Postpartum depression screening at well-child visits: validity of a 2-question screen and the PHQ-9

Systematic Review of Barriers to and Facilitators of Screening for Postpartum Depression at Well-Child Visits in the United States

OBJECTIVE

To identify and evaluate barriers to and facilitators of screening for postpartum depression (PPD) during well-child visits in the United States. Additionally, to describe prior work on PPD screening tool evaluation and outcomes from PPD screenings conducted within the well-child setting.

DATA SOURCES

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Five databases (Pub Med, PsycINFO, Web of Science, CINAHL, and Cochrane Library) were searched.

STUDY SELECTION

Randomized controlled trials, case studies, cross-sectional studies, case-control studies, cohort studies, qualitative studies, and quasi-experimental studies conducted in the United States were included. The Standard Quality Assessment Criteria Tool (QualSyst) was used to assess the methodologic quality of each included study.

DATA EXTRACTION

Sample, setting, methods, screening tools used, location of study setting, intervention, and salient findings were extracted and summarized for further analysis and synthesis.

DATA SYNTHESIS

Quantitative studies were rated on 14 aspects, and qualitative studies were rated on 10 aspects, per QualSyst. Studies received a score of 2, 1, 0, or not applicable based on scoring criteria, with higher scores indicating greater methodologic quality.

CONCLUSION

We found that barriers to PPD screening included concerns regarding time for screening, adequate training, and limited ability for referral. Facilitators of PPD screening included electronic prompts for providers, as well as tool availability and familiarity. Our results indicate that education and training about PPD screening in the pediatric setting are important next steps in addressing the rising concern of PPD in the United States.

Primary care physicians' perspectives on the identification and management of postnatal mental health problems

BACKGROUND

Postnatal mental health problems (PMHPs) are prevalent and negatively affect mothers, children, and society. International and local guidelines recommend that Singapore primary care physicians (PCP) screen, assess, and manage mothers with PMHPs. However, little is known about their experiences and views.

METHODS

We conducted semi-structured interviews with 14 PCPs in Singapore. Interview questions elicited perspectives on the identification and management of mothers with PMHPs. The interview guide was developed from a conceptual framework incorporating the knowledge-attitudes-practices, self-efficacy, and socio-ecological models. Interviews were audio-recorded and transcribed. Thematic analysis was used to identify emergent themes.

RESULTS

Singapore PCPs viewed themselves as key providers of first-contact care to mothers with PMHPs. They believed mothers preferred them to alternative providers because of greater accessibility and trust. In detection, they were vigilant in identifying at-risk mothers and favoured clinical intuition over screening tools. PCPs were confident in diagnosing common PMHPs and believed that mothers not meeting diagnostic criteria must be readily recognized and supported. In managing PMHPs, PCPs expressed varying confidence in prescribing antidepressants, which were viewed as second-line to supportive counselling and psychoeducation. Impeding physician factors, constraining practice characteristics and health system limitations were barriers. Looking forward, PCPs aspired to leverage technology and multidisciplinary teams to provide comprehensive, team-based care for the mother-child dyad.

CONCLUSION

Singapore PCPs are key in identifying and managing mothers with PMHPs. To fully harness their potential in providing comprehensive care, PCPs need greater multidisciplinary support and technological solutions that promote remote disclosure and enhanced preparation for their role.

Identification of depression and anxiety during pregnancy: A systematic review and meta-analysis of test accuracy

INTRODUCTION

Depression and anxiety are significant contributors to maternal perinatal morbidity and a range of negative child outcomes. This systematic review and meta-analysis aimed to review and assess the diagnostic test accuracy of selected screening tools (Edinburgh Postnatal Depression Scale [EPDS], EPDS-3A, Patient Health Questionnaire [PHQ-9]-, PHQ-2, Matthey Generic Mood Question [MGMQ], Generalized Anxiety Disorder scale [GAD-7], GAD-2, and the Whooley questions) used to identify women with antenatal depression or anxiety in Western countries.

MATERIAL AND METHODS

On January 16, 2023, we searched 10 databases (CINAHL, Cochrane Library, CRD Database, Embase, Epistemonikos, International HTA Database, KSR Evidence, Ovid MEDLINE, PROSPERO and PsycINFO); the references of included studies were also screened. We included studies of any design that compared case-identification with a relevant screening tool to the outcome of a diagnostic interview based on the Diagnostic and Statistical Manual of Mental Disorders, fourth or fifth edition (DSM-IV or DSM-5), or the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). Diagnoses of interest were major depressive disorder and anxiety disorders. Two authors independently screened abstracts and full-texts for relevance and evaluated the risk of bias using QUADAS-2. Data extraction was performed by one person and checked by another team member for accuracy. For synthesis, a bivariate model was used. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

REGISTRATION

PROSPERO CRD42021236333.

RESULTS

We screened 8276 records for eligibility and included 16 original articles reporting on diagnostic test accuracy: 12 for the EPDS, one article each for the GAD-2, MGMQ, PHQ-9, PHQ-2, and Whooley questions, and no articles for the EPDS-3A or GAD-7. Most of the studies had moderate to high risk of bias. Ten of the EPDS articles provided data for synthesis at cutoffs ≥10 to ≥14 for diagnosing major depressive disorder. Cutoff ≥10 gave the optimal combined sensitivity (0.84, 95% confidence interval [CI]: 0.75-0.90) and specificity (0.87, 95% CI: 0.79-0.92).

CONCLUSIONS

Findings from the meta-analysis suggest that the EPDS alone is not perfectly suitable for detection of major depressive disorder during pregnancy. Few studies have evaluated the other instruments, therefore, their usefulness for identification of women with depression and anxiety during pregnancy remains very uncertain. At present, case-identification with any tool may best serve as a complement to a broader dialogue between healthcare professionals and their patients.

Racial Disparities in Diagnosis of Postpartum Mood and Anxiety Disorders Among Symptomatic Medicaid Enrollees, 2012-2015

OBJECTIVE

This study quantified the prevalence of postpartum mood and anxiety disorder (PMAD) diagnoses among symptomatic Michigan Medicaid enrollees and explored factors associated with receiving a diagnosis.

METHODS

Data sources comprised Michigan Medicaid administrative claims and Phase 7 Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS) survey responses, linked at the individual level. Participants were continuously enrolled in Michigan Medicaid, delivered a live birth (2012-2015), responded to the survey, and screened positive for PMAD symptoms on the adapted two-item Patient Health Questionnaire. Unadjusted and adjusted weighted logistic regression analyses were used to predict the likelihood of having a PMAD diagnosis (for the overall sample and stratified by race).

RESULTS

The weighted analytic cohort represented 24,353 deliveries across the 4-year study. Only 19.8% of respondents with symptoms of PMAD had a PMAD diagnosis between delivery and 3 months afterward. Black respondents were less likely to have PMAD diagnoses (adjusted odds ratio [AOR]=0.23, 95% CI=0.11-0.49) compared with White respondents. Among White respondents, no covariates were significantly associated with having a diagnosis. However, among Black respondents, more comorbid conditions and more life stressors were statistically significantly associated with having a diagnosis (AOR=3.18, 95% CI=1.27-7.96 and AOR=3.12, 95% CI=1.10-8.88, respectively).

CONCLUSIONS

Rate of PMAD diagnosis receipt differed by race and was low overall. Black respondents were less likely than White respondents to receive a diagnosis. Patient characteristics influencing diagnosis receipt also differed by race, indicating that strategies to improve detection of these disorders require a tailored approach.

Evaluating the diagnostic properties of the Whooley questionnaire as a case-finding instrument for depression among Chinese women during and after pregnancy

Purpose: There is a rising prevalence in undetected perinatal depression in many countries, more effort in screening and early identification of perinatal depression is needed. While the Whooley questionnaire is the recommended case-finding strategy for perinatal depression, there is no validated Chinese version. The aim was to evaluate the diagnostic accuracy and stability of the translated Chinese Whooley questionnaire against gold standard measurement during and early after pregnancy.Materials and Methods: This observational study recruited 131 pregnant women from an antenatal clinic in Hong Kong from September 2019 to May 2020. We translated the Whooley questionnaire in Chinese and evaluated self-reported responses against an interviewer-assessed diagnostic standard (DSM-IV criteria) in 107 women at 26-28 gestational weeks. We calculated sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio, with DSM-IV diagnosis as the gold standard.Results: The Chinese Whooley questions had a sensitivity of 79% (95% CI 54.4-93.9), a specificity of 97% (95% CI 90.4-99.3), a positive likelihood ratio of 23.2 (95% CI 7.4-72.1) and a negative likelihood ratio of 0.2 (95% CI 0.1-0.5) in identifying perinatal depression.Conclusion: The translated Chinese Whooley questionnaire has an acceptable diagnostic accuracy in identifying perinatal depression. It can be implemented in health services among Cantonesespeaking Chinese population.

Timing of Postpartum Depressive Symptoms

Introduction

Postpartum depression is a serious public health problem that can adversely impact mother-child interactions. Few studies have examined depressive symptoms in the later (9-10 months) postpartum period.

Methods

We analyzed data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS) linked with data from a telephone follow-up survey administered to PRAMS respondents 9 to 10 months postpartum in 7 states (N = 1,954). We estimated the prevalence of postpartum depressive symptoms (PDS) at 9 to 10 months overall and by sociodemographic characteristics, prior depression (before or during pregnancy), PDS at 2 to 6 months, and other mental health characteristics. We used unadjusted prevalence ratios (PRs) to examine associations between those characteristics and PDS at 9 to 10 months. We also examined prevalence and associations with PDS at both time periods.

