*Edinburgh Postpartum Depression Scale (EPDS):* This is a 10-item questionnaire that can be used with mothers or to detect PND in fathers (Murray & Cox, 1990; Clement, 1995; Littlewood & McHugh, 1997; Clement & Elliott, 1999). It has been specifically designed to detect PND (Beck C.T., 1992). From 21 items identified, 13 were confirmed after the pilot study and these were subsequently abbreviated into ten statements describing symptoms of depression (Cox, 1986). The statements have four possible answers, recorded on Likert-type scales, which range from zero to three (total maximum score 30). People completing the scale need to choose a response that describes their feelings in the past week (Tully et al., 1998; Vieira, 2002). Since the EPDS is a self-administered questionnaire, the questions need to be acceptable to users who may not regard themselves as unwell or in need of help (Cox et al., 1987). The tool includes symptoms such as the inability to laugh or to look forward to things with enjoyment, blaming oneself unnecessarily, feeling anxious or worried, feeling that things are too difficult to handle, difficulty sleeping because of unhappiness, feeling sad or miserable, crying, and having thoughts of harming oneself (Beck C.T., 1995b). With repeated use of the EPDS, the severity of the symptoms can be traced over time (Cox et al.,

(Vieira, 2002).

depression) (Beck C.T. & Gable, 2001).

1987). Screening at six to eight weeks postnatally and seven to nine months is recommended (Tully et al., 1998). It is said that women who score above a threshold of 12 to 13 are likely to be suffering from depressive illness, but if action is taken at the cut-off score of 9 to 10, the negative predictive value can be reduced to less than 10% (Cox et al., 1987; Wisner et al., 2002). It is recommended that a woman with a score of 9 or higher, or those who answer the tenth question positively (suicide intention), should have a clinical interview. It has been suggested that a score of five to ten needs further evaluation after 2-4 weeks (Wisner et al., 2002). The EPDS has 95% sensitivity (studies vary from 65-100%) and 93% specificity (studies vary from 49-100%) (Eberhard-Gran et al., 2001) and positive predictive values of 35.1% (Cooper & Murray, 1997) for severe depression to 83% overall (Cox et al., 1987), which is satisfactory when tested against the clinical psychiatric interview (Cox, 1986). The EPDS is simple to complete and does not require special psychiatric knowledge from the health care professional who interprets it. The only obstacle could be its use with women who have limited literacy, writing abilities or problems with understanding language of the tool (Cox et al., 1987). Beck C.T. (1995b) added as an obstacle the lack of an opportunity for women to describe their feelings fully. Shakespeare et al. (2003) found in their research that women prefer speaking about their feelings rather than filling out an EPDS questionnaire. Critics of the EPDS state that it does not consider symptoms such as loss of control, obsessive thoughts, loss of self, loneliness, lack of concentration (Vieira, 2002) and cognitive impairment (Powell-Kennedy et al., 2002). Of those symptoms that Beck C.T. (1992) identified to be important in PND, the EPDS includes only thoughts of harming oneself, anxiety and fear. Austin & Lumley (2003) have criticised the EPDS because in their study only 8% of women identified as being at risk actually developed PND. This contradiction could occur because the scale excludes some risk factors that are of importance in the development of PND. Lee et al. (2000) found the EPDS to be less reliable for severe PND, but found that the results could be improved by using it in combination with the General Health Questionnaire (GHQ), which raises the positive predictive value to 78%.

The characteristics of above mentioned tools suggest that the EPDS is currently the most evaluated and therefore appropriate screening tool for PND. It is also the most frequently used tool in studies on PND. New instruments are being developed all the time in order to screen more successfully for PND (for example the Brisbane mother baby scale by Webster et al. (2003) and other similar tools are currently being developed and tested). However, in a systematic review, Austin & Lumley (2003) found that no screening instrument met the criteria for routine application in the antenatal period, because the instruments under-estimated the contribution of key domains (predicting risk factors) and therefore had poor sensitivity and positive predictive values. The lack of consensus regarding the risk factors of PND makes it almost impossible to develop an antenatal screening tool that would cover all the issues that emerged from studies on predicting PND (Skočir, 2004). It is easier to screen postnatally for the symptoms. The specificity of the symptoms in the postnatal period means that instruments developed for detecting general depression are not recommended. A screening programme may open up also other problematic areas. Women with false positive scores may become anxious or consequently develop PND. For this reason it is necessary to explain to them that the purpose of the screening instrument is not to diagnose but only to select individuals that might need additional clinical judgement and psychiatric evaluation, and that the diagnosis of PND can only be determined through a clinical examination. Screening only identifies those individuals that have certain risk characteristics, it does not determine the presence of the disease or provide a diagnosis (Tiran, 2002).

Mood Disorders in the Puerperium and the Role of the Midwife: Study on Improvement

withdrawal syndrome (SIGN, 2002).

**<IP_ADDRESS> Psychotherapeutic methods**

recurrent PND (Boath & Henshaw, 2001; Lawrie et al., 2003).

of Midwives' Knowledge About Post-Natal Depression After an Educational Intervention 297

Special care must be paid in pregnancy, as infant exposure to medication is greater through placental passage than through breast milk postnatally. All psychotropic medications are found in breast milk and are passed to the nursing infant, which is why potential side effects of an infant's exposure must be weighed against the effects of untreated depression (Misri & Kostaras, 2002). In pregnancy there is a risk of teratogenesis, while postnatally neonatal toxicity or the impact on neurodevelopment can be a risk. Usually medications are used only when a clear diagnosis has been made and there are no alternative solutions. It has been recommended that the lowest effective dose of the most established drug must be used for the shortest period (Schottish Intercollegiate Group Network [SIGN], 2002). However, some experts claim that in order to prevent a recurrence of the illness, treatment should continue for 9-12 months after the remission of symptoms (Stowe & Nemeroff, 1995). Wisner et al. (2002) recommend starting with half the dose for the first four days after childbirth, as women are more sensitive at that time and side effects might be more likely. The dose should then be gradually increased until remission. If the woman responds to the initial dose, lasting six to eight weeks, treatment with the same dose should be continued for at least six months until full remission. If there is no improvement in the first six weeks, reevaluation of the medication must be carried out. This kind of treatment is also indicated to prevent a recurrence of PND in women with a history of depression (Wisner et al., 2002). It is important to reduce or discontinue the dose 2-4 weeks before the expected date of delivery, with recommencement after the birth, to prevent perinatal toxic symptoms and

*Hormonal therapy* Already in 1971, Dalton has suggested that PND could be caused by having difficulty adjusting to the marked changes in hormone levels form late pregnancy to the early puerperium. Low progesterone levels after the birth were often attributed responsibility for causing PND (Nott et al., 1976), with this being the main rationale for implementing hormone treatment (Dennis et al., 1999). Dennis et al. (2009) Cochrane review of oestrogens and progestins for inhibiting and remedying PND, includes one perinatal trial by Lawrie et al. (1998), which reported a significant negative effect of progesteron on PND scores. As a consequence, progestogens (e.g. norethisterone), used to prevent PND, are now contraindicated (Wylie et al., 2011). Synthetic progesterons have adverse effects, and their use is associated with an increased risk of PND (Lawrie et al., 2003; Karuppaswamy & Vlies, 2003). Transdermal 17-ßestradiol is useful in chronic PND (Cooper & Murray, 1998) and is of modest value in the treatment of the late stages of severe PND (Lawrie et al., 2003, NICE 2007). Significant improvements have been noticed in the first month of treatment (Gregorie et al., 1996). Hormonal medications have not been validated yet for the prevention of

In depression with mild to moderate symptoms, non-pharmacological treatment is proposed (Misri & Kostaras, 2002), but to be effective the mother must live within a supportive environment (Pinkofsky, 2000). Family involvement, such as marital therapy, has beneficial effects for all family members (Buist, 1997). However, PND which occurs in the context of a »continuum of psychiatric disturbance may be less likely to respond to these interventions« (Holden et al., 1989, p. 225). Psychotherapy can also be offered by health care providers in the primary sector, but these health care providers need to be educated for this approach (Holden et al., 1989; WHO, 1991; Yonkers et al., 2001). Because many women

The other problem is that although the identified antenatal risk factors are very amenable to prevention, they are not defined clearly enough and cannot provide a good basis for any predictive index for PND (Cooper & Murray, 1997). As a result, some researchers are of the opinion that early recognition and treatment would be more effective than preventive measures (Bowe & Watson, 2001). When PND is treated, the duration is much shorter than when it is untreated (England et al., 1994; CRAG, 1996; Barnett & Morgan, 1996; Wisner et al., 2002). It is estimated that the duration of PND can be shortened from seven months to six weeks through treatment (CRAG, 1996; O'Hara et al., 2000).

#### **2.4.5 Prevention and treatment options**

The symptoms of depression or anxiety that occur amongst childbearing women are similar to those that occur at other times of life, however the choices for treatment may differ during pregnancy or when a woman is breastfeeding. The treatment should fit the individual woman's symptoms (DeAngelis, 1997; Beck C.T., 2002) and consider her preferences with regard to the severity of the illness (Wisner et al., 2002), her possible resources for support and breastfeeding (Buist, 1997). Treating PND is challenging and requires specific knowledge and expertise. Includes a variety of options.

#### **<IP_ADDRESS> Pharmacotherapy**

There is much dabate about when to offer pharmacological treatment to women with PND. National Institute for Clinical Excellence [NICE] guidlines state that (2007) antidepressants may be considered for use in women with mild, moderate or severe PND, particularly when they are unresponsive or reluctant to participate in non-drug management programmes. Misri & Kostaras (2002) say if the woman is at risk of suicide or infanticide, or has severe depression that does not respond to non-pharmacological treatment, then pharmacological therapy is recommended. Pharmacological treatments include use of antidepressants (Misri & Kostaras, 2002) and hormone therapies (Lawrie et al., 2003).

There are two types of *antidepressants:* (1) Tricyclic Antidepressants (TCA), e.g. imipramine, nortriptyline and sertraline; and (2) Selective Serotonin Re-uptake Inhibitors (SSRI), e.g. fluoxetine, sertraline and citalopram. TCAs work by blocking neuronal uptake of noradrenaline and serotonin, and SSRIs block the reabsorption of serotonin by the presynaptic neurone (Wylie et al., 2011). When choosing an antidepressant treatment, the following should be considered:

The risks, benefits and side effects (for the mother and the infant) must be carefully reviewed when making the decision about medication (Powell-Kennedy et al., 2002) and a careful follow-up and evaluation of benefits must be undertaken (Brockington, 2000).

