Postpartum Psychosocial and Behavioral Health: A Systematic Review of Self-Administered Scales Validated for Postpartum Women in the United States

Screening for Perinatal Depression: Barriers, Guidelines, and Measurement Scales

Background: Screening for perinatal depression can lower its prevalence and ensure that mothers receive adequate treatment and support. Yet, few practitioners screen for it. The present article is a brief review of barriers to screening, and two screening scales are validated for perinatal women. Findings: Even though health organizations recommend screening, most new mothers are not screened. Providers cite a lack of time, opening "Pandora's box," and a lack of resources for mothers who screen positive as the reasons why they do not screen for this condition. The Edinburgh Postnatal Depression Scale and the Patient Health Questionnaires are brief screening scales validated for new mothers and widely available. Conclusions: Screening is necessary to identify depression in pregnant and postpartum women. Practitioners who screen for this condition need a clear plan and knowledge of how to access available community resources so that they know what to do when a mother screens positive.

Experiences of racism and postpartum depression symptoms, care-seeking, and diagnosis

Postpartum depression (PPD) is common and disproportionately affects people of color. Experiences of emotional upset due to racism (EUR) may be an important predictor of PPD outcomes. Therefore, we aimed to determine if EUR during the 12 months before delivery was associated with PPD symptomology, asking for help for depression, and depression diagnosis among postpartum people of color (PPOC). We conducted a cross-sectional secondary data analysis among PPOC from 11 states and New York City using PRAMS data, 1/1/2015-12/31/2017. We assessed symptomology using an unvalidated PHQ-2. Logistic regression was performed without and with stratification by ethnicity (non-Hispanic PPOC vs Hispanic PPOC) to estimate whether EUR during 12 months before delivery was associated with (1) PPD symptoms, (2) asking for help for depression, and (3) depression diagnosis. Models adjusted for age, educational attainment, timely prenatal care, payment method, stress during pregnancy, and pre-pregnancy depression. Seventy-four thousand nine hundred nine (11.8%) PPOC reported EUR in the 12 months before delivery. After adjustment, EUR was associated with a 10.3 percentage point (%pt; 95% CI: 6.8, 13.8), 13.6%pt (95% CI: 8.8, 18.5), and 4.1%pt (95% CI: 1.4, 8.0) higher probability of positive PPD screening among all PPOC, non-Hispanic PPOC, and Hispanic PPOC, respectively. EUR was not associated with asking for help for depression but was associated with a higher prevalence of depression diagnosis among all PPOC (4.6%pt; 95% CI: 1.0, 8.4) and non-Hispanic PPOC (6.0%pt; 95% CI: 0.8, 11.2).Experiences of EUR are associated with an increased prevalence of PPD symptoms. Additional prospective research spanning the pre-pregnancy through postpartum periods is needed to examine the dynamic relationship between racism, symptomology, help-seeking, and diagnosis of depression.

Body Appreciation, Depressive Symptoms, and Self-Esteem in Pregnant and Postpartum Brazilian Women

Background

During pregnancy and the postpartum period, women experience tremendous biopsychosocial changes in a short period of time. Poor body appreciation, depressive symptoms, and low self-esteem during the perinatal period may cause negative consequences for both the mother and the infant's physiological and psychological health. The aim of this study was to analyze the differences in body appreciation, depressive symptoms, and self-esteem between the three gestational trimesters and the postpartum period.

Methods

Participants (N = 1,423 pregnant and postpartum Brazilian women), aged between 18 and 42 years old (M = 29.22; SD = ±5.72), answered questionnaires on body appreciation, depressive symptoms, and self-esteem. BMI was self-reported. Descriptive and nonparametric covariance analysis were performed, comparing women who were in the first, second, and third trimesters and the postpartum period.

Results

Body appreciation was significantly higher among women in the third trimester compared to those in the first and second trimester. However, it was lower for women in all three gestational trimesters than for those in the postpartum. There was no difference in self-esteem during pregnancy, but it was significantly lower in the postpartum group. Similarly, depressive symptoms did not vary through pregnant groups but it was significantly higher in the postpartum group.