Results

Prevalence of PDS at 9 to 10 months was 7.2%. Of those with PDS at 9 to 10 months, 57.4% had not reported depressive symptoms at 2 to 6 months. Prevalence of PDS at 9 to 10 months was associated with having Medicaid insurance postpartum (PR = 2.34; P = .001), prior depression (PR = 4.03; P <.001), and current postpartum anxiety (PR = 3.58; P <.001). Prevalence of PDS at both time periods was 3.1%. Of those with PDS at both time periods, 68.5% had prior depression.

Conclusion

Nearly 3 in 5 women with PDS at 9 to 10 months did not report PDS at 2 to 6 months. Screening for depression throughout the first postpartum year can identify women who are not symptomatic early in the postpartum period but later develop symptoms.

Predicting postpartum depressive symptoms by evaluating self-report autonomic nervous system reactivity during pregnancy

OBJECTIVE

Altered self-reported autonomic reactivity is associated with worse mental health in the general population. Although dysfunctional changes in ANS during pregnancy have been investigated in relation to depressive symptoms, no studies addressed the relationship between self-report autonomic reactivity during pregnancy and depressive symptoms after the delivery. The present study aimed to assess the impact of prepartum self-reported autonomic reactivity on the development of postpartum depressive symptoms.

METHODS

In this longitudinal study, 170 women were assessed during pregnancy (i.e., second or third trimester) and after childbirth (i.e., one month after the delivery). Self-reported autonomic reactivity was assessed through the Body Perception Questionnaire - Short Form that evaluates the autonomic functions related to organs above (i.e., supradiaphragmatic reactivity) and below (i.e., subdiaphragmatic reactivity) the diaphragm. In addition, prepartum and postpartum depressive symptoms were evaluated using the Patient Health Questionnaire - 9.

RESULTS

Findings showed that higher prepartum supradiaphragmatic reactivity predicted higher depressive symptoms in the postpartum period (β = 0.112, p = 0.009) after controlling for prepartum depressive symptomatology and other potential covariates.

CONCLUSIONS

Evaluation of self-reported autonomic activity may be a useful tool to identify antenatally women at risk of postpartum depressive symptoms. Future studies are needed to evaluate the effectiveness of interventions aimed at reducing the threat-responsive autonomic reactivity at rest and improving adaptive autonomic regulation to prevent postpartum depression.

Protocol for a randomized control trial of the Building Regulation in Dual Generations Program (BRIDGE): preventing the intergenerational transmission of mental illness in at-risk preschool children

BACKGROUND

Since the onset of the COVID-19 pandemic, the worldwide prevalence of maternal depression has risen sharply; it is now estimated that one quarter of mothers experience clinically significant depression symptoms. Exposure to maternal depression during early childhood increases the risk for the development of childhood mental illness (MI) in offspring, with altered parenting practices mediating the association between maternal depression and child outcomes. Dual-generation interventions, which aim to simultaneously treat parent and child mental health, show promise for improving outcomes for mothers with depression and their young children. The Building Regulation in Dual Generations (BRIDGE) program combines Dialectical Behavior Therapy (DBT) and parenting skills training to concurrently treat maternal depression and improve parenting practices. In pilot within-group studies, BRIDGE has led to large reductions in maternal depression and child MI symptoms. The aim of the current study is to evaluate the efficacy of BRIDGE in reducing maternal depression and child MI symptoms (primary outcomes) as well as parenting stress and harsh parenting (secondary outcomes).

METHODS

A three-armed randomized control trial with equal group sizes will be conducted to compare the efficacy of (1) BRIDGE (DBT + parenting skills), (2) DBT skills training, and (3) services-as-usual. Participants (n = 180) will be mothers of 3- to 5-year-old children who report elevated depression symptoms. Those randomized to BRIDGE or DBT skills training will complete a 16-week group therapy intervention. Assessments will be administered at pre-intervention(T1) post-intervention (T2), and 6-month follow-up (T3).

DISCUSSION

Dual-generation programs offer an innovative approach to prevent the intergenerational transmission of mental illness. The current study will add to the evidence base for BRIDGE by comparing it to a stand-alone mental health intervention and a services-as-usual group. These comparisons will provide valuable information on the relative efficacy of including parenting support in a mental health intervention for parents. The results will contribute to our understanding of how maternal depression affects children's development and how intervening at both a mental health and parenting level may affect child and family outcomes.

TRIAL REGISTRATION

Name of registry: Clinical Trials Protocol Registration and Results System; trial registration number: NCT05959538; date of registry: July 24, 2023; available: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05959538.

Postpartum Family Planning in Pediatrics: A Survey of Parental Contraceptive Needs and Health Services Preferences

OBJECTIVE

Infant well-child visits are increasingly being explored as opportunities to address parental postpartum health needs, including those related to reproductive health. To inform potential pediatric clinic-based interventions, this study assessed postpartum contraceptive needs and health services preferences.

METHODS

We surveyed postpartum individuals attending 2 to 6-month well-child visits at three Northern California pediatric clinics (2019-20). We examined unmet contraceptive needs; the acceptability of contraceptive education, counseling, and provision at well-child visits; and sociodemographic and clinical correlates. We conducted univariate and multivariable regression modeling to assess associations between sociodemographic and clinical variables, the status of contraceptive needs, and acceptability measures.

RESULTS

Study participants (n = 263) were diverse in terms of race and ethnicity (13% Asian, 9% Black, 37% Latinx, 12% Multi-racial or Other, 29% White), and socioeconomic status. Overall, 25% had unmet contraceptive needs. Unmet need was more common among participants who had delivered more recently, were multiparous, or reported ≥ 1 barrier to obtaining contraception; postpartum visit attendance, education, race, and ethnicity were not associated with unmet need. Most participants deemed the following acceptable in the pediatric clinic: receiving contraceptive information (85%), discussing contraception (86%), and obtaining a contraceptive method (81%). Acceptability of these services was greater among participants with unmet contraceptive needs, better self-rated health, and private insurance (all P < .05).

CONCLUSIONS

A quarter of participants had unmet contraceptive needs beyond the early postpartum period. Most considered the pediatric clinic an acceptable place to address contraception, suggesting the pediatric clinic may be a suitable setting for interventions aiming to prevent undesired pregnancies and their sequelae.

Improving Postpartum Depression Screening in the NICU: Partnering with Students to Improve Outreach

Infants born to mothers with postpartum depression (PPD) are at risk for adverse developmental outcomes. Mothers of premature infants are 40% more likely to develop PPD when compared with the general population. Current published studies on implementing PPD screening in the Neonatal Intensive Care Unit (NICU) do not comply with the American Academy of Pediatrics (AAP) guideline, which recommends multiple screening points in the first year postpartum and includes partner screening. Our team implemented PPD screening that follows the AAP guideline and includes partner screening for all parents of infants admitted to our NICU beyond 2 weeks of age.

Methods

The Institute For Healthcare Improvement Model for Improvement was the framework for this project. Our initial intervention bundle included provider education, standardized identification of parents to be screened, and bedside screening performed by the nurse with social work follow-up. This intervention transitioned to weekly screening by phone by health professional students and the use of the electronic medical record for notification of team members of screening results.

Results

Under the current process, 53% of qualifying parents are screened appropriately. Of the parents screened, 23% had a positive Patient Health Questionnaire-9 requiring referral for mental health services.

Conclusions

Implementing a PPD screening program that complies with the AAP standard is feasible within a Level 4 NICU. Partnering with health professional students greatly improved our ability to screen parents consistently. Given the high percentage of parents with PPD uncovered with appropriate screening, this type of program has a clear need within the NICU.

Postpartum depression screening in mothers and fathers at well-child visits: a feasibility study within the NASCITA cohort

OBJECTIVE

To assess the feasibility of the family paediatrician's (FP) role in identifying the signs of postpartum depression in parents in time to guarantee child well-being.

DESIGN, SETTING AND PARTICIPANTS

Data for this observational prospective study were collected within the NASCITA (NAscere e creSCere in ITAlia) cohort. During the first visit, paediatricians collected sociodemographic data regarding the parents and information about their health status, the pregnancy and the delivery. Whooley questions were administered during the first and second visits (scheduled 60-90 days after childbirth). Moreover, on the third visit (5-7 months after childbirth) the FP was asked to answer 'yes' or 'no' to a question on the parental postpartum depression, based on his knowledge and on the acquired information.

RESULTS

In 2203 couples who completed the assessment, 529 mothers (19.9%), 141 fathers (6.3%) and 110 (5%) couples reported any depressive symptomatology. Of these, 141 mothers (5.3% of the total sample) and 18 fathers (0.8% of the total sample) were classified as 'likely depressed'. An association was found between maternal postnatal depressive symptoms and having a diagnosed psychiatric disorder during pregnancy (OR 9.49, 95% CI: 3.20 to 28.17), not exclusively breastfeeding at hospital discharge (OR 1.76, 95% CI: 1.19 to 2.61) and the presence of child sleeping disorders at 3 (OR 2.46, 95% CI: 1.41 to 4.28) and 6 months (OR 2.18, 95% CI: 1.37 to 3.47). Another significant predictor of postpartum depression was being primiparous (OR 1.99, 95% CI: 1.31 to 3.02). Concerning the fathers, a significant association was reported only between likely depressed fathers and child sleeping disorders at 3 months (OR 7.64, 95% CI: 2.92 to 19.97). Moreover, having a likely depressed partner was strongly associated with depressive symptoms in fathers (OR 85.53, 95% CI 26.83 to 272.69).