The other problem is that although the identified antenatal risk factors are very amenable to prevention, they are not defined clearly enough and cannot provide a good basis for any predictive index for PND (Cooper & Murray, 1997). As a result, some researchers are of the opinion that early recognition and treatment would be more effective than preventive measures (Bowe & Watson, 2001). When PND is treated, the duration is much shorter than when it is untreated (England et al., 1994; CRAG, 1996; Barnett & Morgan, 1996; Wisner et al., 2002). It is estimated that the duration of PND can be shortened from seven months to

The symptoms of depression or anxiety that occur amongst childbearing women are similar to those that occur at other times of life, however the choices for treatment may differ during pregnancy or when a woman is breastfeeding. The treatment should fit the individual woman's symptoms (DeAngelis, 1997; Beck C.T., 2002) and consider her preferences with regard to the severity of the illness (Wisner et al., 2002), her possible resources for support and breastfeeding (Buist, 1997). Treating PND is challenging and requires specific

There is much dabate about when to offer pharmacological treatment to women with PND. National Institute for Clinical Excellence [NICE] guidlines state that (2007) antidepressants may be considered for use in women with mild, moderate or severe PND, particularly when they are unresponsive or reluctant to participate in non-drug management programmes. Misri & Kostaras (2002) say if the woman is at risk of suicide or infanticide, or has severe depression that does not respond to non-pharmacological treatment, then pharmacological therapy is recommended. Pharmacological treatments include use of antidepressants (Misri

There are two types of *antidepressants:* (1) Tricyclic Antidepressants (TCA), e.g. imipramine, nortriptyline and sertraline; and (2) Selective Serotonin Re-uptake Inhibitors (SSRI), e.g. fluoxetine, sertraline and citalopram. TCAs work by blocking neuronal uptake of noradrenaline and serotonin, and SSRIs block the reabsorption of serotonin by the presynaptic neurone (Wylie et al., 2011). When choosing an antidepressant treatment, the

The risks, benefits and side effects (for the mother and the infant) must be carefully reviewed when making the decision about medication (Powell-Kennedy et al., 2002) and a careful follow-up and evaluation of benefits must be undertaken (Brockington, 2000).

provides complete control of the depressive symptoms is used;

lowest levels in the breast milk (Misri & Kostaras, 2002, p. 908).

six weeks through treatment (CRAG, 1996; O'Hara et al., 2000).

knowledge and expertise. Includes a variety of options.

& Kostaras, 2002) and hormone therapies (Lawrie et al., 2003).

**2.4.5 Prevention and treatment options**

**<IP_ADDRESS> Pharmacotherapy**

following should be considered:

and risk interventions;

Special care must be paid in pregnancy, as infant exposure to medication is greater through placental passage than through breast milk postnatally. All psychotropic medications are found in breast milk and are passed to the nursing infant, which is why potential side effects of an infant's exposure must be weighed against the effects of untreated depression (Misri & Kostaras, 2002). In pregnancy there is a risk of teratogenesis, while postnatally neonatal toxicity or the impact on neurodevelopment can be a risk. Usually medications are used only when a clear diagnosis has been made and there are no alternative solutions. It has been recommended that the lowest effective dose of the most established drug must be used for the shortest period (Schottish Intercollegiate Group Network [SIGN], 2002). However, some experts claim that in order to prevent a recurrence of the illness, treatment should continue for 9-12 months after the remission of symptoms (Stowe & Nemeroff, 1995). Wisner et al. (2002) recommend starting with half the dose for the first four days after childbirth, as women are more sensitive at that time and side effects might be more likely. The dose should then be gradually increased until remission. If the woman responds to the initial dose, lasting six to eight weeks, treatment with the same dose should be continued for at least six months until full remission. If there is no improvement in the first six weeks, reevaluation of the medication must be carried out. This kind of treatment is also indicated to prevent a recurrence of PND in women with a history of depression (Wisner et al., 2002). It is important to reduce or discontinue the dose 2-4 weeks before the expected date of delivery, with recommencement after the birth, to prevent perinatal toxic symptoms and withdrawal syndrome (SIGN, 2002).

*Hormonal therapy* Already in 1971, Dalton has suggested that PND could be caused by having difficulty adjusting to the marked changes in hormone levels form late pregnancy to the early puerperium. Low progesterone levels after the birth were often attributed responsibility for causing PND (Nott et al., 1976), with this being the main rationale for implementing hormone treatment (Dennis et al., 1999). Dennis et al. (2009) Cochrane review of oestrogens and progestins for inhibiting and remedying PND, includes one perinatal trial by Lawrie et al. (1998), which reported a significant negative effect of progesteron on PND scores. As a consequence, progestogens (e.g. norethisterone), used to prevent PND, are now contraindicated (Wylie et al., 2011). Synthetic progesterons have adverse effects, and their use is associated with an increased risk of PND (Lawrie et al., 2003; Karuppaswamy & Vlies, 2003). Transdermal 17-ßestradiol is useful in chronic PND (Cooper & Murray, 1998) and is of modest value in the treatment of the late stages of severe PND (Lawrie et al., 2003, NICE 2007). Significant improvements have been noticed in the first month of treatment (Gregorie et al., 1996). Hormonal medications have not been validated yet for the prevention of recurrent PND (Boath & Henshaw, 2001; Lawrie et al., 2003).

#### **<IP_ADDRESS> Psychotherapeutic methods**

In depression with mild to moderate symptoms, non-pharmacological treatment is proposed (Misri & Kostaras, 2002), but to be effective the mother must live within a supportive environment (Pinkofsky, 2000). Family involvement, such as marital therapy, has beneficial effects for all family members (Buist, 1997). However, PND which occurs in the context of a »continuum of psychiatric disturbance may be less likely to respond to these interventions« (Holden et al., 1989, p. 225). Psychotherapy can also be offered by health care providers in the primary sector, but these health care providers need to be educated for this approach (Holden et al., 1989; WHO, 1991; Yonkers et al., 2001). Because many women

Mood Disorders in the Puerperium and the Role of the Midwife: Study on Improvement

preventing and treating PND (Small et al., 2000; Bick, 2003; Priest et al., 2003).

of Midwives' Knowledge About Post-Natal Depression After an Educational Intervention 299

trauma, which could be a possible reason for post-traumatic stress disorder (Littlewood & McHugh, 1997) and consequently for PND. It is believed to be most effective if conducted 24 to 48 hours after the traumatic experience (Littlewood & McHugh, 1997). According to some authors, listening, support, understanding and explanation are helpful also after the nontraumatic birth, and Lavender & Walkinshaw (1998) recommend it as a routine procedure in postnatal maternity units. However, other researchers have found it to be unsuccessful in

*Listening visits* are also a form of talk therapy and may prevent PND if regularly performed in pregnancy (Clement, 1995). They lessen the mother's feelings of isolation (Gutteridge, 2001). *Self help and support groups* may include peer-based meetings or telephone support from women who are past sufferers of PND. They may be helpful in easing depressive symptoms, and their support has been found to be acceptable to new mothers (Dennis, 2003). Support group meetings can be beneficial, particularly if childcare is provided during the meeting, so that mothers can focus on their own needs. Open discussion can reduce the stigma associated with PND (Mauthner, 1999), as well as the isolation, and at the same time provide an opportunity for knowledge to be disseminated. Cox (1986) found that self-help groups were more effective in reducing PND symptoms when they were facilitated by a health professional. The fact that all participants in the group have a similar experience provides them with feelings of confidence, honesty, freedom and trust, which are the necessary ingredients of a psychotherapeutic relationship (Gutteridge, 2001). These groups may help to raise self-esteem, which is, as previously said, an important factor in the development and persistence of PND (SIGN, 2002). However, some researchers have reported finding no improvement in PND after group interventions (Morgan et al., 1997).

Other psychological aspects of the puerperium, such as stress, should also be assessed and treated through conversation. With support, interventions directed towards women's chronic stressors could raise their self-esteem, which in turn decreases their depressive

*Complementary methods* are nowadays more and more popular method of treatment of postnatal mood disorders. *Partner involvement* studied Misri et al. (2000), who determined the impact of a supportive partner on PND scores. This trial showed the value of including the partner in psychotherapy sessions. Women whose partners had participated in psychotherapy sessions had lower EPDS scores at the final assessment which occurred 10 weeks after the first session than those whose partners had not participated (8.6% vs 14.7%). *St. John's wort* is said to be an effective treatment for mild to moderate depressive symptoms and it is said to be as effective as TCAs but with fewer side effects (SIGN, 2002). However, there is no research evidence regarding its safety which is why some experts suggest it should not be used in the childbearing period (Goldman & Koren, 2003b). *Hypnosis* has been indicated in the treatment of insomnia, as one of the symptoms of PND (Pajntar, 1994). *Acupuncture* has also been used in the treatment of PND (Schnyer et al., 2003), however, there is little evidence to support its effectiveness. *Massage therapy* has been found to be effective in treating the anxiety symptoms of depression (Boath & Henshaw, 2001). *Imagery, art and music therapy* can be used as adjuncts to other treatments (Boath & Henshaw, 2001). *Bright light therapy* has been shown to be effective in treating PND in 49% of cases in a study

symptoms (Hall et al., 1996).

**<IP_ADDRESS> Other methods of treatment**

decline pharmacological treatments, these interventions are often the first line treatment (Austin, 2003). A further advantage of counselling is that it focuses on the problems behind PND and not just on easing the present symptoms (Welburn, 1980). While some experts believe that these therapies are unhelpful in the long term, they admit that there is an improvement in maternal mood right after the application (Cooper et al., 2003).

*Interpersonal therapy (IPT)* attempts to modify women's relationships or expectations about them. The women's expectations about motherhood and partners' support are discussed during counselling sessions and the therapy focuses on an identified problem area (Boath & Henshaw, 2001). The mother gains a feeling of competence and control through different methods such as psychoeducation, which is a strategy to reduce risk factors associated with the development of PND (Benner-Carson, 2000), role-playing and communication analysis (Beck C.T., 2002). Relief is achieved through discussing feelings, which raises self-esteem in coping with the problems (Dietch & Bunney, 2002). IPT is the only psychotherapy that has been shown to be effective in treating PND both before and after birth (Spinelli, 1997; Zlotnick et al., 2001). It is a good alternative to medication in pregnancy (Spinelli, 1997), even in more severe cases (Boath & Henshaw, 2001), and at the same time it promotes more realistic expectations about motherhood (Dietch & Bunney, 2002). It has been recommended also as a preventive measure for women at risk of PND (Zlotnick et al., 2001).

