Addressing inequalities in the identification and management of perinatal mental health difficulties: The perspectives of minoritised women, healthcare practitioners and the voluntary sector

Case-finding with the anxiety sub-scale of the Edinburgh Postnatal Depression Scale in an observational cohort: Sensitivity, specificity, and cost-effectiveness

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) is effective and cost-effective for identifying postnatal depression. Postnatal anxiety is also common and can be identified by three questions on the EPDS (anxiety sub-scale). We aimed to compare EPDS score alone with EPDS score and sub-scale score together (EPDS+) to identify common mental illness (depression or anxiety) in postnatal women.

METHODS

The sensitivity and specificity of the EPDS and sub-scale were explored. We developed a decision tree to compare costs and health outcomes associated with case-finding for postnatal depression or anxiety over one year. Model parameters were derived from secondary data analysis, published literature, and expert consultation. Costs included case-finding and treatment. Health benefit was measured as quality-adjusted life years (QALYs). We explored the cost-effectiveness of using EPDS alone and EPDS+ (versus no case-finding).

RESULTS

The greatest number of true positive outcomes and smallest number of false negative outcomes were seen with EPDS+. However, the number of false positives is also higher for EPDS+. Compared with no case-finding, EPDS alone costs £3365/QALY gained and EPDS+ costs £6405/QALY gained. The additional health gain from EPDS+ (versus EPDS alone) costs £22,104/QALY.

LIMITATIONS

The model does not include long-term impacts of maternal mental illness or impacts on other family members.

CONCLUSIONS

Case-finding for common mental illness in the postnatal period is cost-effective. Compared to no case-finding, EPDS alone is more cost-effective than EPDS+. If decision-makers want to maximise identification of cases, EPDS+ could be cost-effective depending on how much they are willing to pay.

Emotional safety in maternity care: An evolutionary concept analysis

BACKGROUND

Safety in maternity care is a priority, and a broadened view of safety (e.g., emotional, psychological, cultural) is evident in scientific literature and in lay discourse. 'Emotional safety' is being referred to with increasing frequency in this context; however, there is a lack of clarity in its use and meaning.

AIM

The aim of this concept analysis was to examine the concept of emotional safety in maternity care.

METHODS

The evolutionary approach was used for this concept analysis.

DATA SOURCES

This concept analysis was literature-based, with a systematic search conducted of CINAHL, MIDIRS, and MEDLINE databases. Ten articles published between 2006 and 2024 met our criteria for inclusion.

RESULTS

Identified attributes of emotional safety in maternity care included 'feeling secure', 'feeling heard and well taken care of', experiencing 'supportive and respectful care', and being in a 'calm care environment'. Antecedents to emotional safety in maternity care were 'having care needs met', enacting 'personal agency', and engaging in 'trusting relationships'. The consequences of emotional safety for maternity care recipients were 'positive impact on experience', 'feeling empowered', and 'improved outcomes'. A conceptual definition and model resulted that clarify and illustrate the concept of emotional safety in the context of receiving maternity care.

CONCLUSION

This concept analysis contributes to the current body of knowledge of care recipients' views and experiences of safe maternity care and provides a foundation for future concept use in research, education, policy, and clinical practice.

Roles and Dynamics within Community Mental Health Systems During the COVID-19 Pandemic: A Qualitative Systematic Review and Meta-Ethnography

Globally, COVID-19 had an immense impact on mental health systems, but research on how community mental health (CMH) systems and services contributed to the pandemic mental health response is limited. We conducted a systematic review and meta-ethnography to understand the roles of CMH services, determinants of the quality of CMH care, and dynamics within CMH systems during COVID-19. We searched and screened across five databases and appraised study quality using the CASP tool, which yielded 27 qualitative studies. Our meta-ethnographic process used Noblit and Hare's approach for synthesizing findings and applying interpretive analysis to original research. This identified several key themes. Firstly, CMH systems played the valuable pandemic role of safety nets and networks for the broader mental health ecosystem, while CMH service providers offered a continuous relationship of trust to service users amidst pandemic disruptions. Secondly, we found that the determinants of quality CMH care during COVID-19 included resourcing and capacity, connections across service providers, customized care options, ease of access, and human connection. Finally, we observed that power dynamics across the CMH landscape disproportionately excluded marginalized groups from mainstream CMH systems and services. Our findings suggest that while the pandemic role of CMH was clear, effectiveness was driven by the efforts of individual service providers to meet demand and service users' needs. To reprise its pandemic role in the future, a concerted effort is needed to make CMH systems a valuable part of countries' disaster mental health response and to invest in quality care, particularly for marginalized groups.