CONCLUSIONS

The findings of this study support the feasibility of an active screening programme for parental postnatal depression during well-child visits as an integral part of postpartum care.

TRIAL REGISTRATION NUMBER

NCT03894566; Pre-results.

Prevalence and associated factor of postpartum depression among mothers living with HIV at an urban postnatal clinic in Uganda

BACKGROUND

Postpartum depression among mothers living with HIV is a significant public health problem due to its effects on engagement in care, HIV disease progression, and an increased risk of mother-to-child transmission of HIV.

OBJECTIVE

The objective of this study was to determine the prevalence and factors associated with postpartum depression among mothers living with HIV.

DESIGN

The study employed a cross-sectional quantitative research design.

METHODS

In this cross-sectional survey, we consecutively recruited 290 participants among mothers attending postnatal, immunization, and family planning clinics at an urban clinic in Uganda. Using an interviewer-administered questionnaire, we collected data on socio-demographics, obstetric, and HIV-related characteristics. Postpartum depression was assessed using the Patient Health Questionnaire version 9. We classified participants with Patient Health Questionnaire version 9 scores of ⩾10 as having postpartum depression. We conducted logistic regression to examine the association between postpartum depression and independent variables.

RESULTS

The prevalence of postpartum depression was 15.9%. After controlling for other variables, participants who reported poor male partner support were more likely to experience postpartum depression compared to those who had good partner support (adjusted odds ratio = 4.52, confidence interval = 2.31-8.84, p value < 0.001).

CONCLUSION

Mothers living with HIV should be routinely assessed for the presence of depression and male partner support. Health care providers of HIV-infected women should design strategies to promote male partner support for better maternal, infant, and HIV treatment outcomes.

Association of organizational culture and climate with variation in the clinical outcomes of collaborative care for maternal depression in community health centers

Background

Organizational factors may help explain variation in the effectiveness of evidence-based clinical innovations through implementation and sustainment. This study tested the relationship between organizational culture and climate and variation in clinical outcomes of the Collaborative Care Model (CoCM) for treatment of maternal depression implemented in community health centers.

Method

Organizational cultures and climates of 10 community health centers providing CoCM for depression among low-income women pregnant or parenting were assessed using the organizational social context (OSC) measure. Three-level hierarchical linear models tested whether variation in culture and climate predicted variation in improvement in depression symptoms from baseline to 6.5-month post-baseline for N = 468 women with care ±1 year of OSC assessment. Depression symptomology was measured using the Patient Health Questionnaire (PHQ-9).

Results

After controlling for patient characteristics, case mix, center size, and implementation support, patients served by centers with more proficient cultures improved significantly more from baseline to 6.5-month post-baseline than patients in centers with less proficient cultures (mean improvement = 5.08 vs. 0.14, respectively, p = .020), resulting in a large adjusted effect size of dadj = 0.78. A similar effect was observed for patients served by centers with more functional climates (mean improvement = 5.25 vs. 1.12, p < .044, dadj = 0.65). Growth models indicated that patients from all centers recovered on average after 4 months of care. However, those with more proficient cultures remained stabilized whereas patients served by centers with less proficient cultures deteriorated by 6.5-month post-baseline. A similar pattern was observed for functional climate.

Conclusions

Variation in clinical outcomes for women from historically underserved populations receiving Collaborative Care for maternal depression was associated with the organizational cultures and climates of community health centers. Implementation strategies targeting culture and climate may improve the implementation and effectiveness of integrated behavioral health care for depression.

Describing 24-hour movement behaviours among preconception and recently pregnant Canadian parents: who do we need to target?

This study aimed to describe adherence to 24-hour movement guidelines and determine factors associated with meeting guidelines in pregnancy planning and recently postpartum parents. A survey of preconception care attitudes and beliefs was conducted in Canadian adults who were pregnancy planning or ≤5 years postpartum. The Global Physical Activity Questionnaire was used to evaluate physical activity and sedentary time. Respondents reported the number of hours spent sleeping and using a screen per day. Multiple logistic regressions were run to determine factors (sociodemographic and health related) associated with meeting each individual movement guideline and number of guidelines met. 1080 females and 224 males provided survey data. 54.0% (n = 654) of the sample met the physical activity guideline, with no difference between females and males. More than 78.4% (n = 909) met the sedentary behavior guideline, 56.4% (n = 679) met the sleep guideline, and 15.4% (n = 187) met the screen time guideline. Only 5.0% (n = 60) of the sample met all four guidelines. Higher odds of meeting more guidelines were associated with parity and perceived health. Lower odds of meeting more guidelines were associated with obesity and overweight; and with depression. Most parents and parents-to-be are not meeting 24-hour movement guidelines. Interventions should focus on optimizing movement behaviors in the peri-partum period, while focusing on mental health, obesity, and general wellbeing.

Maternal stress and mental health before pregnancy and offspring diurnal cortisol in early childhood

The current study investigates whether prepregnancy maternal posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, and stress predict children's cortisol diurnal slopes and cortisol awakening responses (CARs) adjusting for relevant variables. Mothers were enrolled after delivering a baby and followed through their subsequent pregnancy with 5 years of longitudinal data on their subsequent child. This prospective design allowed assessment of PTSD symptoms, depressive symptoms, and perceived stress prior to pregnancy. Children provided three saliva samples per day on three consecutive days at two timepoints in early childhood (M age = 3.7 years, SD = 0.38; M age = 5.04 years, SD = 0.43). Mothers' PTSD symptoms prior to pregnancy were significantly associated with flatter child diurnal cortisol slopes at 4 and 5 years, but not with child CAR. Findings at the age of 4 years, but not 5 years, remained statistically significant after adjustment for maternal socioeconomic status, race/ethnicity, child age, and other covariates. In contrast, maternal prepregnancy depressive symptoms and perceived stress did not significantly predict cortisol slopes or CAR. Results suggest that maternal prepregnancy PTSD symptoms may contribute to variation in early childhood physiology. This study extends earlier work demonstrating risk of adverse outcomes among children whose mothers experienced trauma but associations cannot be disentangled from effects of prenatal mental health of mothers on children's early childhood.

Meta-analysis of diagnostic properties of the Whooley questions to identify depression in perinatal women

BACKGROUND

This study's objective was to assess the diagnostic properties of the Whooley questions in identifying depression among perinatal women according to previously published studies. We conducted a systematic review and meta-analysis of studies investigating the diagnostic accuracy of the Whooley questions in perinatal women.

METHODS

Nine databases were searched in October 2021. All primary studies evaluated the diagnostic properties of the Whooley questions compared with a diagnostic gold standard in women during the perinatal period or, if not identified as being in the perinatal stage within the study, women between 20 weeks' gestation to 4 weeks post-delivery. A bivariate mixed-effects meta-analysis was performed to estimate pooled diagnostic properties and measure heterogeneity. Meta-regression was conducted to evaluate factors contributing to heterogeneity.

RESULTS

Six studies were included in the review; five were used in the meta-analysis. The pooled sensitivity (95 % confidence interval) was 0.95 (0.81-0.99), pooled specificity was 0.60 (0.44-0.74), pooled positive likelihood ratio was 2.4 (1.6-3.4), pooled negative likelihood ratio was 0.09 (0.02-0.32), and pooled diagnostic odds ratio was 27 (7-106); heterogeneity was substantial (I² = 0.90, 0.81-1.00). Participant age and setting (community vs. hospital) significantly contributed to heterogeneity.

CONCLUSIONS

The Whooley questions have high sensitivity but moderate specificity for perinatal women. The Whooley questions are a short and acceptable tool for identifying depression in perinatal women. However, a potential risk exists of incorrectly identifying a high proportion of women as positive. Using the Whooley questions followed by a secondary case-finding tool could reduce the misdiagnosis risk.

Musculoskeletal Pain Management and Patient Mental Health and Well-being

Orthopaedic trauma patients have high rates of psychiatric disorders, which put them at risk for worse outcomes after injury and surgery, including worse pain. Mental health conditions, such as depression and anxiety, can affect the perception of pain. Pain can also exacerbate or contribute to the development of mental illness after injury. Interventions to address both mental health and pain among orthopaedic trauma patients are critical. Balancing safety and comfort amid a drug overdose epidemic is challenging, and many clinicians do not feel comfortable addressing mental health or have the resources necessary. We reviewed the literature on the complex relationship between pain and mental health and presented examples of scalable and accessible interventions that can be implemented to promote the health and recovery of our patients. Interventions described include screening for depression in the orthopaedic trauma clinic and the emergency department or inpatient setting during injury and using a comprehensive and evidence-based multimodal pain management regimen that blends pharmacologic alternatives to opioids and physical and cognitive strategies to manage pain.

Medical, behavioural and social preconception and interconception risk factors among pregnancy planning and recently pregnant Canadian women

OBJECTIVES

The objective of this study is to describe the clustering of medical, behavioural and social preconception and interconception health risk factors and determine demographic factors associated with these risk clusters among Canadian women.

DESIGN

Cross-sectional data were collected via an online questionnaire assessing a range of preconception risk factors. Prevalence of each risk factor and the total number of risk factors present was calculated. Multivariable logistic regression models determined which demographic factors were associated with having greater than the mean number of risk factors. Exploratory factor analysis determined how risk factors clustered, and Spearman's r determined how demographic characteristics related to risk factors within each cluster.

SETTING

Canada.

PARTICIPANTS

Participants were recruited via advertisements on public health websites, social media, parenting webpages and referrals from ongoing studies or existing research datasets. Women were eligible to participate if they could read and understand English, were able to access a telephone or the internet, and were either planning a first pregnancy (preconception) or had ≥1 child in the past 5 years and were thus in the interconception period.