*Cognitive behavioural therapy (CBT)* aims to change negative thoughts that are a product of biased perception and to lift depression (Littlewood & McHugh, 1997). First the negative thoughts must be identified and then the process of alteration begins (Cox, 1986). With successful accomplishment of given tasks, the woman achieves self-esteem and sharpens her problem solving skills (Dietch & Bunney, 2002). It is indicated for mild to moderate forms of PND (SIGN, 2002; Meager & Milgrom, 1996). NICE (2007) recommends 4-6 sessions of CBT or IPT for pregnant women with symptoms of depression and/or anxiety who do not meet diagnostic criteria, but symptoms interfere with social functioning. Talking therapies such as Non-directive counselling and CBT, without concurrent use of antidepressants, are both methods of treating PND (Wiley et al., 2011).

*Non-directive counselling* is a less intensive form of psychotherapy. The art of efficient counselling is not to give advice (Welburn, 1980). The environment should be empathic but non-interfering, close but not intimate (Cox, 1986). Therapeutic listening and extra support are said to be helpful in the treatment of depression or can be an adjunctive therapy to pharmacological treatment (Holden et al., 1989). Non-directive counselling has been shown to be as effective as antidepressant treatment for mild to moderate forms of PND, although the effects of treatment are quicker with medication (Chilvers et al., 2001). Some researchers have found non-directive counselling to be more efficient than CBT (Boath & Henshaw, 2001). The key elements of counselling are:

*Debriefing* can be a form of therapeutic counselling. During the process, the mother integrates her childbirth experience into her life (Beck, C.T., 2002). An emotional »catharsis« that can be achieved by encouraging the woman to recollect her birth, can alleviate birth trauma, which could be a possible reason for post-traumatic stress disorder (Littlewood & McHugh, 1997) and consequently for PND. It is believed to be most effective if conducted 24 to 48 hours after the traumatic experience (Littlewood & McHugh, 1997). According to some authors, listening, support, understanding and explanation are helpful also after the nontraumatic birth, and Lavender & Walkinshaw (1998) recommend it as a routine procedure in postnatal maternity units. However, other researchers have found it to be unsuccessful in preventing and treating PND (Small et al., 2000; Bick, 2003; Priest et al., 2003).

*Listening visits* are also a form of talk therapy and may prevent PND if regularly performed in pregnancy (Clement, 1995). They lessen the mother's feelings of isolation (Gutteridge, 2001).

*Self help and support groups* may include peer-based meetings or telephone support from women who are past sufferers of PND. They may be helpful in easing depressive symptoms, and their support has been found to be acceptable to new mothers (Dennis, 2003). Support group meetings can be beneficial, particularly if childcare is provided during the meeting, so that mothers can focus on their own needs. Open discussion can reduce the stigma associated with PND (Mauthner, 1999), as well as the isolation, and at the same time provide an opportunity for knowledge to be disseminated. Cox (1986) found that self-help groups were more effective in reducing PND symptoms when they were facilitated by a health professional. The fact that all participants in the group have a similar experience provides them with feelings of confidence, honesty, freedom and trust, which are the necessary ingredients of a psychotherapeutic relationship (Gutteridge, 2001). These groups may help to raise self-esteem, which is, as previously said, an important factor in the development and persistence of PND (SIGN, 2002). However, some researchers have reported finding no improvement in PND after group interventions (Morgan et al., 1997).

Other psychological aspects of the puerperium, such as stress, should also be assessed and treated through conversation. With support, interventions directed towards women's chronic stressors could raise their self-esteem, which in turn decreases their depressive symptoms (Hall et al., 1996).

#### **<IP_ADDRESS> Other methods of treatment**

298 Clinical, Research and Treatment Approaches to Affective Disorders

decline pharmacological treatments, these interventions are often the first line treatment (Austin, 2003). A further advantage of counselling is that it focuses on the problems behind PND and not just on easing the present symptoms (Welburn, 1980). While some experts believe that these therapies are unhelpful in the long term, they admit that there is an

*Interpersonal therapy (IPT)* attempts to modify women's relationships or expectations about them. The women's expectations about motherhood and partners' support are discussed during counselling sessions and the therapy focuses on an identified problem area (Boath & Henshaw, 2001). The mother gains a feeling of competence and control through different methods such as psychoeducation, which is a strategy to reduce risk factors associated with the development of PND (Benner-Carson, 2000), role-playing and communication analysis (Beck C.T., 2002). Relief is achieved through discussing feelings, which raises self-esteem in coping with the problems (Dietch & Bunney, 2002). IPT is the only psychotherapy that has been shown to be effective in treating PND both before and after birth (Spinelli, 1997; Zlotnick et al., 2001). It is a good alternative to medication in pregnancy (Spinelli, 1997), even in more severe cases (Boath & Henshaw, 2001), and at the same time it promotes more realistic expectations about motherhood (Dietch & Bunney, 2002). It has been recommended

*Cognitive behavioural therapy (CBT)* aims to change negative thoughts that are a product of biased perception and to lift depression (Littlewood & McHugh, 1997). First the negative thoughts must be identified and then the process of alteration begins (Cox, 1986). With successful accomplishment of given tasks, the woman achieves self-esteem and sharpens her problem solving skills (Dietch & Bunney, 2002). It is indicated for mild to moderate forms of PND (SIGN, 2002; Meager & Milgrom, 1996). NICE (2007) recommends 4-6 sessions of CBT or IPT for pregnant women with symptoms of depression and/or anxiety who do not meet diagnostic criteria, but symptoms interfere with social functioning. Talking therapies such as Non-directive counselling and CBT, without concurrent use of antidepressants, are both

*Non-directive counselling* is a less intensive form of psychotherapy. The art of efficient counselling is not to give advice (Welburn, 1980). The environment should be empathic but non-interfering, close but not intimate (Cox, 1986). Therapeutic listening and extra support are said to be helpful in the treatment of depression or can be an adjunctive therapy to pharmacological treatment (Holden et al., 1989). Non-directive counselling has been shown to be as effective as antidepressant treatment for mild to moderate forms of PND, although the effects of treatment are quicker with medication (Chilvers et al., 2001). Some researchers have found non-directive counselling to be more efficient than CBT (Boath & Henshaw,

*Debriefing* can be a form of therapeutic counselling. During the process, the mother integrates her childbirth experience into her life (Beck, C.T., 2002). An emotional »catharsis« that can be achieved by encouraging the woman to recollect her birth, can alleviate birth

improvement in maternal mood right after the application (Cooper et al., 2003).

also as a preventive measure for women at risk of PND (Zlotnick et al., 2001).

methods of treating PND (Wiley et al., 2011).

2001). The key elements of counselling are:

*Complementary methods* are nowadays more and more popular method of treatment of postnatal mood disorders. *Partner involvement* studied Misri et al. (2000), who determined the impact of a supportive partner on PND scores. This trial showed the value of including the partner in psychotherapy sessions. Women whose partners had participated in psychotherapy sessions had lower EPDS scores at the final assessment which occurred 10 weeks after the first session than those whose partners had not participated (8.6% vs 14.7%). *St. John's wort* is said to be an effective treatment for mild to moderate depressive symptoms and it is said to be as effective as TCAs but with fewer side effects (SIGN, 2002). However, there is no research evidence regarding its safety which is why some experts suggest it should not be used in the childbearing period (Goldman & Koren, 2003b). *Hypnosis* has been indicated in the treatment of insomnia, as one of the symptoms of PND (Pajntar, 1994). *Acupuncture* has also been used in the treatment of PND (Schnyer et al., 2003), however, there is little evidence to support its effectiveness. *Massage therapy* has been found to be effective in treating the anxiety symptoms of depression (Boath & Henshaw, 2001). *Imagery, art and music therapy* can be used as adjuncts to other treatments (Boath & Henshaw, 2001). *Bright light therapy* has been shown to be effective in treating PND in 49% of cases in a study

Mood Disorders in the Puerperium and the Role of the Midwife: Study on Improvement

alcohol or drugs as a form of self medication, eg binging;

1996).

include:

**disorders**

of Midwives' Knowledge About Post-Natal Depression After an Educational Intervention 301

otherwise the dangers of infection and violence arise. It is absolutely necessary for the staff to have appropriate knowledge of mental health and childcare issues (Barnett & Morgan,

PND affects the quality of life of mothers, has negative consequences for the emotional, behavioral, and cognitive functioning of their infants, and threatens the healthy functioning of the entire family (Sobey, 2002). It is therefore vital to assess what thoughts mother has been having and if she is concerned for herself. Family and/or partners may not know how to respond to these feelings and thoughts.The areas of risk that need to be assessed should

bonding and attachment.; infanticide is a rare but devastating outcome of PND; - mental health risks - the woman may not be acknowledging the degree of severity of her symptoms and therefore not seeking or accepting treatment, she may be

deteriorating rapidly.; her well-being can be put at increased risk (PaNDa, 2011). Also Hagen (1999) says mothers with PND commonly have thoughts of harming themselves or their children. He claims these women exhibit fewer positive emotions and more negative emotions towards their children, are less responsive and less sensitive to infant cues, have a less successful maternal role attainment, and have consequently infants, who are less securely attached (Hagen, 1999). Beck C.T. (2002) writes that evidences show that this mood disorder not only has adverse effects on maternal-infant interaction during the first year of age, but may also have long-term effects on children over the age of one year. The mother's ongoing depression can cause harmful effects also for siblings and can contribute to emotional, behavioral, cognitive, and interpersonal problems later in life (Miller, 2002).

PND also has an effect on the couple's relationship. Living with a woman experiencing PND is difficult. Partners need a lot of support too and are known to be at risk of developing depression themselves. They often feel confused, lost and helpless (PaNDa, 2011). They can be the target of their partner's distress and irritability as she attempts to make sense of what is happening to her. There is an increase in marital discord and conflict, and men may

**2.5 The role of midwives in the prevention, detection and treatment of postnatal mood**

The literature suggests that 75% of cases of PND could be managed in the primary level of health care (Mc Carthy, 1998) and that midwives and nurses are capable of preventing, detecting and treating PND. Many studies have described midwives and nurses as having a pivotal role in the prevention, education, early recognition and support or treatment of women that suffer from PND (Leonard, 1998; Holden, 1996; Taylor, 1997; Wood et al., 1997; Gutteridge, 2001; Stewart & Henshaw, 2002). Lepper et al. (1994) claim that health workers

become depressed when their wives or partners have PND (Burke, 2003).