Conclusions

The results showed that the postpartum period can be a difficult experience for women. They presented poor body appreciation and lower self-esteem and higher depressive symptoms compared to the pregnancy period. Therefore, it is necessary for public health policies to support women in this period, preserving their mental health and making this experience more positive.

An Association Between Psychological Childbirth Trauma and Hazardous Alcohol Use

Hazardous alcohol use is increasing amongst some groups of women, yet little is known about the underlying reasons or gender-specific influences. The purpose of this study was to explore the association between psychological childbirth trauma and women’s hazardous alcohol use. We aimed to identify predictors of hazardous alcohol use given childbirth-related trauma, other life trauma (combat, natural disasters, physical or sexual assault, experiences threatening loss of life or loss of loved ones) and coping motives for drinking, whilst controlling for age, socio-economic status, negative affect and other drinking motives (enhancement and social motives). Australian data from the Why Women Drink survey (N = 301) was analysed. Women who experienced childbirth as traumatic scored higher overall for hazardous drinking and endorsed coping reasons more strongly than those who did not. Analyses of individual differences affecting hazardous drinking revealed coping reasons, rather than trauma itself, as the strongest predictor in a regression model. Other significant predictors included socio-economic status, enhancement of positive emotions and, marginally, negative affect. Findings identified a link between traumatic childbirth and hazardous drinking as a coping strategy. Prospective research is required to characterise predisposing and perpetuating vulnerabilities determining maladaptive coping after traumatic childbirth, and to inform effective interventions.

Validated tools to identify common mental disorders in the perinatal period: A systematic review of systematic reviews

BACKGROUND

Uncertainty remains regarding the validity of screening tools to detect common mental disorders (CMDs) during perinatal periods. This umbrella review aims to provide an up-to-date summary of psychometric properties of tools for the identification of perinatal CMDs.

METHODS

Reviews were identified via Ovid MEDLINE, PsychINFO, EMBASE, Global Health and Cochrane Database of Systematic Reviews electronic databases with no date or language restriction. Pooled sensitivity and specificity estimates and ranges were extracted and summarised using forest plots. Quality assessment was conducted using Measurement Tool to Assess Systematic Reviews (AMSTAR-2).

RESULTS

Of 7,891 papers identified, 31 reviews met inclusion criteria. 76 screening tools were identified; most frequently validated were Edinburgh Postnatal Depression Scale (EPDS) (n = 28 reviews), Beck's Depression Inventory (BDI) (n = 13 reviews) and Patient Health Questionnaire (PHQ) (n = 12 reviews). Forest plots demonstrated a pattern of decreasing sensitivity and increasing specificity with increasing cut-off scores. Sub-group analysis of data extracted from low quality reviews demonstrated wider 95% CIs and overall lower specificity. Validity also varied according to ethnicity, socio-economic background and age.

LIMITATIONS

Despite a low Covered Corrected Area (CCA) score the primary studies included within reviews overlapped; therefore we were unable perform meta-analysis.

CONCLUSIONS

The evidence suggests that the EPDS, PHQ and BDI are useful across a range of diverse settings but the context of tool application is a key factor determining validity. This review highlights that utilizing screening tools in clinical practice is complex and requires careful consideration of the population, context, and health system it will be used in.

Socioeconomic and racial/ethnic disparities in postpartum consultation for mental health concerns among US mothers

Limited research has examined factors that impact access to postpartum mental healthcare. We investigated the predisposing, enabling, and need factors associated with postpartum consultation for mental health concerns in US mothers with or without depressive symptoms and examined potential disparities in access. We utilized cross-sectional data from the Listening to Mothers II Survey, the second national US survey of women's childbearing experiences. The survey recruited 1573 women, aged 18-45 years, who spoke English and had given birth. Depressive symptoms were measured with the Postpartum Depression Screening Scale (PDSS-SF). The dependent variable was postpartum consultation for mental health concerns. Logistic regression analyses showed that mothers with scores of 14-21 and 22-35 on the PDSS-SF had higher odds of consulting a provider for mental health concerns (OR 3.97; OR 12.91). Latinas had lower odds of seeking mental health consultations than Whites (OR 0.39). Mothers who were employed prenatally full-time or part-time had lower odds of seeking consultations than non-employed mothers (OR 0.62; OR 0.52). Mothers with household incomes of $50,000-$74,999 had higher odds of seeking consultations than those with incomes less than $25,000 (OR 2.20). When regression analyses were restricted to mothers with PDSS-SF scores ≥ 14, findings were similar by race/ethnicity and prenatal employment. Significant depressive symptoms are common in women after giving birth and few sought any form of mental health consultation. Latinas and low-income women are less likely to seek postpartum mental health consultations. Mental health care interventions could be geared towards targeting these at-risk groups.