RESULTS

Most women (n=1080) were 34 or older, and were in the interconception period (98%). Most reported risks in only one of the 12 possible risk factor categories (55%), but women reported on average 4 risks each. Common risks were a history of caesarean section (33.1%), miscarriage (27.2%) and high birth weight (13.5%). Just over 40% had fair or poor eating habits, and nearly half were not getting enough physical activity. Three-quarters had a body mass index indicating overweight or obesity. Those without a postsecondary degree (OR 2.35; 95% CI 1.74 to 3.17) and single women (OR 2.22, 95% CI 1.25 to 3.96) had over twice the odds of having more risk factors. Those with two children or more had 60% lower odds of having more risk factors (OR 0.68, 95% CI 0.52 to 0.86). Low education and being born outside Canada were correlated with the greatest number of risk clusters.

CONCLUSIONS

Many of the common risk factors were behavioural and thus preventable. Understanding which groups of women are prone to certain risk behaviours provides opportunities for researchers and policy-makers to target interventions more efficiently and effectively.

Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Symptoms of Postpartum Anxiety and Depression: Feasibility Randomized Controlled Trial

Background

Postpartum depression (PPD) and postpartum anxiety (PPA) are often comorbid and are associated with significant personal and economic costs. Fewer than half of the mothers experiencing PPD or PPA symptoms receive face-to-face treatment, suggesting a need for alternative delivery formats such as internet-delivered cognitive behavioral therapy (ICBT).

Objective

This pilot study aimed to examine the impact of a therapist-assisted, transdiagnostic ICBT program on symptoms of PPD and PPA, as there is only one previous study on transdiagnostic ICBT with this population, which did not include therapist assistance.

Methods

Clients endorsing the symptoms of PPD or PPA (N=63) were randomized to an 8-week transdiagnostic ICBT course (Wellbeing Course for New Moms) or to treatment as usual (TAU). Clients completed measures of depression, anxiety, stress, postnatal bonding, and relationship satisfaction, as well as measures of treatment satisfaction and therapeutic alliance, before treatment, after treatment, and at the 1-month follow-up. Outcome measures were also completed at the 6-month follow-up for clients who completed the ICBT course.

Results

Both the ICBT and TAU groups experienced statistically significant improvements over time. The ICBT group experienced larger improvements after treatment and at the 1-month follow-up on more measures than the TAU group, with medium between-group Cohen d effects on primary outcome measures for anxiety (Cohen d=0.65, 95% CI 0.13-1.17), PPD (Cohen d=0.52, 95% CI 0.01-1.04), and depression (Cohen d=0.56, 95% CI 0.05-1.08), and on secondary outcome measures of overall distress (Cohen d=0.69, 95% CI 0.17-1.21), anxiety (Cohen d=0.59, 95% CI 0.07-1.11), and stress (Cohen d=0.76, 95% CI 0.23-1.28). Time-by-group interactions for proportional reductions between groups over time were only significant after treatment and at the 1-month follow-up for the primary anxiety measure (P=.006). This study was underpowered for detecting small or medium effects. Overall, clients perceived the treatment as credible, and 95% (21/22) of the clients were satisfied with the treatment content and therapist support.

Conclusions

Findings from this pilot study provide preliminary support for transdiagnostic ICBT in treating PPD and PPA symptoms to improve access to psychological treatments.

Trial Registration

ClinicalTrials.gov NCT04012580; https://clinicaltrials.gov/ct2/show/NCT04012580

A Brief Depression Screening Tool for Perinatal Clinical Practice: The Performance of the PHQ-2 Compared with the PHQ-9

INTRODUCTION

There is ongoing interest in using brief screening instruments to identify perinatal depression in clinical practice. One ultra-brief screening instrument for depression is the Patient Health Questionnaire-2 (PHQ-2), but thus far its accuracy in perinatal clinical practice has been barely researched. In the present study, we aimed to assess the screening accuracy of the PHQ-2 against the Patient Health Questionnaire-9 (PHQ-9) in a large sample of perinatal women.

METHOD

A total of 1155 consecutive women attending 11 health care centers throughout Italy completed the PHQ-9 (which includes the PHQ-2) during pregnancy (27-40 weeks) or postpartum (1-13 weeks). Sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio positive, likelihood ratio negative, and overall accuracy were calculated using cut points 3 or greater and 2 or greater.

RESULTS

During pregnancy, PHQ-2 greater than or equal to 3 revealed low sensitivity (38.4%-44.7%) but high specificity (97.8%-99.3%). In postpartum, it revealed moderate sensitivity (56.9%-70.6%), high specificity (95.8%-99.8%), and fair overall accuracy in pregnancy (70%). The alternative threshold greater than or equal to 2 revealed very high sensitivity (pregnancy: 92.1%-95.2%; postpartum: 87.1%-95.2%), moderate specificity (pregnancy: 78.1%-83.2%; postpartum: 68.8%-81.1%) and good overall accuracy, both during pregnancy (87%) and postpartum (84%).

DISCUSSION

The PHQ-2 provided acceptable accuracy for screening for depression compared with the PHQ-9. In perinatal screening practice, a threshold of 2 or greater should be preferred as this ensures high sensitivity, missing only approximately 6% to 8% of cases, and a false-positive rate (percentage of women classified as affected with depressive symptoms when they are not) of 19% to 25%.

Perinatal Complications, Poor Hospital Treatment, and Positive Screen for Postpartum Depressive Symptoms Among Black Women

Though mandatory screening for depression during pregnancy and the postpartum period is recommended, postpartum depression is still underdiagnosed and overlooked among Black women. Understanding risk factors during pregnancy and delivery that may increase the risk for postpartum depression is important for Black women. Thus, the purpose of this study is to examine the relationship between perinatal complications (i.e., preterm birth, low birth weight, gestational diabetes, unplanned cesarean section, undesired pregnancy, depression during pregnancy), poor hospital treatment, and postpartum depressive symptoms (i.e., depressed mood, anhedonia, and positive screen on PHQ-2) among Black women. Using the Listening to Mothers III survey, we conducted logistic regression analyses in a nationally representative sample of 368 Black women to examine the relationship between perinatal complications, poor hospital treatment, and positive screen for postpartum depressive symptoms, measured by the Patient Health Questionnaire-2 (PHQ-2). We also examined these factors in predicting anhedonia and depressed mood. Poor hospital treatment was associated with a positive screen for postpartum depression, anhedonia, and depressed mood. Perinatal complications, when measured continuously, were associated with a positive screen for depression and depressed mood. Gestational diabetes and preterm birth were associated with depressed mood while depression during pregnancy was associated with anhedonia. Perinatal complications during pregnancy and delivery may increase the risk for postpartum depression among Black women. When screening for postpartum depression, it may also be important to inquire about poor hospital treatment and stressors emanating from these experiences.

The Importance of Monitoring the Postpartum Period in Moderate to Severe Crohn's Disease

BACKGROUND

Prior research demonstrates Crohn's disease patients often do well in pregnancy; however, less is known about the risk of flare in the postpartum period.

METHODS

A retrospective chart review was conducted at a tertiary care inflammatory bowel disease center. All pregnant women with Crohn's disease who were followed in the postpartum period, defined as 6 months after delivery, were included. Statistical analysis included χ 2 analysis, Wilcoxon rank sum test, and logistic regression analysis. The primary outcome of interest was rate of flare in the postpartum period.

RESULTS

There were 105 patients included in the study, with a majority (68%) on biologic medication during pregnancy. Thirty-one patients (30%) had a postpartum flare at a median of 9 weeks (range 2-24 weeks). Twenty-five patients (81%) had their postpartum flare managed in the outpatient setting with medications (only 4 of these patients required prednisone). 6 of 31 patients (19%) were hospitalized at a median of 4 weeks (range 2-26 weeks) after delivery, requiring intravenous corticosteroids or surgery. In multivariable regression, there was no significant increase in risk of postpartum flare with increasing maternal age, flare during pregnancy, or steroid or biologic use during pregnancy. Smoking during pregnancy increased risk of postpartum flare (odds ratio, 16.2 [1.72-152.94], P < 0.05).

CONCLUSION

In a cohort of Crohn's disease patients, 30% experienced a postpartum flare despite being on medical therapy, but most were able to be managed in the outpatient setting.

Prospective Associations Between Fathers' Engagement in Infant Caregiving and Their Weight-Related Behaviors and Mental Health

Fathers’ engagement in infant caregiving is linked with positive social, emotional, and developmental outcomes in children; however, its relationship with fathers’ own health is largely unknown. This longitudinal study examined associations between fathers’ caregiving engagement with their 6-month-old infants and their physical activity, sugar-sweetened beverage (SSB) consumption, nighttime sleep duration, and depressive symptoms 6 months later when infants were 12 months old. Participants were 143 fathers of infants (62.7% non-Hispanic White, 82.3% with a bachelor’s degree). Fathers reported their frequency of engagement in seven caregiving activities when infants were 6 months old. Fathers’ physical activity, SSB consumption, nighttime sleep duration, and depressive symptoms were assessed when infants were 6 and 12 months old. Multivariate logistic regression analysis was used to assess if fathers who reported higher infant caregiving at 6 months had more positive health outcomes at 12 months, controlling for fathers’ age, race/ethnicity, education, employment, household income, and the outcome at 6 months. Fathers who reported higher caregiving engagement when infants were 6 months old had increased odds of being sufficiently physically active 6 months later (unadjusted odds ratio [OR] = 1.19, 95% confidence interval [CI] = [1.00, 1.41]; adjusted OR = 1.47, 95% CI = [1.11, 1.96]). No links were identified between fathers’ caregiving engagement and their SSB consumption, nighttime sleep duration, or depressive symptoms. In summary, fathers’ engagement in infant caregiving may be beneficial to their physical activity in the first year after birth. There was insufficient evidence in this study that the benefits of caregiving engagement were experienced broadly across multiple health outcomes.