**2.4.6 The effects of mother's postnatal mood disorder on other family members**

by Oren et al. (2002). One hour of diffuse white-fluorescent light morning sessions eased symptoms of depression and had no adverse effects (Corral et al., 2000; Oren et al., 2002). *Kangaroo (skin to skin) therapy* was found to be an effective treatment for PND and also a prophylactic measure against PND (Dombrowski et al., 2001). *Physical activity* is said by some authors to have good effects on postnatal depressive symptoms (Powell-Kennedy et al., 2002; Armstrong & Edwards, 2003) because of the effect of raised endorphines. Some researchers advocate that women with PND should exercise regularly as part of their treatment (Sampselle et al., 1999).

*Electro convulsive therapy (ECT)*, a method of passing limited electric shocks through the brain, is believed by some to be a safe treatment option for severe types of depression where there is a danger of suicide (Misri & Kostaras, 2002). However, it is generally reserved for women with persistent PND and women who do not respond to psychotherapy or to pharmacotherapeutics (Dietch & Bunney, 2002; Bott, 1999). The major side effect is memory loss (Welburn, 1980). ECT is performed in the hospital as the severe forms of postnatal mood disorders need hospitalisation.

A combination of treatment methods is said to be the most effective intervention (Boath & Henshaw, 2001). It is not only the immediate initiation of the intervention that is successful, but the intervention also needs to be specifically matched to the individual depressive symptomatology of a mother (Beck C.T., 2002).

#### **<IP_ADDRESS> Place of treatment**

It is stated that in 75% of cases, the treatment of PND could be managed within primary care (Yonkers et al, 2001). When hospital admission is necessary, the mother and the child should not be separated, but the safety of the child must be assured. Where hospital treatment is required, it is preferable that women are treated in out-patient clinics or mother-baby units (Aiken, 2000), which were first suggested by Thomas Main in 1948 (Buist, 1997). The majority of women with severe depression and psychosis need hospitalisation and in such cases these units are useful because the mother and child stay together and can improve their relationship.

For some women, admission to hospital may cause problems (single parents for example), which is why day-clinics (Littlewood & McHugh, 1997) or units for admission of the whole family have begun to be established (Barnett & Morgan, 1996). The mother can care for the child with the support of health workers who provide her with knowledge and raise her self-esteem. Besides that, mothers are observed if there is a risk of infanticide (Cox, 1986). However, the responsibility for the child must be clearly defined (SIGN, 2002) so that the role of the mother is not taken away by the nurses and midwives.

Mother-baby units are said to be more successful in the treatment of PND than primary care as they are specifically designed for this group of women. Shorter duration of hospitalisation, lower relapse rate and enhanced mother's self-confidence were observed in the study by Boath & Henshaw (2001). Available treatment otherwise depends on the nature and capacity of the clinic and the consistent availability of the nurse is of great value (Barnett & Morgan, 1996).

Mother-baby units are a more costly option than primary care, because more staff and space are needed. Every mother needs a nurse to take care of her and her baby in a private room, otherwise the dangers of infection and violence arise. It is absolutely necessary for the staff to have appropriate knowledge of mental health and childcare issues (Barnett & Morgan, 1996).

#### **2.4.6 The effects of mother's postnatal mood disorder on other family members**

PND affects the quality of life of mothers, has negative consequences for the emotional, behavioral, and cognitive functioning of their infants, and threatens the healthy functioning of the entire family (Sobey, 2002). It is therefore vital to assess what thoughts mother has been having and if she is concerned for herself. Family and/or partners may not know how to respond to these feelings and thoughts.The areas of risk that need to be assessed should include:

300 Clinical, Research and Treatment Approaches to Affective Disorders

by Oren et al. (2002). One hour of diffuse white-fluorescent light morning sessions eased symptoms of depression and had no adverse effects (Corral et al., 2000; Oren et al., 2002). *Kangaroo (skin to skin) therapy* was found to be an effective treatment for PND and also a prophylactic measure against PND (Dombrowski et al., 2001). *Physical activity* is said by some authors to have good effects on postnatal depressive symptoms (Powell-Kennedy et al., 2002; Armstrong & Edwards, 2003) because of the effect of raised endorphines. Some researchers advocate that women with PND should exercise regularly as part of their

*Electro convulsive therapy (ECT)*, a method of passing limited electric shocks through the brain, is believed by some to be a safe treatment option for severe types of depression where there is a danger of suicide (Misri & Kostaras, 2002). However, it is generally reserved for women with persistent PND and women who do not respond to psychotherapy or to pharmacotherapeutics (Dietch & Bunney, 2002; Bott, 1999). The major side effect is memory loss (Welburn, 1980). ECT is performed in the hospital as the severe forms of postnatal

A combination of treatment methods is said to be the most effective intervention (Boath & Henshaw, 2001). It is not only the immediate initiation of the intervention that is successful, but the intervention also needs to be specifically matched to the individual depressive

It is stated that in 75% of cases, the treatment of PND could be managed within primary care (Yonkers et al, 2001). When hospital admission is necessary, the mother and the child should not be separated, but the safety of the child must be assured. Where hospital treatment is required, it is preferable that women are treated in out-patient clinics or mother-baby units (Aiken, 2000), which were first suggested by Thomas Main in 1948 (Buist, 1997). The majority of women with severe depression and psychosis need hospitalisation and in such cases these units are useful because the mother and child stay together and can improve

For some women, admission to hospital may cause problems (single parents for example), which is why day-clinics (Littlewood & McHugh, 1997) or units for admission of the whole family have begun to be established (Barnett & Morgan, 1996). The mother can care for the child with the support of health workers who provide her with knowledge and raise her self-esteem. Besides that, mothers are observed if there is a risk of infanticide (Cox, 1986). However, the responsibility for the child must be clearly defined (SIGN, 2002) so that the

Mother-baby units are said to be more successful in the treatment of PND than primary care as they are specifically designed for this group of women. Shorter duration of hospitalisation, lower relapse rate and enhanced mother's self-confidence were observed in the study by Boath & Henshaw (2001). Available treatment otherwise depends on the nature and capacity of the clinic and the consistent availability of the nurse is of great value

Mother-baby units are a more costly option than primary care, because more staff and space are needed. Every mother needs a nurse to take care of her and her baby in a private room,

role of the mother is not taken away by the nurses and midwives.

treatment (Sampselle et al., 1999).

mood disorders need hospitalisation.

**<IP_ADDRESS> Place of treatment**

their relationship.

(Barnett & Morgan, 1996).

symptomatology of a mother (Beck C.T., 2002).

Also Hagen (1999) says mothers with PND commonly have thoughts of harming themselves or their children. He claims these women exhibit fewer positive emotions and more negative emotions towards their children, are less responsive and less sensitive to infant cues, have a less successful maternal role attainment, and have consequently infants, who are less securely attached (Hagen, 1999). Beck C.T. (2002) writes that evidences show that this mood disorder not only has adverse effects on maternal-infant interaction during the first year of age, but may also have long-term effects on children over the age of one year. The mother's ongoing depression can cause harmful effects also for siblings and can contribute to emotional, behavioral, cognitive, and interpersonal problems later in life (Miller, 2002).

PND also has an effect on the couple's relationship. Living with a woman experiencing PND is difficult. Partners need a lot of support too and are known to be at risk of developing depression themselves. They often feel confused, lost and helpless (PaNDa, 2011). They can be the target of their partner's distress and irritability as she attempts to make sense of what is happening to her. There is an increase in marital discord and conflict, and men may become depressed when their wives or partners have PND (Burke, 2003).

#### **2.5 The role of midwives in the prevention, detection and treatment of postnatal mood disorders**

The literature suggests that 75% of cases of PND could be managed in the primary level of health care (Mc Carthy, 1998) and that midwives and nurses are capable of preventing, detecting and treating PND. Many studies have described midwives and nurses as having a pivotal role in the prevention, education, early recognition and support or treatment of women that suffer from PND (Leonard, 1998; Holden, 1996; Taylor, 1997; Wood et al., 1997; Gutteridge, 2001; Stewart & Henshaw, 2002). Lepper et al. (1994) claim that health workers

Mood Disorders in the Puerperium and the Role of the Midwife: Study on Improvement

ANTENATAL PERIOD - Screening about risk factors

ADDITIONAL INTERVENTIONS - EPDS screening in pregnancy

Fig. 1. Protocol of activities and referrals that midwives can perform regarding pre- and post- nataly according to results of EPDS screening (adapted from SIGN, 2002 and

Welburn (1980) has noted that there is often a lack of discussion in antenatal classes about the feelings and emotions of pregnancy and the postnatal period, and this could be improved by the midwives who run these lessons. In particular, midwives could be of great help in fostering effective coping skills for new mothers and facilitating their adjustment to motherhood, according to McQueen & Mander (2003); among others also with practical skills about newborn care that would raise parents' self-confidence. It is therefore very important that competent health professionals conduct antenatal classes (Nolan, 1997; Svensson et al., 2009). It is also useful that antenatal classes continue postpartally as postpartum support groups to offer woman continuous support with concrete problems (Pairman et al., 2006).

Maternal and neonatal morbidity and mortality are often considered very powerful indicators of the quality of intrapartum care. Women's satisfaction with the experience and her feelings are often neglected (Oakley, 1993). Labour is exhausting, painful and potentially a frightening experience for women. A bad birth experience can be directly connected with PND (Welburn, 1980; Webster et al., 2003). As a consequence, midwives are in a position to indirectly prevent PND by offering adequate support, such as emotional support, comfort measures, advocacy, supporting the partner and information or advice (Hodnett, 1996).

POSTNATAL PERIOD Screening (EPDS)\*

\*

**2.5.2 Labour**

Multidisciplinary working group for Grampian, 2001).

of Midwives' Knowledge About Post-Natal Depression After an Educational Intervention 303

**TIME ACTIVITY**

EPDS Results:

referral to support group)

reassessment after 2 weeks)

reassessment with EPDS)

Interventions on the basis of EPDS scores

of risk factors

can play an important role in fostering maternal mental and emotional health in pregnancy and the postnatal period. It is the provision of psychological care where midwives or other primary care providers are said to be of the most assistance (Powell-Kennedy et al., 2002). Trustful relationship is crucial if we want woman to reveal ambivalent or even negative feelings about the pregnancy, her baby and own mental health. Such relationship can be built only through time and therefore the continuity of care is very important. New models of midwifery care that enable continuity and individual care during pregnancy, labour and postpartum are appropriate. With continuous care, PND is early detected and diagnosed, woman is referred to proper professionals and therefore treatment results are better (Marks et al., 2003).