Development and Psychometric Properties of the Self-Acceptance Scales for Pregnant and Postpartum Women

Self-acceptance, that is, a person's acceptance of their own psychological and physical attributes, is considered critical for mental wellbeing. A lack of self-acceptance may contribute to the development of psychopathology. In the peripartum period, self-acceptance has particular relevance, as major psychological and body changes are normative during this time. This research presents the development and validation of the Self-Acceptance Scale for Pregnant Women (SAS-PW) and the Self-Acceptance Scale for Postpartum Women (SAS-PPW). Participants were aged 18-52. In Study 1, we developed 77 items for the SAS-PW and 74 items the SAS-PPW, based on literature review, previous scales, and qualitative study. In Study 2, nine experts and 60 representatives of the target population evaluated the instruments' content validity, leading some items to be excluded and others to be modified. Studies 3 and 4 analyzed the instruments' psychometric qualities among respondents to the instruments, 1254 pregnant women and 607 postpartum women from across Brazil. We conducted exploratory and confirmatory factor analyses with independent samples. The final SAS-PW (10 items and two-factors) and SAS-PPW (14 items and three-factors) demonstrated adequate psychometric quality for use with Brazilian pregnant and postpartum women, respectively.

An application of psychosocial frameworks for eating disorder risk during the postpartum period: A review and future directions

The postpartum period may be a particular window of vulnerability for eating disorder symptoms given changes to body shape and weight that women experience. However, no quantitative studies have identified risk factors for postpartum eating disorder symptoms, and current psychosocial frameworks of risk may be missing key elements unique to this period. This manuscript reviews existing quantitative and qualitative literature regarding the developmental trajectory of eating disorder symptoms during the perinatal period and proposes an application of three psychosocial models of eating disorder risk (objectification theory, the tripartite influence model of body image and eating disturbances, and social comparison theory) to the postpartum period. Drawing on quantitative and qualitative literature, this paper identifies novel postpartum-specific factors that should be included for consideration in psychosocial models (e.g., self-oriented body comparison and pressure to achieve a prepregnancy weight and shape). This review is the first to theorize potential postpartum-specific risk factors for postpartum eating disorder symptoms. Prior models of eating disorder risk omit key psychosocial factors that are unique to the postpartum period. Other limitations of prior research relate to measurement and methodology. This critical window of vulnerability has been largely ignored in the quantitative literature and necessitates further research.

Maternal Obesity and Perinatal Depression: An Updated Literature Review

The objective of this review was to determine if there is an association between maternal obesity and increased risk of perinatal depression. Original research articles were found by conducting an electronic database search of PubMed, ClinicalKey, PsycINFO, and Cochrane Library. Seven articles, published in the last five years, were reviewed. Of the seven articles, five demonstrated an association between some level of maternal obesity and increased risk of perinatal depressive symptoms. The two remaining articles did initially find an association, but it was no longer significant after adjusting for or mediating the analysis with covariates. There appears to be an association between peripartum depressive symptoms and some level of maternal obesity and its comorbidities. More research is needed to determine the mechanism and degree of the association and its clinical significance.