Perinatal Experiences of Asian American Women During COVID-19

PURPOSE

To explore the wellbeing, pregnancy, childbirth, and postpartum experiences of Asian American women who gave birth during the COVID-19 pandemic.

STUDY DESIGN

Qualitative exploratory design.

METHODS

Using convenience and snowball sampling, we recruited Asian American women who gave birth during the COVID-19 pandemic via social media. Participants completed sociodemographic and depressive symptom questionnaires and took part in a virtual semistructured interview where they were asked to describe their pregnancy, birth, and postpartum experiences in the midst of the COVID-19 pandemic. Qualitative content analysis methods were used to identify themes from participant narratives.

RESULTS

Thirty-eight Asian American women representing several racial ethnic subgroups (Asian Indian, Chinese, Filipino, Hmong, Laotian, Vietnamese) participated in our study. Participants were on average 34 (SD = 3.5) years of age; the majority were married and lived in California. At the time of data collection, participants were 3.7 (SD = 2.07) months postpartum and 5.3 to 10.5 months into the COVID-19 pandemic. Qualitative content analysis revealed two main themes: 1) unexpected perinatal journey, and 2) the emotional and psychological consequences of COVID-19.

CLINICAL IMPLICATIONS

Our findings are not unique to Asian American women, but they offer insight for nurses taking care of all childbearing women. Nurses can provide individually tailored anticipatory guidance to help women navigate perinatal changes and manage expectations during future public health crises. Nurses can also encourage and help perinatal women identify ways to increase their own social support networks during the pregnancy and postpartum period.

The limited screening accuracy of the Patient Health Questionnaire-2 in detecting depression among perinatal women in Italy

BACKGROUND

The PHQ-2 was recently recommended by the International Consortium for Health Outcomes Measurement as a form of initial perinatal screening, followed by the EPDS only for women with positive PHQ-2 score. However, the accuracy of the PHQ-2 in perinatal clinical practice has been barely researched, to date. In the present study, we aim to assess the accuracy of the PHQ-2 against the EPDS in a large sample of perinatal women.

METHODS

A total of 1155 consecutive women attending eleven primary or secondary health care centres throughout Italy completed the EPDS and the PHQ-2 during pregnancy (27-40-weeks) or postpartum (1-13-weeks). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio, negative likelihood ratio, post-test probabilities and area under the curve (AUC) of the PHQ-2, using a cut-off of ≥ 3, were calculated.

MAIN FINDINGS

During pregnancy, PHQ-2 revealed low sensitivity (39.5%) and PPV (39.4%) but high specificity and NPV (97.5%). In postpartum, it revealed very low sensitivity (32.7%) and moderately high NPV (80.9%), but high specificity (99.3%) and PPV (94.4%). Given the low sensitivity despite the high specificity, the PHQ-2 demonstrated poor accuracy (AUC from 0.66 to 0.68).

CONCLUSION

Initial screening by means of PHQ-2 failed to identify an acceptable number of perinatal women at-risk of depression in Italian clinical practice. The PHQ-2 performance suggested that it has insufficient sensitivity and discriminatory power, and may be inadequate as a screening tool for maternal depression.

Interconception Care for Primary Care Providers: Consensus Recommendations on Preconception and Postpartum Management of Reproductive-Age Patients With Medical Comorbidities

Severe maternal morbidity and mortality continue to increase in the United States, largely owing to chronic and newly diagnosed medical comorbidities. Interconception care, or care and management of medical conditions between pregnancies, can improve chronic disease control before, during, and after pregnancy. It is a crucial and time-sensitive intervention that can decrease maternal morbidity and mortality and improve overall health. Despite these potential benefits, interconception care has not been well implemented by the primary care community. Furthermore, there is a lack of guidelines for optimizing preconception chronic disease, risk stratifying postpartum chronic diseases, and recommending general collaborative management principles for reproductive-age patients in the period between pregnancies. As a result, many primary care providers, especially those without obstetric training, are unclear about their specific role in interconception care and may be unsure of effective methods for collaborating with obstetric care providers. In particular, internal medicine physicians, the largest group of primary care physicians, may lack sufficient clinical exposure to medical conditions in the obstetric population during their residency training and may feel uncomfortable in caring for these patients in their subsequent practice.

The objective of this article is to review concepts around interconception care, focusing specifically on preconception care for patients with chronic medical conditions (eg, chronic hypertension, chronic diabetes mellitus, chronic kidney disease, venous thromboembolism, and obesity) and postpartum care for those with medically complicated pregnancies (eg, hypertensive disorders of pregnancy, gestational diabetes mellitus, excessive gestational weight gain, peripartum cardiomyopathy, and peripartum mood disorders). We also provide a pragmatic checklist for preconception and postpartum management.

Selective cutoff reporting in studies of the accuracy of the Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale: Comparison of results based on published cutoffs versus all cutoffs using individual participant data meta-analysis

OBJECTIVES

Selectively reported results from only well-performing cutoffs in diagnostic accuracy studies may bias estimates in meta-analyses. We investigated cutoff reporting patterns for the Patient Health Questionnaire-9 (PHQ-9; standard cutoff 10) and Edinburgh Postnatal Depression Scale (EPDS; no standard cutoff, commonly used 10-13) and compared accuracy estimates based on published cutoffs versus all cutoffs.

METHODS

We conducted bivariate random effects meta-analyses using individual participant data to compare accuracy from published versus all cutoffs.

RESULTS

For the PHQ-9 (30 studies, N = 11,773), published results underestimated sensitivity for cutoffs below 10 (median difference: -0.06) and overestimated for cutoffs above 10 (median difference: 0.07). EPDS (19 studies, N = 3637) sensitivity estimates from published results were similar for cutoffs below 10 (median difference: 0.00) but higher for cutoffs above 13 (median difference: 0.14). Specificity estimates from published and all cutoffs were similar for both tools. The mean cutoff of all reported cutoffs in PHQ-9 studies with optimal cutoff below 10 was 8.8 compared to 11.8 for those with optimal cutoffs above 10. Mean for EPDS studies with optimal cutoffs below 10 was 9.9 compared to 11.8 for those with optimal cutoffs greater than 10.

CONCLUSION

Selective cutoff reporting was more pronounced for the PHQ-9 than EPDS.

International survey on fear and childbirth experience in pregnancy and the postpartum period during the COVID-19 pandemic: study protocol

INTRODUCTION

The COVID-19 pandemic has caused unprecedented disruptions around the world. Adding to the existing stress surrounding pregnancy and childbirth, the threat of infection and social isolation policies may negatively impact pregnant women and new mothers. Literature on the effect of COVID-19 on fear during pregnancy and childbirth experience is limited. As the COVID-19 pandemic continues to affect the global population, it is important to understand how it has impacted pregnant women and new mothers' experiences worldwide to inform perinatal care and interventions.

METHODS AND ANALYSIS

This multicountry study involving China and Canada targets to recruit 1000 pregnant women and new mothers who gave birth since 2020 in each participating country. Participants will be recruited online in the local language through mothers' groups, antenatal and postnatal clinics and hospital wards. All questionnaires will be completed online. Participants' level of fear, depression and childbirth experience will be assessed along with other sociodemographic, medical and COVID-related measures. Regression models will be used to compare the outcomes among the participating countries.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the institutional review boards of the participating countries. Findings will be disseminated in peer-reviewed journals and academic conferences. Results from this study may guide the formulation of future health guidelines and policies in the face of a pandemic.

Depressive Symptoms among Pregnant and Postpartum Women in Prison

INTRODUCTION

Women in prison experience high rates of mental and physical health problems, and pregnant and postpartum women in prison may be particularly vulnerable. Very few studies have examined depressive symptoms among women who are pregnant and give birth in prison. We assessed depressive symptoms longitudinally from pregnancy into the postpartum period in a sample of 58 women who gave birth in prison. We also considered whether incarceration-related factors (length of time incarcerated while pregnant, remaining length of sentence to serve after birth) were associated with depressive symptoms.

METHODS

Data were collected as part of an ongoing evaluation of a prison-based pregnancy and parenting support program at one women's state prison. At prenatal and postpartum visits with their doula, women completed the Patient Health Questionnaire-9 (PHQ-9), a measure of depressive symptom severity.

RESULTS

More than one-third of our sample of women who were incarcerated and gave birth in custody met criteria for moderate to severe depression on the PHQ-9 during pregnancy or the postpartum period. Women who faced longer periods of incarceration following birth and separation from their newborns reported higher levels of postpartum depressive symptoms.

DISCUSSION

Findings have implications for practice and policy aimed at supporting the mental health needs of women who are pregnant in prison, particularly those women who give birth in custody and are separated from their newborns.

Major depressive disorder in detention officers

OBJECTIVE

To identify factors associated with major depressive disorder (MDD) in detention officers.

METHODS

This cross-sectional study included all detention officers from the largest prison complex in the state of Bahia, Brazil. A self-reported questionnaire collected sociodemographic, occupational and health data. The outcome variable - MDD - was evaluated by the Patient Health Questionnaire-9 (PHQ-9) and classified by the cut-off point ≥ 10 method and the algorithm method. The association measure used was the prevalence ratio (PR). Following Cox multivariate regression, the variables were divided into two blocks: sociodemographic characteristics and work, in that order. Only variables with adjusted PR (PRadj) ≥ 1.30 were selected to compose the final models.