#### **2.5.1 Pregnancy**

Depression in pregnancy is as common as depression in puerperium, therefore a lot of interventions can be used already antenatally (Lee & Chung, 2007; Watson et al., 1984; Dennis & Creedy, 2004; Evans et al., 2001). Researchers have been testing different preventive measures in order to estimate their efficacy. One successful prevention procedure was found to be general social support – wide social netwwork (Elliott, 1989), especially when targeted at women at risk of PND (Zlotnick et al., 2001; Elliott et al., 2002). Eden (1989) found that it was helpful for a woman to have someone to talk to and to have continuity of carer.

Because history of previous depression is an important risk factor for PND, it is important that midwives discuss also mental health issues with pregnant woman (Altschuler et al., 2001; Nonacs & Cohen, 2002) during their antenatal examinations. Therefore it is important for midwives to have knowledge about the risk factors and symptoms of depression and to have protocols and referral systems for depressed woman that enable succesful management, such as Protokol, presented in Figure 1 (SIGN, 2002; Multidisciplinary working group for Grampian, 2001).

As shown in Figure 1 midwives can detect for PND, using interactive conversation or consultations (for example listening visits) (Holden, 1996; Welburn, 1980; Elliot et al., 2007; Jardri et al., 2010). They can also perform routinous detection in third trimester of pregnancy with screening tools like EPDS (Clement, 1995). However midwives need knowledge and skills to perform such therapeutic interventions (Taylor, 1997).

Although some authors claim that discussion about PND in pregnancy might predispose women to PND (Combes & Sconveld, 1992; Bowe & Watson, 2001; Austin, 2003b; Bick, 2003), it could be argued that the first possible action taken in pregnancy should be education about PND, as first time mothers have no experience about how they are likely to feel after the birth (Brockington, 2000; Shu-Shya & Yu-Ying, 2003). Dietch & Bunney (2002, p.144) suggest that: »Health care providers need to be proactive in educating women about their risks for depression, making them aware of symptoms«. Leaflets about the symptoms of PND and the different forms of postnatal mood disorders can be developed and distributed by antenatal health care providers (Brockington, 2000). Beck C.T. (2002) indicates that this can dispel unrealistic myths about motherhood that set women up to label themselves as failures as mothers, since mothers often have unrealistic expectations about labour and life in postnatal period (Renkert & Beam, 2001; Mivšek, 2007; Hillan, 1992).

Fig. 1. Protocol of activities and referrals that midwives can perform regarding pre- and post- nataly according to results of EPDS screening (adapted from SIGN, 2002 and Multidisciplinary working group for Grampian, 2001).

Welburn (1980) has noted that there is often a lack of discussion in antenatal classes about the feelings and emotions of pregnancy and the postnatal period, and this could be improved by the midwives who run these lessons. In particular, midwives could be of great help in fostering effective coping skills for new mothers and facilitating their adjustment to motherhood, according to McQueen & Mander (2003); among others also with practical skills about newborn care that would raise parents' self-confidence. It is therefore very important that competent health professionals conduct antenatal classes (Nolan, 1997; Svensson et al., 2009). It is also useful that antenatal classes continue postpartally as postpartum support groups to offer woman continuous support with concrete problems (Pairman et al., 2006).

#### **2.5.2 Labour**

302 Clinical, Research and Treatment Approaches to Affective Disorders

can play an important role in fostering maternal mental and emotional health in pregnancy and the postnatal period. It is the provision of psychological care where midwives or other primary care providers are said to be of the most assistance (Powell-Kennedy et al., 2002). Trustful relationship is crucial if we want woman to reveal ambivalent or even negative feelings about the pregnancy, her baby and own mental health. Such relationship can be built only through time and therefore the continuity of care is very important. New models of midwifery care that enable continuity and individual care during pregnancy, labour and postpartum are appropriate. With continuous care, PND is early detected and diagnosed, woman is referred to proper professionals and therefore treatment results are better (Marks

Depression in pregnancy is as common as depression in puerperium, therefore a lot of interventions can be used already antenatally (Lee & Chung, 2007; Watson et al., 1984; Dennis & Creedy, 2004; Evans et al., 2001). Researchers have been testing different preventive measures in order to estimate their efficacy. One successful prevention procedure was found to be general social support – wide social netwwork (Elliott, 1989), especially when targeted at women at risk of PND (Zlotnick et al., 2001; Elliott et al., 2002). Eden (1989) found that it was helpful for a woman to have someone to talk to and to have

Because history of previous depression is an important risk factor for PND, it is important that midwives discuss also mental health issues with pregnant woman (Altschuler et al., 2001; Nonacs & Cohen, 2002) during their antenatal examinations. Therefore it is important for midwives to have knowledge about the risk factors and symptoms of depression and to have protocols and referral systems for depressed woman that enable succesful management, such as Protokol, presented in Figure 1 (SIGN, 2002; Multidisciplinary

As shown in Figure 1 midwives can detect for PND, using interactive conversation or consultations (for example listening visits) (Holden, 1996; Welburn, 1980; Elliot et al., 2007; Jardri et al., 2010). They can also perform routinous detection in third trimester of pregnancy with screening tools like EPDS (Clement, 1995). However midwives need knowledge and

Although some authors claim that discussion about PND in pregnancy might predispose women to PND (Combes & Sconveld, 1992; Bowe & Watson, 2001; Austin, 2003b; Bick, 2003), it could be argued that the first possible action taken in pregnancy should be education about PND, as first time mothers have no experience about how they are likely to feel after the birth (Brockington, 2000; Shu-Shya & Yu-Ying, 2003). Dietch & Bunney (2002, p.144) suggest that: »Health care providers need to be proactive in educating women about their risks for depression, making them aware of symptoms«. Leaflets about the symptoms of PND and the different forms of postnatal mood disorders can be developed and distributed by antenatal health care providers (Brockington, 2000). Beck C.T. (2002) indicates that this can dispel unrealistic myths about motherhood that set women up to label themselves as failures as mothers, since mothers often have unrealistic expectations about labour and life in postnatal period (Renkert & Beam, 2001; Mivšek, 2007; Hillan, 1992).

et al., 2003).

**2.5.1 Pregnancy**

continuity of carer.

working group for Grampian, 2001).

skills to perform such therapeutic interventions (Taylor, 1997).

Maternal and neonatal morbidity and mortality are often considered very powerful indicators of the quality of intrapartum care. Women's satisfaction with the experience and her feelings are often neglected (Oakley, 1993). Labour is exhausting, painful and potentially a frightening experience for women. A bad birth experience can be directly connected with PND (Welburn, 1980; Webster et al., 2003). As a consequence, midwives are in a position to indirectly prevent PND by offering adequate support, such as emotional support, comfort measures, advocacy, supporting the partner and information or advice (Hodnett, 1996).

Mood Disorders in the Puerperium and the Role of the Midwife: Study on Improvement

adress women's needs, decrease incidence of PND for 40% (De Craene, 2002).

is quite capable of sapping the carer too (Kuipers & Bebbington, 1997).

about being a mother) (WHO, 1991; Barnett &Morgan, 1996).

of Midwives' Knowledge About Post-Natal Depression After an Educational Intervention 305

available to the woman (Beck C.T. et al., 1992; Thompson et al., 2000). Returning home may be a pleasant but also a frustrating situation, when the mother feels responsible but lacks confidence with a new experience (Nicolson, 1998). Health professionals need to provide support in addition to professional help. This has been stated to be crucial (Nicolson, 1998), however, the term »psychosocial support« is hard to define. For some women this means practical help, while for others it means listening and emotional support (Clement & Elliott, 1999). Women must be given the opportunity to talk freely about their concerns regarding parenting difficulties. Sometimes they just need a sympathetic ear or social support; mobilising friends and the community could help in such cases (Powell-Kennedy, 2002). The attachment with the child can be a reason for anxiety in women, therefore should be presented in a positive and relaxed manner (Welburn, 1980). Midwives should avoid giving conflicting advice as they may cause uncertainty for mothers and lower their self-esteem. They must help women to adapt to a new role (Bott, 1999). If their help is appropriate, they can efficiently cutdown the incidence of PND. Frequent visits during the first two postpartum months that

For all women, preventive screening should be performed by community midwives or nurses at six weeks, four and eight months postnatally. In case of any abnormalities, nurses and midwives could, on the basis of the screening test results, refer a woman to her general practitioner (SIGN, 2002; Holden, 1996). Mothers at risk can be given special support and observation by their caregivers (Holden et al., 1989; Clement, 1995; Brockington, 2000). A number of researchers have found that nurses and midwives can manage non-psychotic depression using counselling (Holden et al., 1989; Prendergast & Austin 2001; Stewart & Henshaw, 2002) and they can play a major role in the treatment of PND (Taylor, 1997). Littlewood & McHugh (1997) identified seven basic principles in the philosophy of care for women with PND: assessment, relief of symptoms, maternal autonomy and self-esteem, individuality, universality, realism/ socialisation and group identity. These can all be incorporated within support groups (also for partners) and peer self-help groups that are facilitated by nurses and midwives. Educating women about PND and giving relevant advice can alleviate the guilt and shame they might be feeling (Powell-Kennedy et al., 2002; Brockington, 2002) and, in a non-judgemental environment, self-esteem may be enhanced. This is also an opportunity to check for signs of PND or identify mothers at risk (Cox, 1986). Health workers can also establish a support phone-line that would connect past sufferers of PND with women who currently have PND (Holden, 1996) or organise support groups for people who live with depressed women, to provide them with support and information (Gutteridge, 2000). It is said that depressive illness is the hardest mental condition for the family supporters, as it

In more serious conditions, where medical treatment is needed, nurses and midwives can help women to make informed choices about their treatment. They can suggest them about available resources and treatment options (Beck C.T., 2002; Wood et al., 1997). And if the hospitalization is needed, women should be hospitalized with a baby (in mother-baby units); midwife can play an important role in fostering the relationship between mother and a child with help, support and possitive feedback (praise can raise mother's self esteem

The ideal approach is inter-disciplinary. Healing can be achieved only with collaborative work (Tully et al., 1998; Powell-Kennedy et al., 2002) and with the help of mental health

Nicolson (1998) has pointed out that it is dangerous when midwives, in their eagerness to deliver a healthy child, forget the mother. During the process of labour the mother is supposed to be an active participant in making decisions. The concepts of choice, control and active participation are closely linked with the satisfaction with the birth (Green & Murray, 1994; Slade et al., 1993; Waldenström et al., 2000; Berg et al., 1996). Factors that affect the feeling of control are: continuity of care, informations about the labouring process and feeling of cooperation (Green & Murray, 1994; Slade et al., 1993; Waldenström et al., 2000; Waldenström, 1999; Berg et al., 1996; Brown & Lumley, 1998; Brown et al., 1994; Martin, 1994). These factors affect also woman-midwife relationship (Berg et al., 1996; Fraser, 1999; Hallsdorsdottir & Karlsdottir, 1996).