Is Postpartum Depression Different From Depression Occurring Outside of the Perinatal Period? A Review of the Evidence

Whether a major depressive episode occurring in the postpartum period (i.e., postpartum depression [PPD]) is sufficiently distinct from major depressive episodes occurring at other times (i.e., major depressive disorder) to warrant a separate diagnosis is a point of debate with substantial clinical significance. The evidence for and against diagnostic distinction for PPD is reviewed with respect to epidemiology, etiology, and treatment. Overall, evidence that PPD is distinct from major depressive disorder is mixed and is largely affected by how the postpartum period is defined. For depression occurring in the early postpartum period (variably defined, but typically with onset in the first 8 weeks), symptom severity, heritability, and epigenetic data suggest that PPD may be distinct, whereas depression occurring in the later postpartum period may be more similar to major depressive disorder occurring outside of the perinatal period. The clinical significance of this debate is considerable given that PPD, the most common complication of childbirth, is associated with immediate and enduring adverse effects on maternal and offspring morbidity and mortality. Future research investigating the distinctiveness of PPD from major depressive disorder in general should focus on the early postpartum period when the rapid decline in hormones contributes to a withdrawal state, requiring profound adjustments in central nervous system function.

Associations of Prenatal and Postnatal Maternal Depressive Symptoms with Offspring Cognition and Behavior in Mid-Childhood: A Prospective Cohort Study

Exposure to maternal depressive symptoms in the peri-pregnancy periods may be associated with poorer child development, but research is often limited to only maternal assessments of behavior and cognition. This study investigates the specific periods of prenatal and postnatal exposure to maternal depressive symptoms in association with child development using reports from teachers and mothers. This study is based on 1225 mother–child pairs from Project Viva, a prospective pre-birth cohort study. Mothers reported depressive symptoms on the Edinburgh Postpartum Depression Scale (EPDS) in mid-pregnancy as well as at 6 months and 12 months postpartum. Teachers and mothers reported child executive functions using the Behavioral Rating Inventory of Executive Function (BRIEF) and behavior using the Strengths and Difficulties Questionnaire (SDQ). Children completed the Kaufman Brief Intelligence Test (KBIT-2), the Wide Range Assessment of Visual Motor Abilities (WRAVMA), and the Visual Memory Index of the Wide Range Assessment of Memory and Learning (WRAML). We used multivariable linear regression models to examine associations of prenatal and postpartum depressive symptoms with outcomes. Many of the crude associations observed were attenuated after adjusting for demographic factors and maternal IQ, yet some remained significant. For example, high prenatal maternal depressive symptoms were associated with poorer scores on the BRIEF Behavior Regulation Index and some SDQ scales based on reports from teachers and mothers. High prenatal maternal depressive symptoms were associated with poorer behavioral development. Postpartum symptoms did not show strong associations with outcomes once we adjusted for the prenatal period.

End-of-life decision making by family caregivers of persons with advanced dementia: A literature review of decision aids

Objectives:

To investigate existing knowledge in the literature about end-of-life decision making by family caregivers of persons with dementia, focusing on decision aids for caregivers of persons with advanced dementia, and to identify gaps in the literature that can guide future research.

Methods:

A literature review through systematic searches in PubMed, CINAHL Plus with Full Text, and PsycINFO was conducted in February 2018; publications with full text in English and published in the past 10 years were selected in multiple steps.

Results:

The final sample included five decision aids with predominantly Caucasian participants; three of them had control groups, and three used audiovisual technology in presenting the intervention materials. No other technology was used in any intervention. Existing interventions lacked tailoring of information to caregivers’ preferences for different types and amounts of information necessary to make decisions consistent with patients’ values.

Conclusion:

Research is needed in exploring the use of technology in decision aids that could provide tailored information to facilitate caregivers’ decision making. More diverse samples are needed.

Psychosocial Risk Factors for Perinatal Depression among Female Adolescents: A Systematic Review

Perinatal depression is a health concern among pregnant and postpartum adolescents as it may negatively impact fetal development and result in complications such as preterm delivery, low infant birth weight, and poor maternal-infant attachment. The purpose of this systematic review is to examine psychosocial risk factors for depression among adolescents during pregnancy and postpartum. A literature search was conducted from five databases from 1995 to 2016. A total of 17 studies matched the inclusion criteria. Lack of social support, perceived stress, prior history of depression, and a history of sexual or physical violence were most frequently identified as potential risk factors for perinatal depression. Additional risk factors include the adolescent's perception of her pregnancy, family criticism, self-efficacy, self-esteem, substance use, parental stress, community violence, anxiety, and African-American ethnicity. Research and clinical implications are indicated for adolescents at risk for perinatal depression.