RESULTS

The MDD prevalence by the cut-off point ≥ 10 (simple) and algorithm method in the 401 officers investigated was 18.8% and 9.3%, respectively. MDD prevalence by cut-off point ≥ 10 was higher in female officers (PRadj = 2.77), who suffered threat from factions (PRadj = 2.05), did not report institutional training for the position (PRadj = 1.38), stated that the environment and working conditions interfered in their physical health (PRadj = 3.51) and performed stress-generating activities (PRadj in increasing gradient). MDD prevalence by the algorithm method was higher in female agents (PRadj = 3.45), with tertiary education (PRadj = 1.71), who stated that the environment and working conditions interfered in their physical health (PRadj = 6.33), suffered threat from factions (PRadj = 2.14), did not report institutional training (PRadj = 1.50) and have frequent contact with inmates at work (PRadj = 1.48).

CONCLUSION

The high MDD prevalence in these detention officers was associated with sociodemographic factors and, especially, aspects of their work.

Effect of Community-Initiated Kangaroo Mother Care on Postpartum Depressive Symptoms and Stress Among Mothers of Low-Birth-Weight Infants: A Randomized Clinical Trial

IMPORTANCE

Approximately 1 in 5 women in low- and middle-income countries experience postpartum depression, and the risk is higher among mothers of low-birth-weight (LBW) infants. Kangaroo mother care (KMC) is effective in improving survival among LBW infants, but the benefits of KMC for mothers are not well described.

OBJECTIVE

To estimate the effects of community-initiated KMC (ciKMC) on maternal risk of moderate-to-severe postpartum depressive symptoms and on salivary cortisol concentration, a biomarker of stress.

DESIGN, SETTING, AND PARTICIPANTS

This was an unmasked, parallel-group, individually randomized clinical trial. Participants included 1950 mothers of stable LBW infants (weighing 1500-2250 g) in rural and semiurban low-income populations in North India enrolled between April 2017 and March 2018. Data analysis was performed from January to July 2020.

INTERVENTIONS

Eligible participants were randomly assigned to the intervention or control group by block randomization. The mothers in the intervention group were supported to practice ciKMC until 28 days after birth or until the infant wriggled out of the KMC position (ie, was no longer staying in the KMC position). The intervention included promotion and support of skin-to-skin contact and exclusive breastfeeding through home visits.

MAIN OUTCOMES AND MEASURES

Postpartum depressive symptoms at the end of the neonatal period were measured using the Patient Health Questionnaire-9, with a score of 10 or higher used to identify moderate-to-severe depressive symptoms. Salivary cortisol concentration was measured in a subsample of 550 mothers before and after breastfeeding on day 28 after birth.

RESULTS

Of the 1950 participants (mean [SD] age, 23 [3.5] years), outcome assessment was completed for 974 of 1047 participants (93%) in the intervention group and 852 of 903 participants (94%) in the control group. Sixty-four percent of participants (1175 of 1826 participants) belonged to the lowest 3 wealth quintiles. The proportion of mothers with moderate-to-severe postpartum depressive symptoms was 10.8% (95% CI, 8.9%-12.9%; 105 of 974 mothers) in the intervention group vs 13.6% (95% CI, 11.4%-16.1%; 116 of 852 mothers) in the control group. The adjusted relative risk of moderate-to-severe maternal postpartum depressive symptoms was 0.75 (95% CI, 0.59-0.96), or an efficacy of 25%. There was no difference in day-28 salivary cortisol concentration between the ciKMC and control group mothers before or after breastfeeding. The analysis estimated that supporting 36 mothers to perform KMC at home would prevent 1 mother from experiencing moderate-to-severe postpartum depressive symptoms.

CONCLUSIONS AND RELEVANCE

These findings suggest that ciKMC practice may substantially reduce the risk of moderate-to-severe maternal postpartum depressive symptoms. This evidence supports KMC as an intervention to be incorporated in essential newborn care programs in low- and middle-income settings.

TRIAL REGISTRATION

Clinical Trials Registry-India Identifier: CTRI/2017/04/008430.

Polybrominated Diphenyl Ether Serum Concentrations and Depressive Symptomatology in Pregnant African American Women

(1) Polybrominated diphenyl ethers (PBDEs) were widely produced in the United States until 2004 but remain highly persistent in the environment. The potential for PBDEs to disrupt normal neuroendocrine pathways resulting in depression and other neurological symptoms is largely understudied. This study examined whether PBDE exposure in pregnant women was associated with antenatal depressive symptomatology. (2) Data were collected from 193 African American pregnant women at 8–14 weeks gestation. Serum PBDEs and depressive symptoms were analyzed and a mixture effect was calculated. (3) Urban pregnant African American women in the Southeastern United States had a high risk of depression (27%) compared to the National average. Increased levels of PBDEs were found. BDE-47 and -99 exposures are significantly associated with depressive symptomatology in the pregnant cohort. The weighted body burden estimate of the PBDE mixture was associated with a higher risk of mild to moderate depression using an Edinburgh Depression Scale cutoff score of ≥10 (OR = 2.93; CI 1.18, 7.82). (4) Since antenatal depression may worsen in postpartum, reducing PBDE exposure may have significant clinical implications.

Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): A systematic review and meta-analysis

OBJECTIVES

Perinatal depression (PND) is a prevalent and disabling problem both during pregnancy and the postpartum period. The legacy screening measure has been the Edinburgh Postnatal Depression Scale (EPDS). This systematic review examines the validity of the PHQ-9 as a screener for PND.

METHODS

The following databases were searched from January 2001 (when the PHQ-9 was first published) through June 2020: MEDLINE, Embase, and PsychInfo. Studies that compared the PHQ-9 to a criterion standard psychiatric interview were used to determine the operating characteristics of sensitivity, specificity and area under the curve (AUC). Studies comparing the PHQ-9 to the EPDS and other depression scales evaluated convergent validity.

RESULTS

A total of 35 articles were eligible for criterion (n = 10) or convergent (n = 25) validity. Meta-analysis of the 7 criterion validity studies using the standard PHQ-9 cut point ≥10 showed a pooled sensitivity, specificity and AUC of 0.84, 0.81 and 0.89, respectively. Operating characteristics of the PHQ-9 and EPDS were nearly identical in head-to-head comparison studies. The median correlation between the PHQ-9 and EPDS was 0.59, and categorical agreement was moderate.

CONCLUSIONS

The PHQ-9 appears to be a viable option for perinatal depression screening with operating characteristics similar to the legacy EPDS.

Does Perceived Quality of Care Moderate Postpartum Depression? A Secondary Analysis of a Two-Stage Survey

OBJECTIVE

The purpose of this study was to examine if women's perceptions of the quality of hospital care during childbirth moderate their risks for symptoms of postpartum depression (PPD).

METHODS

This cross-sectional secondary analysis analyzed data from the Listening to Mothers III (2013) series surveys with a weighted sample size of 1057 of women surveyed from across the United States. PPD symptoms were defined according the Patient Health Questionnaire-2. Associations between risk factors and PPD symptoms were tested using logistic regressions with the moderating variable of perceived quality of care then added to models with significant risk factors.

RESULTS

Of the 22 potential risk factors for PPD symptoms, 10 were found to be significantly associated with PPD symptoms in this sample of women. Very good perceived quality of care moderated the following risk factors for PPD symptoms in a protective direction: relationship status (p = 0.01), pre-pregnancy BMI (p = 0.02), and pain that interfered with routine activities 2 months postpartum (p = 0.003).

CONCLUSIONS

These findings suggest risk factors for PPD symptoms are moderated by perceived quality of care and therefore, maternity providers can influence women's psychological wellbeing postpartum by providing very good perceived quality of care during the hospital stay for birth. However, these findings should be interpreted cautiously due to a lack of a direct, proven relationship between provider action and women's perceived quality of care.

Accuracy of Self-Reported Items for the Screening of Depression in the General Population

INTRODUCTION

Though self-reported items (SRD, self-reported depression) are commonly used in health surveys and cohort studies, their metric properties as a depression indicator remain unclear. The aims were to evaluate the measurement properties of SRD using the Patient Health Questionnaire-8 (PHQ-8) as reference and to identify factors related to the agreement between both indicators.

METHODS

Data from the European Health Interview Survey in Spain in 2014/2015 (n = 22,065) were analyzed. Two indicators of depression were considered: SRD based on two items yes/no (positive: both yes), and the PHQ-8 (positive ≥ 10). Socioeconomic factors and use of health services were considered as independent variables. The prevalence of depression, sensitivity, specificity, global agreement, and positive and negative predictive values (PPV and NPV) of SRDs were evaluated using the PHQ-8 as a reference. Logistic regression models were fitted to determine factors associated with the agreement between indicators.

RESULTS

The prevalence of depression was lower when assessed with PHQ-8 (5.9%) than with SRD (7.7%). SRD sensitivity and PPV were moderate-low (52.9% and 40.4%, respectively) whereas global agreement, specificity, and NPV were high (92.7%, 95.1%, and 97.0%, respectively). Positive agreement was associated with marital status, country of birth, employment status, and social class. Negative agreement was related to all independent variables except country of birth.

CONCLUSIONS

SRD items tend to overestimate the current prevalence of depression. While its use in health surveys and cohorts may be appropriate as a quick assessment of possible depression, due to their low sensitivity, its use in clinical contexts is questionable.