However, in some cases the mother may be totally at the mercy of health professionals and therefore she feels vulnerable (Welburn, 1980). Loss of control (over what is happening or over her own body) is related to the concept of choice and is said to be one of the basic triggers for PND (Beck C.T., 1995a; Nicolson, 1998). The loss can provoke unfulfilled expectations about the birth process. A dehumanising process, technology and lack of information during labour can contribute to fear that provokes stress in mothers. Even with lots of support, the maternity ward is still unknown territory, which is why home births are sometimes desired by women (Welburn, 1980). The support of a companion in labour (usually the partner) is a bond with the "known world" that can positively affect the psychosocial state of the woman (Wolman et al., 1994).

#### **2.5.3 Postpartum**

The period immediately after the birth is a time of emotional and physical vulnerability. Women need support (informational, physical, psychological and social) (Raphael-Leff, 1991; Hobfoll et al., 1995; Magill-Cuerden, 2000)). One of the interventions of psychological support presents concept of debriefing, so that every woman is given an opportunity to discuss her labour, which is said to be helpful (Taylor, 1997; Lavender & Walkinshaw, 1998). As its success largely depends on the quality of the relationship that the woman has with the person who provides the debriefing, it would be ideal if the midwife who cared for the woman antenatally continued to provide care after the birth. This would enable the midwife to use listening visits in pregnancy and debriefing at mutually convenient times (Littlewood & McHugh, 1997).

During the first few days, it is important to be sensitive for signs of postpartum blues, since when this condition lasts for a longer period, can develop into PND. With appropriate interventions we can prevent more serious mental conditions can be prevented (Price, 2007). According to Bozoky & Corwin (2002), PND can be prevented also through the treatment of postnatal fatigue, which untreated can lead to a downward spiral of postnatal mental disorders.

Some researchers blame early discharge for the development of PND, as women may not be prepared yet to take over the role of mother (Hickey et al., 1997). Ball (1982) states that the decision regarding the length of hospital stay should be made by the midwife in agreement with the woman. However, this can only be done if the midwife knows the mother from the pregnancy onwards. On the other hand, some studies have found that there is no connection between early discharge and PND if sufficient professional and non-professional support is

Nicolson (1998) has pointed out that it is dangerous when midwives, in their eagerness to deliver a healthy child, forget the mother. During the process of labour the mother is supposed to be an active participant in making decisions. The concepts of choice, control and active participation are closely linked with the satisfaction with the birth (Green & Murray, 1994; Slade et al., 1993; Waldenström et al., 2000; Berg et al., 1996). Factors that affect the feeling of control are: continuity of care, informations about the labouring process and feeling of cooperation (Green & Murray, 1994; Slade et al., 1993; Waldenström et al., 2000; Waldenström, 1999; Berg et al., 1996; Brown & Lumley, 1998; Brown et al., 1994; Martin, 1994). These factors affect also woman-midwife relationship (Berg et al., 1996;

However, in some cases the mother may be totally at the mercy of health professionals and therefore she feels vulnerable (Welburn, 1980). Loss of control (over what is happening or over her own body) is related to the concept of choice and is said to be one of the basic triggers for PND (Beck C.T., 1995a; Nicolson, 1998). The loss can provoke unfulfilled expectations about the birth process. A dehumanising process, technology and lack of information during labour can contribute to fear that provokes stress in mothers. Even with lots of support, the maternity ward is still unknown territory, which is why home births are sometimes desired by women (Welburn, 1980). The support of a companion in labour (usually the partner) is a bond with the "known world" that can positively affect the

The period immediately after the birth is a time of emotional and physical vulnerability. Women need support (informational, physical, psychological and social) (Raphael-Leff, 1991; Hobfoll et al., 1995; Magill-Cuerden, 2000)). One of the interventions of psychological support presents concept of debriefing, so that every woman is given an opportunity to discuss her labour, which is said to be helpful (Taylor, 1997; Lavender & Walkinshaw, 1998). As its success largely depends on the quality of the relationship that the woman has with the person who provides the debriefing, it would be ideal if the midwife who cared for the woman antenatally continued to provide care after the birth. This would enable the midwife to use listening visits in pregnancy and debriefing at mutually convenient times (Littlewood

During the first few days, it is important to be sensitive for signs of postpartum blues, since when this condition lasts for a longer period, can develop into PND. With appropriate interventions we can prevent more serious mental conditions can be prevented (Price, 2007). According to Bozoky & Corwin (2002), PND can be prevented also through the treatment of postnatal fatigue, which untreated can lead to a downward spiral of postnatal mental

Some researchers blame early discharge for the development of PND, as women may not be prepared yet to take over the role of mother (Hickey et al., 1997). Ball (1982) states that the decision regarding the length of hospital stay should be made by the midwife in agreement with the woman. However, this can only be done if the midwife knows the mother from the pregnancy onwards. On the other hand, some studies have found that there is no connection between early discharge and PND if sufficient professional and non-professional support is

Fraser, 1999; Hallsdorsdottir & Karlsdottir, 1996).

psychosocial state of the woman (Wolman et al., 1994).

**2.5.3 Postpartum**

& McHugh, 1997).

disorders.

available to the woman (Beck C.T. et al., 1992; Thompson et al., 2000). Returning home may be a pleasant but also a frustrating situation, when the mother feels responsible but lacks confidence with a new experience (Nicolson, 1998). Health professionals need to provide support in addition to professional help. This has been stated to be crucial (Nicolson, 1998), however, the term »psychosocial support« is hard to define. For some women this means practical help, while for others it means listening and emotional support (Clement & Elliott, 1999). Women must be given the opportunity to talk freely about their concerns regarding parenting difficulties. Sometimes they just need a sympathetic ear or social support; mobilising friends and the community could help in such cases (Powell-Kennedy, 2002). The attachment with the child can be a reason for anxiety in women, therefore should be presented in a positive and relaxed manner (Welburn, 1980). Midwives should avoid giving conflicting advice as they may cause uncertainty for mothers and lower their self-esteem. They must help women to adapt to a new role (Bott, 1999). If their help is appropriate, they can efficiently cutdown the incidence of PND. Frequent visits during the first two postpartum months that adress women's needs, decrease incidence of PND for 40% (De Craene, 2002).

For all women, preventive screening should be performed by community midwives or nurses at six weeks, four and eight months postnatally. In case of any abnormalities, nurses and midwives could, on the basis of the screening test results, refer a woman to her general practitioner (SIGN, 2002; Holden, 1996). Mothers at risk can be given special support and observation by their caregivers (Holden et al., 1989; Clement, 1995; Brockington, 2000). A number of researchers have found that nurses and midwives can manage non-psychotic depression using counselling (Holden et al., 1989; Prendergast & Austin 2001; Stewart & Henshaw, 2002) and they can play a major role in the treatment of PND (Taylor, 1997). Littlewood & McHugh (1997) identified seven basic principles in the philosophy of care for women with PND: assessment, relief of symptoms, maternal autonomy and self-esteem, individuality, universality, realism/ socialisation and group identity. These can all be incorporated within support groups (also for partners) and peer self-help groups that are facilitated by nurses and midwives. Educating women about PND and giving relevant advice can alleviate the guilt and shame they might be feeling (Powell-Kennedy et al., 2002; Brockington, 2002) and, in a non-judgemental environment, self-esteem may be enhanced. This is also an opportunity to check for signs of PND or identify mothers at risk (Cox, 1986). Health workers can also establish a support phone-line that would connect past sufferers of PND with women who currently have PND (Holden, 1996) or organise support groups for people who live with depressed women, to provide them with support and information (Gutteridge, 2000). It is said that depressive illness is the hardest mental condition for the family supporters, as it is quite capable of sapping the carer too (Kuipers & Bebbington, 1997).

In more serious conditions, where medical treatment is needed, nurses and midwives can help women to make informed choices about their treatment. They can suggest them about available resources and treatment options (Beck C.T., 2002; Wood et al., 1997). And if the hospitalization is needed, women should be hospitalized with a baby (in mother-baby units); midwife can play an important role in fostering the relationship between mother and a child with help, support and possitive feedback (praise can raise mother's self esteem about being a mother) (WHO, 1991; Barnett &Morgan, 1996).

The ideal approach is inter-disciplinary. Healing can be achieved only with collaborative work (Tully et al., 1998; Powell-Kennedy et al., 2002) and with the help of mental health

Mood Disorders in the Puerperium and the Role of the Midwife: Study on Improvement

Mivšek et al., 2008) and from concepts identified in the professional literature.

irrelevant when completing the questionnaire (Skočir & Hundley, 2006).

**3.2 Research tool**

**3.3 Reliability and validity**

Skočir & Hundley, 2006).

**3.5 Data collection**

**3.6 Ethical considerations**

(61).