Current perspectives on perinatal mental health and neurobehavioral development: focus on regulation, coregulation and self-regulation

PURPOSE OF REVIEW

Perinatal mental health research provides an important perspective on neurobehavioral development. Here, we aim to review the association of maternal perinatal health with offspring neurodevelopment, providing an update on (self-)regulation problems, hypothesized mechanistic pathways, progress and challenges, and implications for mental health.

RECENT FINDINGS

(1) Meta-analyses confirm that maternal perinatal mental distress is associated with (self-)regulation problems which constitute cognitive, behavioral, and affective social-emotional problems, while exposure to positive parental mental health has a positive impact. However, effect sizes are small. (2) Hypothesized mechanistic pathways underlying this association are complex. Interactive and compensatory mechanisms across developmental time are neglected topics. (3) Progress has been made in multiexposure studies. However, challenges remain and these are shared by clinical, translational and public health sciences. (4) From a mental healthcare perspective, a multidisciplinary and system level approach employing developmentally-sensitive measures and timely treatment of (self-)regulation and coregulation problems in a dyadic caregiver-child and family level approach seems needed. The existing evidence-base is sparse.

SUMMARY

During the perinatal period, addressing vulnerable contexts and building resilient systems may promote neurobehavioral development. A pluralistic approach to research, taking a multidisciplinary approach to theoretical models and empirical investigation needs to be fostered.

Addressing Maternal Health Disparities: Building a Novel Two-Generation Approach to Comprehensive Postpartum Care

The United States is facing a maternal health crisis with increasing rates of severe maternal morbidity and mortality. To improve maternal health and promote health equity, the authors developed a novel 2-generation model of postpartum and pediatric care. This article describes the Two-Generation Clinic (Two-Gen) and model of care. The model combines a dyadic strategy for simultaneous maternal and pediatric care with the collaborative care model in which seamless primary and behavioral health care are delivered to address the physical health, behavioral health, and social service needs of families. The transdisciplinary team includes primary care physicians, nurse practitioners, psychiatrists, obstetrician-gynecologists, social workers, care navigators, and lactation specialists. Dyad clinic visits are coscheduled (at the same time) and colocated (in the same examination room) with the same primary care provider. In the Two-Gen, the majority (89%) of the mothers self-identify as racial and ethnic minorities. More than 40% have a mental health diagnosis. Almost all mothers (97.8%) completed mental health screenings, >50.0% have received counseling from a social worker, 17.2% had a visit with a psychiatrist, and 50.0% received lactation counseling. Over 80% of the children were up to date with their well-child visits and immunizations. The Two-Gen is a promising model of care that has the potential to inform the design of postpartum care models and promote health equity in communities with the highest maternal health disparities.

An economic evaluation of targeted case-finding strategies for identifying postnatal depression: A model-based analysis comparing common case-finding instruments

BACKGROUND

Half of women with postnatal depression (PND) are not identified in routine care. We aimed to estimate the cost-effectiveness of PND case-finding in women with risk factors for PND.

METHODS

A decision tree was developed to represent the one-year costs and health outcomes associated with case-finding and treatment for PND. The sensitivity and specificity of case-finding instruments, and prevalence and severity of PND, for women with ≥1 PND risk factor were estimated from a cohort of postnatal women. Risk factors were history of anxiety/depression, age < 20 years, and adverse life events. Other model parameters were derived from published literature and expert consultation. Case-finding for high-risk women only was compared with no case-finding and universal case-finding.

RESULTS

More than half of the cohort had one or more PND risk factor (57.8 %; 95 % CI 52.7 %-62.7 %). The most cost-effective case-finding strategy was the Edinburgh Postnatal Depression Scale with a cut-off of ≥10 (EPDS-10). Among high-risk women, there is a high probability that EPDS-10 case-finding for PND is cost-effective compared to no case-finding (78.5 % at a threshold of £20,000/QALY), with an ICER of £8146/QALY gained. Universal case-finding is even more cost-effective at £2945/QALY gained (versus no case-finding). There is a greater health improvement with universal rather than targeted case-finding.

LIMITATIONS

The model includes costs and health benefits for mothers in the first year postpartum, the broader (e.g. families, societal) and long-term impacts are also important.

CONCLUSIONS

Universal PND case-finding is more cost-effective than targeted case-finding which itself is more cost-effective than not case-finding.