Associations between commonly used patient-reported outcome tools in postpartum depression clinical practice and the Hamilton Rating Scale for Depression

The objective of this study is to explore the associations between the patient-reported Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ)-9 and clinician-reported 17-item Hamilton Depression Rating Scale (HAMD-17) in order to facilitate clinical decision-making. An integrated efficacy dataset of three randomized placebo-controlled trials (NCT02614547, NCT02942004, and NCT02942017) evaluating brexanolone injection, a neuroactive steroid chemically identical to allopregnanolone, in women with postpartum depression was used for this post hoc analysis. Data were pooled across treatment arms. Associations were assessed at day 30 (end-of-trial follow-up). Pearson correlation assessed the relationship between EPDS and PHQ-9 item and total scores and HAMD-17 total score. Cohen's kappa assessed agreement of EPDS remission (score < 10) and PHQ-9 remission (score < 5) with HAMD-17 remission (score ≤ 7). Ordinary least squares (OLS) regression models were used to develop equations estimating HAMD-17 total scores from EPDS and PHQ-9 scores, respectively. The total scores showed large correlations (HAMD-17/EPDS: r = 0.71, p < 0.001; HAMD-17/PHQ-9: r = 0.75, p < 0.001). Individual EPDS and PHQ-9 items significantly correlated (r= 0.35 to 0.67, all p < 0.001) with HAMD-17 total score. EPDS had 79% sensitivity and 67% specificity to detect HAMD-17 remission; corresponding estimates for PHQ-9 were 76% and 78%. OLS models yielded the following equations: HAMD-17 total = 2.66 + (EPDS total × 0.87) and HAMD-17 total = 3.99 + (PHQ-9 total × 0.97). There were large and statistically significant associations between patient-reported outcomes (EPDS, PHQ-9) and clinician-reported outcomes (HAMD-17) as clinical improvements were associated with patient-reported symptom improvement. These results provide tools to help translate clinical trial data to clinical practice, thus aiding shared decision-making for this critical population.

Validation of Neuro-QoL and PROMIS Mental Health Patient Reported Outcome Measures in Persons with Huntington Disease

BACKGROUND

Patient-reported outcomes (PROs) for mental health are important for persons with Huntington disease (HD) who commonly experience symptoms of depression, anxiety, irritability, anger, aggression, and apathy. Given this, there is a need for reliable and valid patient-reported outcomes measures of mental health for use as patient-centered outcomes in clinical trials.

OBJECTIVE

Thus, the purpose of this study was to establish the psychometric properties (i.e., reliability and validity) of six Neuro-QoL and PROMIS mental health measures to support their clinical utility in persons with HD.

METHODS

294 individuals with premanifest (n = 102) or manifest HD (n = 131 early HD; n = 61 late HD) completed Neuro-QoL/PROMIS measures of Emotional and Behavioral Dyscontrol, Positive Affect and Well-Being, Stigma, Anger, Anxiety, and Depression, legacy measures of self-reported mental health, and clinician-rated assessments of functioning.

RESULTS

Convergent validity and discriminant validity for the Neuro-QoL and PROMIS measures of Emotional and Behavioral Dyscontrol, Positive Affect and Well-Being, Stigma, Anger, Anxiety, and Depression, were supported in persons with HD. Neuro-QoL measures of Anxiety and Depression also demonstrated moderate sensitivity and specificity (i.e., they were able to distinguish between individuals with and without clinically significant anxiety and depression).

CONCLUSIONS

Findings provide psychometric support for the clinical utility of the Neuro-QoL/PROMIS measures of mental health measures in persons with HD. As such, these measures should be considered for the standardized assessment of health-related quality of life in persons with HD.

Optimizing interconception care: Rationale for the IMPLICIT model

Despite traditional prenatal interventions, the incidence of low birth weight and prematurity in the United States have not significantly decreased. Interconception care for women between pregnancies has been proposed as a method of improving various perinatal outcomes. Although broadly advocated by national groups, interconception care (ICC) has not been widely implemented. We describe best practices for an ICC model based on screening mothers for tobacco use, depression, folic acid intake, and inter-pregnancy interval at well child visits. Because of the model's flexibility, sites can readily customize implementation by incorporating the questions directly into existing workflows and using local service providers already working in maternal-child health. This model has demonstrated promising results and ease of implementation thus far, and offers great potential for improved perinatal outcomes and promotion of health equity.

Comparison of screening accuracy of the Patient Health Questionnaire-2 using two case-identification methods during pregnancy and postpartum

Background

Variation exists regarding perinatal depression screening. A two-step screening method has been recommended. According to a maternity-focused core outcome set developed by the International Consortium for Health Outcomes Measurement, women who score 3 or more on the PHQ-2 then complete the Edinburgh Postnatal Depression Scale (EPDS). Limited evidence exists regarding the screening accuracy of the PHQ-2 in childbearing women. An alternative case-identification method may be more sensitive for perinatal women. We aimed to [1] evaluate the screening accuracy of the PHQ-2 during the perinatal period using two case-identification methods, and [2] measure the variability of accuracy over four time-points during pregnancy and postpartum.

Methods

A prospective, longitudinal cohort study was conducted with 309 consecutive women who completed the PHQ-2 and EPDS during pregnancy (booking, 36-weeks) and postpartum (6-, 26-weeks). EPDS was the reference standard using cut-off scores for ‘at least probable minor depression’ during pregnancy (≥ 13) and postpartum (≥ 10) and for ‘probable major depression’ during pregnancy (≥ 15) and postpartum (≥ 13). PHQ-2 was analysed using two methods: [1] scored (cut-points ≥ 2 and ≥ 3), [2] dichotomous yes/no (positive response to either question) against EPDS cut-points for at least probable minor and probable major depression. Receiver operating characteristic analyses determined accuracy.

Results

Probable major depression: Over four timepoints PHQ-2 ≥ 3 revealed lowest sensitivity (36–79%) but highest specificity (94–98%). An alternative case-identification method revealed high sensitivity (93–100%), but lowest specificity (58–71%). Minor depression: PHQ-2 ≥ 3 revealed the lowest sensitivity (19–50%) but highest specificity (95–98%). An alternative case-identification method revealed the highest sensitivity (81–100%) and moderate specificity (60–74%).

Conclusions

Recommended method of case-identification (PHQ-2 ≥ 3) missed an unacceptable number of women at-risk of depression. As a clinical decision-making tool, an alternative, dichotomous method maximized case-identification and is recommended. Further, the literature identified inconsistent reporting of the PHQ-2 and the alternative case-identification method hindering the ability to synthesise data. The future use and reporting of consistent question wording and response format will improve outcome reporting and synthesis. Further research in larger and diverse maternity populations is recommended.

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

OBJECTIVES

Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.

STUDY DESIGN AND SETTING

Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.

RESULTS

A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%).

CONCLUSION

PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

Sequential screening for depression in humanitarian emergencies: a validation study of the Patient Health Questionnaire among Syrian refugees

BACKGROUND

Despite the need for mental health surveillance in humanitarian emergencies, there is a lack of validated instruments. This study evaluated a sequential screening process for major depressive disorder (MDD) using the two- and eight-item Patient Health Questionnaires (PHQ-2 and PHQ-8, respectively).

METHODS

This study analyzed data collected during a cross-sectional survey in a Syrian refugee camp in Greece (n = 135). The response rate for each instrument was assessed, and response burden was calculated as the number of items completed. The sequential screening process was simulated to replicate the MDD classifications captured if the PHQ-2 was used to narrow the population receiving the full PHQ-8 assessment. All respondents were screened using the PHQ-2. Only respondents scoring ≥ 2 are considered at risk for symptoms of MDD and complete the remaining six items. The positive and negative percent agreement of this sequential screening process were evaluated.

RESULTS

The PHQ-2, PHQ-2/8 sequential screening process, and PHQ-8 were completed by 91%, 87%, and 84% of respondents, respectively. The sequential screening process had a positive percent agreement of 89% and a negative percent agreement of 100%, and eliminated the need to complete the full PHQ-8 scale for 34 (25%) respondents.

CONCLUSIONS

The benefits of the sequential screening approach for the classification of MDD presented here are twofold: preserving classification accuracy relative to the PHQ-2 alone while reducing the response burden of the PHQ-8. This sequential screening approach is a pragmatic strategy for streamlining MDD surveillance in humanitarian emergencies.

The best perinatal depression screening: Is self-administered PHQ2 more feasible than a nurse-administered one?

PURPOSE

To assess perinatal depression screening via self-administered PHQ2 (SAP) vs nurse-administered PHQ2 (NAP).

DESIGN AND METHODS

NAP screening was performed for 3 months, followed by SAP. Data were gathered from visits at 24 to 28 weeks gestation.

FINDINGS

One hundred twenty-seven patients were in NAP arm, 100 in SAP arm. SAP had higher rates of screening (odds ratio [OR], 3.25; 95% confidence interval [CI], 1.63-6.49), but no difference in positive PHQ2 screens. The SAP rate of therapeutic action for positive screens was lower (OR, 0.24; 95% CI, 0.12-0.50).

PRACTICE IMPLICATIONS

SAP provided higher perinatal depression screening rates compared to NAP, but decreased therapeutic action.