**3.4 Sampling and study setting**

deadline was extended fort two more weeks.

participate in the study and that their participation is anonimous.

of Midwives' Knowledge About Post-Natal Depression After an Educational Intervention 307

The questionnaire used was the same as in the study in 2003 (Skočir, 2004; Skočir & Hundley, 2006), developed on the basis of previously conducted focus groups (Skočir, 2004;

It covered four key topics: employment data, knowledge about PND, experiences and opinions about PND and demographic data. Most of the questions were closed with a variety of possible answers. Some questions included a category »other« to allow participants to add alternative responses. The section of the questionnaire that dealt with opinions and experiences used more subjective approaches and gave participants the opportunity to justify their choices with open questions. A 5-point Likert-type scale was used to assess participants' opinion of their role in the management of women with PND. In the last part of the questionnaire personal data were gathered and the participants were given an opportunity to add any information or explain things that they found unclear or

For the purpose of better reliability and validity of the study it is reccommended to use questionnaires which were tested already in previous surveys. Therefore the questionnaire from the 2003 study was used. Face and content validity of the questionnaire were assessed through review by colleagues, academic supervisors and experts in the fiel das suggested in the literature (Polit et al., 2001). The pilot study further assessed validity and asked participants whether they understood the questionnaire or had any queries; on the basis of pilot study some modifications were made (Skočir, 2004;

Five generations of midwifery students (150) attended the new midwifery study programme from 2004 in which curriculum of Midwifery was implemented with the lectures about postnatal mood disorders. Study sample was composed of those who already graduated

Questionnaires were distributed via mail in May 2011. The stamped envelope was included to the letter to raise response rate. Paricipant were asked to return the questionnaire within two weeks. After this time, written reminder was sent to all the participants and the

Participants'conntact details were obtained from the Faculty's register. Considering data protection act (Državni zbor RS, 1999), declaration was signed to use the data only for the purpose of the study and to assure participants of the study confidentiality. It was made clear to participants in the cover letter of the questionnaire that they could refuse to

professionals (Taylor, 1997). However one key element in this process is continuity of the caregiver, which can break the process of depersonalised care (Clement & Eliott, 1999). Such care needs to be flexible and individually planned for each woman (MacArthur et al., 2002).

Despite very firm arguments that midwives can manage mild prenatal and postnatal mood disorders, different studies (Eden, 1989; Stewart & Henshaw, 2002; Mivšek & Hundley, 2006; Keng, 2005; Ross-Davie et al., 2006; Sullivan et al., 2003; Isik & Bilgili, 2010) show that midwives are not prepared for this role.

#### **3. Methodology**

The question was, whether midwives are adequately prepared to take over the role of prevention and treatment of postnatal mood disorders and whether they feel prepared and willing to take over the responsibility for the care of these women.

Two stage study approach was therefore adopted. Results from 2003 study, which explored knowledge and opinions about PND of slovenian midwives and nurses who worked in the maternity hospital or in the community with pregnant, labouring or postnatal women (Skočir, 2004; Skočir & Hundley, 2006; Mivšek et al., 2008) showed very clearly that they lack knowledge about postnatal mental health issues and therefore do not feel competent to take over more active role in the management of postnatal mental health disorders. 134 nurses and midwives participated in the study (76,6% response rate). Only 24% of participants knew when PND usually bursts out and only 35% correctly estimated the incidence of PND. They often confused symptoms of postnatal blues or psychosys with PND and rarely knew about screening tests for PND (21%). Most of them knew only for medical options for the treatment of PND and were expressing low confidence in their ability to prevent, detect or manage postnatal mood disorders. 99% of them expressed the need for additional training in this field of care. One of main reccommendations of the study was that it is crucial to provide health workers who work with women in reproductive age with more information about mental health issues relevant for this population (Skočir, 2004; Skočir & Hundley, 2006; Mivšek et al., 2008).

#### **3.1 Research design**

On the basis of the recommendations from the study in 2003 (Skočir, 2004; Skočir & Hundley, 2006; Mivšek et al., 2008), the undergraduate study programme for midwives was implemented in 2004 with the lectures about postnatal mood disorders. The topic was included in the content of the subject Midwifery (in the third year of the study). Aim of the study was to explore whether educational intervention raised midwives' knowledge and affected their abilities in the management of postnatal mood disorders. The hypothesis tested in the study was that midwives, who finished the implemented midwifery study programme, with additional lectures in postnatal mental health issues, show greater knowledge about postnatal mood disorders, know to differentiate among different forms of postnatal mood disorders and express higher ability for management of those conditions. As the goal of this research was to explore and describe perceptions and experiences, a qualitative approach was adopted as suggested in the literature (Rezabek, 2000); questionnaire survey was used to gather the data.

#### **3.2 Research tool**

306 Clinical, Research and Treatment Approaches to Affective Disorders

professionals (Taylor, 1997). However one key element in this process is continuity of the caregiver, which can break the process of depersonalised care (Clement & Eliott, 1999). Such care needs to be flexible and individually planned for each woman (MacArthur et

Despite very firm arguments that midwives can manage mild prenatal and postnatal mood disorders, different studies (Eden, 1989; Stewart & Henshaw, 2002; Mivšek & Hundley, 2006; Keng, 2005; Ross-Davie et al., 2006; Sullivan et al., 2003; Isik & Bilgili, 2010) show that

The question was, whether midwives are adequately prepared to take over the role of prevention and treatment of postnatal mood disorders and whether they feel prepared and

Two stage study approach was therefore adopted. Results from 2003 study, which explored knowledge and opinions about PND of slovenian midwives and nurses who worked in the maternity hospital or in the community with pregnant, labouring or postnatal women (Skočir, 2004; Skočir & Hundley, 2006; Mivšek et al., 2008) showed very clearly that they lack knowledge about postnatal mental health issues and therefore do not feel competent to take over more active role in the management of postnatal mental health disorders. 134 nurses and midwives participated in the study (76,6% response rate). Only 24% of participants knew when PND usually bursts out and only 35% correctly estimated the incidence of PND. They often confused symptoms of postnatal blues or psychosys with PND and rarely knew about screening tests for PND (21%). Most of them knew only for medical options for the treatment of PND and were expressing low confidence in their ability to prevent, detect or manage postnatal mood disorders. 99% of them expressed the need for additional training in this field of care. One of main reccommendations of the study was that it is crucial to provide health workers who work with women in reproductive age with more information about mental health issues relevant for this population (Skočir, 2004; Skočir & Hundley,

On the basis of the recommendations from the study in 2003 (Skočir, 2004; Skočir & Hundley, 2006; Mivšek et al., 2008), the undergraduate study programme for midwives was implemented in 2004 with the lectures about postnatal mood disorders. The topic was included in the content of the subject Midwifery (in the third year of the study). Aim of the study was to explore whether educational intervention raised midwives' knowledge and affected their abilities in the management of postnatal mood disorders. The hypothesis tested in the study was that midwives, who finished the implemented midwifery study programme, with additional lectures in postnatal mental health issues, show greater knowledge about postnatal mood disorders, know to differentiate among different forms of postnatal mood disorders and express higher ability for management of those conditions. As the goal of this research was to explore and describe perceptions and experiences, a qualitative approach was adopted as suggested in the literature (Rezabek, 2000);

willing to take over the responsibility for the care of these women.

al., 2002).

**3. Methodology**

2006; Mivšek et al., 2008).

questionnaire survey was used to gather the data.

**3.1 Research design**

midwives are not prepared for this role.

The questionnaire used was the same as in the study in 2003 (Skočir, 2004; Skočir & Hundley, 2006), developed on the basis of previously conducted focus groups (Skočir, 2004; Mivšek et al., 2008) and from concepts identified in the professional literature.

It covered four key topics: employment data, knowledge about PND, experiences and opinions about PND and demographic data. Most of the questions were closed with a variety of possible answers. Some questions included a category »other« to allow participants to add alternative responses. The section of the questionnaire that dealt with opinions and experiences used more subjective approaches and gave participants the opportunity to justify their choices with open questions. A 5-point Likert-type scale was used to assess participants' opinion of their role in the management of women with PND. In the last part of the questionnaire personal data were gathered and the participants were given an opportunity to add any information or explain things that they found unclear or irrelevant when completing the questionnaire (Skočir & Hundley, 2006).

#### **3.3 Reliability and validity**

For the purpose of better reliability and validity of the study it is reccommended to use questionnaires which were tested already in previous surveys. Therefore the questionnaire from the 2003 study was used. Face and content validity of the questionnaire were assessed through review by colleagues, academic supervisors and experts in the fiel das suggested in the literature (Polit et al., 2001). The pilot study further assessed validity and asked participants whether they understood the questionnaire or had any queries; on the basis of pilot study some modifications were made (Skočir, 2004; Skočir & Hundley, 2006).

#### **3.4 Sampling and study setting**

Five generations of midwifery students (150) attended the new midwifery study programme from 2004 in which curriculum of Midwifery was implemented with the lectures about postnatal mood disorders. Study sample was composed of those who already graduated (61).

#### **3.5 Data collection**

Questionnaires were distributed via mail in May 2011. The stamped envelope was included to the letter to raise response rate. Paricipant were asked to return the questionnaire within two weeks. After this time, written reminder was sent to all the participants and the deadline was extended fort two more weeks.

#### **3.6 Ethical considerations**

Participants'conntact details were obtained from the Faculty's register. Considering data protection act (Državni zbor RS, 1999), declaration was signed to use the data only for the purpose of the study and to assure participants of the study confidentiality. It was made clear to participants in the cover letter of the questionnaire that they could refuse to participate in the study and that their participation is anonimous.

 Comparison of the answers about the facts on PND between the 2003 and 2011 group

participants in 2003 group (25%). Even if the difference is not statistically significant it might be that with the educational intervention they become more sensitive for women's mental

They were also mora active in the management of those cases. The only action that participants in 2003 group mentioned was that they talked with women with PND and gave advice, however participants from 2011 group also notified woman's general practitioner,

**yes, often no I don't**

of participants. Expected answers are in blue fields.

talked with woman's partner and referred woman to the therapists.

**3-6 days and lasts for a year**

**in the first year and lasts few months**

**know** Total

Total

#### **3.7 Analysis**

The data were collated and entered into the SPSS database. Answers to the open-ended questions were grouped in the same cathegories as the data from the 2003 study. Descriptive statistics were produced for all variables. Data were compared with the results from the study performed in 2003 (midwives with higher education only) (Skočir, 2004) and statistical tests for significant differences were calculated.

#### **4. Results and discussion**

The study included 9 participants (29%) in the 2003 group and 22 participants (79%) in the 2011 group; alltogether 31 participants (100%). They were all female, aged from 20 to 29 years with 1 to 5 years of working experience. They all had higher education; finished undergraduate midwifery study. Participants in 2011 study all undergone implemented programme which included 5 hour of lectures about postnatal mood disorders.

There were evident differences in the answers to the questions of both groups. The participants in 2011 group more often gave the expected answer to the question about the onset of PND; there was significant statistical difference between groups in this answer (2Î = 11,064, df = 3, sig.= 0,011), however there were no improvements in estimation of the incidence of PND and they also underestimated the possibility of prenatal depression (Figure 2).

