is used to measure probability and degree in which a woman may be
experiencing PPD. Their research helped identify situations or scenarios that increased or
decreased the severity and/or prevalence of PPD in primiparous women, meaning first
living child, compared to multiparous women, meaning more than one living child.
Youash et al. (2013) demonstrated with their statistical analysis the positive relationship
and influence between the level of health information and the degree of PPD.
An important finding is that they believe anxiety and depression to go hand and
hand; therefore, anxiety during pregnancy is one of the strongest predictors of PPD.
Many women with clinical PPD are thought to exhibit comorbid anxiety, with prevalence
reports of up to 50% (Youash et al., 2013, p. 490). Life stressors were also found to be
the strongest predictor of EPDS scores in the primiparous sample (Youash et al., 2013,
p. 496). Stress causes anxiety; anxiety increases PPD. Therefore, if we increase the

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amount of information about the postpartum period, we can decrease anxiety, which
would directly impact the severity or risk of PPD.
Primiparous women are generally in a very fragile place in their life. They are
beginning a completely new journey down the road of motherhood, and having limited to
no health information, regarding the postpartum period, can be detrimental to the health
of both the mother and also the baby. It was found, by Youash et al. (2013), that
primiparous women whom have an increase in both postnatal informational factors,
demonstrated the largest change of magnitude with a fourfold decrease in EPDS score.
When it came down to it, Shieh et al. (2009) established that primiparous women exhibit
a higher degree of information seeking (as cited in Youash et al., 2013, p. 491). These
women are hungry for information to guide them. Although Avison et al. (2013) does not
say so directly, they presume, through their analysis, that if a new mother is presented
with proper information regarding the postpartum period, then they are less likely to
suffer from PPD. This information illustrates that it is important to screen women in the
postpartum period using the EPDS, or some equivalent evaluation tool, to determine the
women who are at risk for developing PPD.
This research is extremely important to postpartum depression screening because
it clearly illustrates that the more information a new mother has in the postpartum period,
the less likely she is to suffer from severe postpartum depression. As this research was
conducted, the readers observe a definitive decrease in EPDS scores in relation to
education and information pertaining to PPD. The better a woman feels about herself and
her ability to be an effective and loving new mother, the less likelihood of her developing
severe postpartum depression, if at all.

EFFECTIVENESS OF POSTPARTUM DEPRESSION SCREENING

The mandate of universal prenatal education on depression and screening for

depressive symptoms at the hospital is feasible, results in the majority of women being
educated and screened, and as this research proves, necessary. In just one year of New
Jersey mandating this PPD evaluation, the rates of women screened improved from
87.8% in 2009 to 91.3% in 2010 (Farr et al., 2014). Even though the screening is now a
mandated law, it was found that there were practitioners that still werent screening or
educating their patients about PPD. The reasons for this are unknown. However,
speculations remain that it has to do with their lack of time or knowledge, lack of recall
about education by the woman, or that the physicians provided all their patients with
reading materials, but only screened the women that they felt were at higher risk of
developing PPD (Farr et al., 2014, p. 661).
Available Resources for New Mothers
Farr et al. (2014), recognizes that screening alone is not sufficient enough to help
women with PPD. It is crucial that postpartum women be educated about the resources
that they have available to them outside of the hospital and their physicians office.
Further research and studies must be done to create systems to ensure that women who
screen positive for PPD can and will receive proper support, assessment, and treatment.
Some resources that Farr et al. (2014), believes could be beneficial for women at risk
include, but are not limited to, Woman Infant Child (WIC), Neonatal Intensive Care Unit
(NICU) encounters, and well-baby visits. Farr et al. (2014) writes that additional efforts
may be needed to ensure depressed women get treatment. Some ideas that were given
include monitoring and enforcing the screening requirement, paying providers to screen

EFFECTIVENESS OF POSTPARTUM DEPRESSION SCREENING

and follow-up with women, and further research on effective interventions for depressed
women.
This article helps conclude that screening alone may not be enough to achieve a
reduction in the severity of postpartum depression. However, this research was limited to
a small population in New Jersey so it is limited in its information in that regards.
However, using this small population to illustrate the effectiveness that screening can
have in bettering a new mothers life is very necessary in the grand scheme of things. The
more physicians begin using an effective screening tool, like the EPDS, we should see the
percentages of women suffering from PPD continue to decline.
Having the ability to routinely screen new mothers with a mandated, consistent
evaluation would make a significant difference in the decline of new mothers suffering
from PPD within the first year. Recognizing the women at risk, or those who screen
positive on the EPDS, will allow health care professionals to guide women to the
necessary resources available for help. Schaar & Hall (2013) reviewed several different
studies and found that the information indicates that PPD impacts not only the mother, it
impacts the development of infants social interaction, maternal-infant attachment,
negative family dynamics, postpartum psychosis, suicide, decreased maternal quality of
life, and paternal postpartum depression.
Maternal Infant Bond
Postpartum depression, in new mothers, causes a breakdown in the family
dynamic and the maternal-infant bond in the initial stages of life. Women suffering from
postpartum depression can cloud a new mothers mind through negative thoughts, anger
toward their baby or significant other, ideations of harming the baby or self, or disinterest