Perinatal e-screening and clinical decision support: the Maternity Case-finding Help Assessment Tool (MatCHAT)

ABSTRACT INTRODUCTIONScreening tools assist primary care clinicians to identify mental health, addiction and family violence problems. Electronic tools have many advantages, but there are none yet available in the perinatal context. AIMTo assess the acceptability and feasibility of the Maternity Case-finding Help Assessment Tool (MatCHAT), a tool designed to provide e-screening and clinical decision support for depression, anxiety, cigarette smoking, use of alcohol or illicit substances, and family violence among pre- and post-partum women under the care of midwives. METHODSA co-design approach and an extensive consultation process was used to tailor a pre-existing electronic case-finding help assessment tool (eCHAT) to a maternity context. Quantitative MatCHAT data and qualitative data from interviews with midwives were analysed following implementation. RESULTSFive midwives participated in the study. They reported that MatCHAT was useful and acceptable and among the 20 mothers screened, eight reported substance use, one depression and five anxiety. Interviews highlighted extensive contextual barriers of importance to the implementation of maternity-specific screening. DISCUSSIONMatCHAT has potential to optimise e-screening and decision support in maternity settings, but in this study, use was impeded by multiple contextual barriers. The information from this study is relevant to policymakers and future researchers when considering how to improve early identification of common mental health, substance use and family violence problems.

Is socioeconomic inequality in postnatal depression an early-life root of disadvantage for children?

This paper investigates the role that socioeconomic inequality in postnatal depression might play in intergenerational transmission of inequality. Infants' development is thought to be particularly sensitive to mothers' mental health at this time, suggesting that greater early-life exposure to maternal depression among disadvantaged groups might be a root of later socioeconomic inequalities. Heightened contact with health services during this period presents opportunities for intervention, but higher unmet need for treatment of postnatal depression among the disadvantaged might be widening inequalities. The aim of this study is to quantify the potential contribution of postnatal depression to socioeconomic inequalities in adverse childhood health and development outcomes. Regression-based decomposition of the concentration index is used to explore the association between income inequality in postnatal depressive symptoms and income inequality in children's outcomes. Four problems of early adolescence are explored: emotional and conduct problems, special educational needs, and low self-assessed health. Data are taken from the UK Millennium Cohort Study, with a sample of 4359 mothers and children with complete data on outcomes and covariates, and a second sample of 5441 when missing covariates are filled using multiple imputation. The key finding is that socioeconomic inequality in maternal postnatal depression is a significant contributor to inequalities in special educational needs, emotional problems, and low self-assessed health for children at age 11 years, even after accounting for a range of other factors that might explain such associations. These findings highlight the importance of understanding the impact of postnatal depression interventions on inequalities, and the downstream influence on children's outcomes. Addressing inequalities in mothers' postnatal depression might be an avenue for reducing early-life disadvantage for children.

Thiamine dose response in human milk with supplementation among lactating women in Cambodia: study protocol for a double-blind, four-parallel arm randomised controlled trial

INTRODUCTION

Thiamine (vitamin B1) deficiency remains a concern in Cambodia where women with low thiamine intake produce thiamine-poor milk, putting their breastfed infants at risk of impaired cognitive development and potentially fatal infantile beriberi. Thiamine fortification of salt is a potentially low-cost, passive means of combating thiamine deficiency; however, both the dose of thiamine required to optimise milk thiamine concentrations as well as usual salt intake of lactating women are unknown.

METHODS AND ANALYSIS

In this community-based randomised controlled trial, 320 lactating women from Kampong Thom, Cambodia will be randomised to one of four groups to consume one capsule daily containing 0, 1.2, 2.4 or 10 mg thiamine as thiamine hydrochloride, between 2 and 24 weeks postnatal. The primary objective is to estimate the dose where additional maternal intake of thiamine no longer meaningfully increases infant thiamine diphosphate concentrations 24 weeks postnatally. At 2, 12 and 24 weeks, we will collect sociodemographic, nutrition and health information, a battery of cognitive assessments, maternal (2 and 24 weeks) and infant (24 weeks only) venous blood samples (biomarkers: ThDP and transketolase activity) and human milk samples (also at 4 weeks; biomarker: milk thiamine concentrations). All participants and their families will consume study-provided salt ad libitum throughout the trial, and we will measure salt disappearance each fortnight. Repeat weighed salt intakes and urinary sodium concentrations will be measured among a subset of 100 participants. Parameters of Emax dose-response curves will be estimated using non-linear least squares models with both 'intention to treat' and a secondary 'per-protocol' (capsule compliance ≥80%) analyses.

ETHICS AND DISSEMINATION

Ethical approval was obtained in Cambodia (National Ethics Committee for Health Research 112/250NECHR), Canada (Mount Saint Vincent University Research Ethics Board 2017-141) and the USA (University of Oregon Institutional Review Board 07052018.008). Results will be shared with participants' communities, as well as relevant government and scientific stakeholders via presentations, academic manuscripts and consultations.

TRIAL REGISTRATION NUMBER

NCT03616288.

Use of Text Messaging for Postpartum Depression Screening and Information Provision

OBJECTIVE

The objective of this study was to evaluate the feasibility of using text messages to enhance mental health screening and education of women in the immediate postpartum period.

METHODS

A total of 937 postpartum women were recruited from an obstetrics and gynecology clinic of a large urban hospital. Participants received a text message containing a two-question screen for postpartum depression every two weeks and three text messages per week about postpartum mental health for the first 12 weeks postpartum. Those who screened positive were administered the Edinburgh Postnatal Depression Scale. They were matched with a subset of women who were also assessed with the Edinburgh Postnatal Depression Scale after screening negative for depression with the text messaging screen. At 12 to 13 weeks postpartum, all participants received an online survey assessing satisfaction with the text messages.

RESULTS

Of 937 participants, 126 (13%) screened positive. Agreement between the texted screen and the Edinburgh Postnatal Depression Scale was moderate (κ=0.45), with good sensitivity (0.90, 95% confidence interval [95% CI]=0.81-0.96) and specificity (0.82, 95% CI=0.79-0.85). Nine hundred thirty (99%) participants responded to at least one of the six texted screens, whereas 632 (67%) responded to all six. Of the 589 (63%) who responded to the satisfaction survey, 459 (78%) recommended that all women be screened for postpartum depression via text messaging and that all women in the postpartum period be sent information texts about postpartum depression (N=504, 91%).

CONCLUSIONS

Using text messaging technology to screen women for postpartum depression and provide information on postpartum mental health appears to be sensitive, feasible, and well accepted.

Maternal Sociodemographic Characteristics, Experiences and Health Behaviors Associated with Postpartum Care Utilization: Evidence from Maryland PRAMS Dataset, 2012-2013

Objectives Postpartum visits are increasingly recognized as a window of opportunity for health care providers to counsel new mothers and promote healthy behaviors, including increasing contraceptive use and screening for postpartum depression. In Maryland, there is a lack of research on postpartum visit (PPV) attendance and the specific risk factors associated with not receiving postpartum care. In this study, we estimated the proportion of mothers in Maryland who attended a PPV and assessed maternal sociodemographic characteristics and health behaviors associated with PPV non-attendance. Methods Data were analyzed from the 2012 and 2013 Maryland Pregnancy Risk Assessment Monitoring System (n = 2204). Bivariate and multivariable logistic regression were performed to examine the association between covariates and PPV non-attendance. Results Overall, 89.6% of women reported PPV attendance. Bivariate analyses between maternal sociodemographic and health behavior characteristics and PPV non-attendance indicated that being unmarried (OR 3.03, 95% CI 2.12-4.31), experiencing infant loss (OR 7.17, 95% CI 2.57-19.97), working during pregnancy (OR 0.44, 95% CI 0.31-0.63) and not receiving dental care (OR 2.03, 95% CI 1.43-2.88) as significant risk factors for PPV non-attendance. After controlling for known and theoretical confounders, experiencing an infant loss (aOR 5.18, 95% CI 1.54-17.4), not receiving dental care (aOR 1.54, 95% CI 1.06-2.26) and working during pregnancy (aOR 0.61, 95% CI 0.41-0.93) emerged as strong predictors of PPV non-attendance. Conclusions for Practice Mothers who recently experienced an infant death were at greatest risk for not attending a PPV, suggesting the need to establish comprehensive support networks, including grief counseling and additional service reminders for mothers who experienced an infant death.

A randomized controlled trial of 'MUMentum Pregnancy': Internet-delivered cognitive behavioral therapy program for antenatal anxiety and depression

BACKGROUND

Anxiety and depression are common during pregnancy and associated with adverse outcomes for the mother and infant if left untreated. Despite the need to improve treatment accessibility and uptake in this population, no studies have investigated internet-delivered cognitive behavioural therapy (iCBT) for antenatal anxiety and depression. In a randomised controlled trial, we examined the efficacy and acceptability of a brief, unguided iCBT intervention - the MUMentum Pregnancy program - in pregnant women with anxiety and/or depression.

METHODS

Participants meeting clinical threshold on validated self-report measures of generalised anxiety and/or depression were recruited online and randomised to iCBT (n = 43) or a treatment as usual (TAU) control (n = 44). Outcomes were assessed at baseline, post-treatment and four-week follow-up; and included anxiety, depression, psychological distress, antenatal bonding, quality of life, and treatment acceptability.

RESULTS

Of the 36 women who started iCBT, 26 completed all three lessons of treatment (76% adherence rate). iCBT produced moderate to large effect size reductions for anxiety on the GAD-7 (Hedges' g = 0.76) and psychological distress on the Kessler-10 (g = 0.88) that were superior to TAU. Only small nonsignificant differences were found for depression outcomes (g = < 0.35). Participants reported that iCBT was an acceptable treatment for antenatal anxiety and/or depression.

LIMITATIONS

Lack of an active control condition and long-term postpartum follow-up.

CONCLUSIONS

This is the first study to evaluate brief unguided iCBT for antenatal anxiety and depression. While our findings are promising, particularly for anxiety reduction, additional RCTs are required to establish treatment efficacy.