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in being a mother. Brealey, Hewitt, Green, Morrell, and Gilbody (2010) performed a
systematic review and meta-synthesis that looked at evidences to determine whether
screening for Postnatal Depression (PND) is acceptable to women and healthcare
professionals. Most of their research focused on the validity and effectiveness of the
EPDS. More specifically, they looked at the concerns about the comfort levels of the
women being screened, and how those statistics affected the process of being screened
and the effective communication levels between the mother and the healthcare
professional. Hearn et al., (1998) pointed out less than 50% of cases of PND are
identified by primary healthcare professionals in routine clinical practice (as cited in
Brealey et al., 2010, p. 329).
The question remains why half of these women, in the postnatal period, are not
appropriately being screened for PND, when the impact of PND has such severe
consequences on the life of mom and baby. Pop et al. (1993) found that PPD can affect
maternal-infant interactions, women can display less affectionate behavior, are less
responsive to their infants, and are more withdrawn compared to those without such
condition (as cited in Youash et al., 2013, p. 489). Schaar & Hall (2013) reviewed
several different studies and found that PPD impacts not only the mother, it impacts the
development of infants social interaction, maternal-infant attachment, negative family
dynamics, postpartum psychosis, suicide, decreased maternal quality of life, and paternal
postpartum depression.
An interesting find by Brealey et al. (2010) is that many women expressed
concerns of fear & shame over offering truthful answers about depression and the
possibility that their honest answers may result in their child being taken away from

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them. Women in four studies reported that they deliberately lied on the questionnaire for
fear of answering questions honestly (Alder et al., 2007, as cited in Brealey et al., 2010,
p. 339). To help ensure that women give truthful answers, having a supporting and caring
relationship with the healthcare professional is extremely beneficial, and this process can
begin early on in the antenatal experience, to help decrease PND, through early
identification and/or screening. In conclusion, this meta-synthesis found that women and
healthcare professionals found the EPDS to be a valuable screening tool to help identify
the women at risk; however, the way in which the questionnaire is implemented as a
screening instrument is key in the results that practitioners discover.
Synthesis
Interestingly enough, while most the research supported that proper PPD
screening and education will benefit the mothers in the postpartum period, Maldanado,
Hiner, and Lanciers (2015), found that the postpartum period is actually most important
for identifying women at risk for depression, and that education during this time may not
be effective. The limited time that nurses have in the hospital with their new mothers is
better spent on implementing a mechanism for ensuring adequate follow-up after
discharge for women at risk. When women are knowledgeable about the resources
available to them, they are more likely to ask for and seek out help. It is imperative that
we provide the proper tools and resources for the women who do test positive for PPD. It
isnt enough to just diagnose it, we have to then treat it, and not let the mother fight this
battle alone. This in turn would negatively impact the life of the innocent child.
A consistent finding through all the research is that screening alone is not enough.
Ensuring proper follow-up, in the postpartum period, is vital for women to get the help

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that is needed. Also, the EPDS, or other questionnaires or screening tools, are not
diagnostic (Brealey et al., 2010); a clinical assessment is also necessary to determine the
women who are suffering from PPD. This will help ensure that no woman, or as few as
possible, fall through the cracks. The EPDS, as a screening tool, should be used as an
aide to help identify the women who need further help or assessment. A healthcare
professional should use their clinical decision-making skills and an open dialogue to
further explore the issues with women at risk for PPD.
Conclusion
In the process of writing this source evaluation, I was confronted with a lot of
research that all seemed alike. It was very difficult to comb through the articles to find
those that would be beneficial to support and question the thesis of this paper. Im
appreciative I was able to find an article that had an opposing view to my own because it
allowed me to introduce a different perspective in my evaluation. I believe to my core
that post partum depression is going undiagnosed causing negative impacts on these
women and their new babies. The research supports this same belief, and it is time that
things change, in the form of more thorough examination of post partum women.
Postpartum depression is real, its common, and it is debilitating. If we continue to
let it go undetected, we will continue to see an increase in the numbers of women
diagnosed with this type of depression each year. If we mandate that healthcare
professionals screen women in the postpartum period we will see a decrease in the
severity and numbers in new mothers. Requiring a universal screening tool be used
during postpartum visits, to detect PPD, will allow healthcare providers to recognize
those women at risk, discuss depression with new mothers, explain what symptoms these

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women should be aware of, and refer these women to necessary resources. Overall, it will
help improve the mother infant bond that PPD can impact so negatively.

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References
Brealey, S., Hewitt, C., Green, J., Morrell, J., & Gilbody, S. (2010). Screening for
postnatal depression -- is it acceptable to women and healthcare professionals? A
systematic review and meta-synthesis. Journal Of Reproductive & Infant
Psychology, 28(4), 328-344. doi:10.1080/02646838.2010.513045
Farr, S. L., Denk, C. E., Dahms, E. W., & Dietz, P. M. (2014). Evaluating Universal
Education and Screening for Postpartum Depression Using Population-Based
Data. Journal Of Women's Health (15409996), 23(8), 657-663.
doi:10.1089/jwh.2013.4586
Malagon-Maldonado, G., Hiner, J. B., & Lanciers, M. (2015). Broadening the Horizons
on Predictors of Discharge Teaching, Discharge Readiness, and Postdischarge
Outcomes...Proceedings of the 2015 AWHONN Convention. JOGNN: Journal Of
Obstetric, Gynecologic & Neonatal Nursing, 44S58-S58. doi:10.1111/15526909.12628
Schaar, G. L., & Hall, M. (2013). A Nurse-led Initiative to Improve Obstetricians'
Screening for Postpartum Depression. Nursing For Women's Health, 17(4), 306316. doi:10.1111/1751-486X.12049
Youash, S., Campbell, K., Avison, W., Peneva, D., Sharma, V., & Xie, B. (2013).
Influence of health information levels on postpartum depression. Archives Of
Women's Mental Health, 16(6), 489-498. doi:10.1007/s00737-013-0368-5