There were no significant differences in citing and ranking symptoms of PND. Both groups most often exposed weepiness as the main problem (100% of participants in 2003 group and 97% of respondents in 2011 group). The next most commonly quoted symptom was insomnia (93%) in 2011 group and hallucinations (100%) in 2003 group. The third most common symptom, as perceived by the participants, was tiredness (83%) in 2011 group and guilt (100%) in 2003 group. It can be said that there was a slight improvement in differentiating PND and puerperal psychosys in the 2011 group of participants, not exposing hallucinations as the main symptom of PND.

Obvious differences were found in testing the statements about detection of PND, as shown in Figure 3. Answers about the PND screening tests showed statistically significant differences between groups (2Î = 20,728, df = 4, sig.= 0,000). Participants in 2011 group were more aware of screening possibilities for PND.

They were also more aware of existing support groups where they can refer woman who suffers from PND. Almost half of the participants in 2011 group knew support groups, while none of the participants in 2003 group knew any. The difference in the answers to this question was statistically significant (2Î =7,970, df = 1, sig.= 0,005).

As the first line treatment, participants in 2003 group cited counselling (50%), as the second option they quoted medicaments (25%) and psychotherapy (25%). In the 2011 group, participants choose psychotherapy (50%) or counselling (25%) as the first line treatment, than support groups (20%) and medicaments (4%).

Many participants already had experiences in caring for women with diagnosed PND or for women they suspected suffering PND. Despite similar length of work in both groups, participants in 2011 group reported more women with PND they cared for (35,7%) than

The data were collated and entered into the SPSS database. Answers to the open-ended questions were grouped in the same cathegories as the data from the 2003 study. Descriptive statistics were produced for all variables. Data were compared with the results from the study performed in 2003 (midwives with higher education only) (Skočir, 2004) and statistical

The study included 9 participants (29%) in the 2003 group and 22 participants (79%) in the 2011 group; alltogether 31 participants (100%). They were all female, aged from 20 to 29 years with 1 to 5 years of working experience. They all had higher education; finished undergraduate midwifery study. Participants in 2011 study all undergone implemented

There were evident differences in the answers to the questions of both groups. The participants in 2011 group more often gave the expected answer to the question about the onset of PND; there was significant statistical difference between groups in this answer (2Î = 11,064, df = 3, sig.= 0,011), however there were no improvements in estimation of the incidence of PND and they also underestimated the possibility of prenatal depression

There were no significant differences in citing and ranking symptoms of PND. Both groups most often exposed weepiness as the main problem (100% of participants in 2003 group and 97% of respondents in 2011 group). The next most commonly quoted symptom was insomnia (93%) in 2011 group and hallucinations (100%) in 2003 group. The third most common symptom, as perceived by the participants, was tiredness (83%) in 2011 group and guilt (100%) in 2003 group. It can be said that there was a slight improvement in differentiating PND and puerperal psychosys in the 2011 group of participants, not

Obvious differences were found in testing the statements about detection of PND, as shown in Figure 3. Answers about the PND screening tests showed statistically significant differences between groups (2Î = 20,728, df = 4, sig.= 0,000). Participants in 2011 group were

They were also more aware of existing support groups where they can refer woman who suffers from PND. Almost half of the participants in 2011 group knew support groups, while none of the participants in 2003 group knew any. The difference in the answers to this

As the first line treatment, participants in 2003 group cited counselling (50%), as the second option they quoted medicaments (25%) and psychotherapy (25%). In the 2011 group, participants choose psychotherapy (50%) or counselling (25%) as the first line treatment,

Many participants already had experiences in caring for women with diagnosed PND or for women they suspected suffering PND. Despite similar length of work in both groups, participants in 2011 group reported more women with PND they cared for (35,7%) than

programme which included 5 hour of lectures about postnatal mood disorders.

**3.7 Analysis**

(Figure 2).

tests for significant differences were calculated.

exposing hallucinations as the main symptom of PND.

question was statistically significant (2Î =7,970, df = 1, sig.= 0,005).

more aware of screening possibilities for PND.

than support groups (20%) and medicaments (4%).

**4. Results and discussion**

Fig. 2. Comparison of the answers about the facts on PND between the 2003 and 2011 group of participants. Expected answers are in blue fields.

participants in 2003 group (25%). Even if the difference is not statistically significant it might be that with the educational intervention they become more sensitive for women's mental health issues.

They were also mora active in the management of those cases. The only action that participants in 2003 group mentioned was that they talked with women with PND and gave advice, however participants from 2011 group also notified woman's general practitioner, talked with woman's partner and referred woman to the therapists.

Mood Disorders in the Puerperium and the Role of the Midwife: Study on Improvement

of Midwives' Knowledge About Post-Natal Depression After an Educational Intervention 311

Perception of more active involvement in the management of mental health issues changed also their perception of the best place for treatment of woman with PND. More participants in 2011 group think that women should be treated at primary level of health care and stay at home with the family (66%) than in 2003 group (56%). However if they would need hospitalization due to severerity of illness, the participants in 2011 group prefer an option of woman to be accepted in psychiatry unit located in the maternity hospital (31%) over the hospitalization in psychiatric hospital that 2003 group of participants chose most often (25%); the answers showed statistically significant differences (2Î =5,513, df = 1, sig.= 0,019). Participants in 2011 also more frequently disagreed with the need of separation from the baby (83% vs 78% in 2003 group) as they felt that baby belongs with mother and that a childcare could be beneficial for woman (58% in comparison with 18% in 2003 group).

Participants felt more prepared to manage postnatal mental health issues after the educational intervention, as shown in Figure 4, however the difference in answers was not

> **SELF-CONFIDENCE FOR ACIVE ROLE IN ADDRESSING POSTNATAL HEALTH ISSUES**

> > **might could help**

f 11 8 3 22 f (%) 50,0 36,4 13,6 100,0

f 8 1 0 9 f (%) 88,9 11,1 ,0 100,0

f 19 9 3 31 f (%) 61,3 29,0 9,7 100,0

Fig. 4. Comparison of the answers about confidence in managing postnatal mental health

Despite raised awareness about their role in the management of postnatal mental health and greater subtlety for women's mental needs, there was not so much improvement in participants' knowledge as we expected and also they alone expressed desire for additional information and training. Unexpectedly participants in 2011 more often quoted the need for theoretical knowledge (57%) than participants in 2003 group (25%). It is possible that the educational intervention made them more critical about their knowing. They also wished opportunities for practical skills on counselling and leading postnatal support groups (40% of participants in 2011 group). This might indicate that only theoretical intervention does not provide enough knowledge for midwives to be more confident. Counselling skills

Approach to management of perinatal mental health issues is affected by the perception of cause. Doctors usually consider postnatal mood disorders pathological and treat them with

problems between the 2003 and 2011 group of participants.

should be also provided as a practical component of additional training.

**not confident, so I**

Total

**very confident, I could help the woman**

significant.

2011

2003

Total

**5. Conclusion**

Fig. 3. Comparison of the answers about the screening on PND between the 2003 and 2011 group of participants. Expected answers are in blue fields.

Participants in 2003 group consider partner as the most appropriate person for detection of PND (75%) and psyciatrists or psychologists as the most important for the treatment (100%), while 2011 participants comprehend the responsibility for detection and treatment of PND more as a team work; their answers are very dispersed. They consider community nurses and midwives (31%), partner (24%), nurses and midwives in maternity hospital (10%) and psyhologists (10%) as the most appropriate people for detection of PND. As for the treatment, they quote psychologists and psyhiatrists (66%) as the most appropriate, followed by community midwives and nurses and family (8%). However the reasons for such choice are the same in both groups. The most important person for detection is chosen because of the regular contact with women and the most appropriate person for treatment is chosen on the basis of the professional knowledge about PND.

According to this, participants in 2011 group feel more responsible to take care for women's mental health in antenatal (education in antenatal classes), intrapartum (support during birth, debriefing) and postpartum period (detection, referrals, consultations). There were statistically significant differences between the groups particularly in the awareness of their role in support during labour (t= -2,778, df = 7,135, sig.= 0,027), their role in detection of PND (t= -2,953, df = 9,511, sig.= 0,015) and their role in discussing PND with woman in antenatal classes (2Î =11,476, df = 1, sig.= 0,001).

Perception of more active involvement in the management of mental health issues changed also their perception of the best place for treatment of woman with PND. More participants in 2011 group think that women should be treated at primary level of health care and stay at home with the family (66%) than in 2003 group (56%). However if they would need hospitalization due to severerity of illness, the participants in 2011 group prefer an option of woman to be accepted in psychiatry unit located in the maternity hospital (31%) over the hospitalization in psychiatric hospital that 2003 group of participants chose most often (25%); the answers showed statistically significant differences (2Î =5,513, df = 1, sig.= 0,019). Participants in 2011 also more frequently disagreed with the need of separation from the baby (83% vs 78% in 2003 group) as they felt that baby belongs with mother and that a childcare could be beneficial for woman (58% in comparison with 18% in 2003 group).

Participants felt more prepared to manage postnatal mental health issues after the educational intervention, as shown in Figure 4, however the difference in answers was not significant.

Fig. 4. Comparison of the answers about confidence in managing postnatal mental health problems between the 2003 and 2011 group of participants.

Despite raised awareness about their role in the management of postnatal mental health and greater subtlety for women's mental needs, there was not so much improvement in participants' knowledge as we expected and also they alone expressed desire for additional information and training. Unexpectedly participants in 2011 more often quoted the need for theoretical knowledge (57%) than participants in 2003 group (25%). It is possible that the educational intervention made them more critical about their knowing. They also wished opportunities for practical skills on counselling and leading postnatal support groups (40% of participants in 2011 group). This might indicate that only theoretical intervention does not provide enough knowledge for midwives to be more confident. Counselling skills should be also provided as a practical component of additional training.

#### **5.  Comparison of the answers about the screening on PND between the 2003 and 2011

Participants in 2003 group consider partner as the most appropriate person for detection of PND (75%) and psyciatrists or psychologists as the most important for the treatment (100%), while 2011 participants comprehend the responsibility for detection and treatment of PND more as a team work; their answers are very dispersed. They consider community nurses and midwives (31%), partner (24%), nurses and midwives in maternity hospital (10%) and psyhologists (10%) as the most appropriate people for detection of PND. As for the treatment, they quote psychologists and psyhiatrists (66%) as the most appropriate, followed by community midwives and nurses and family (8%). However the reasons for such choice are the same in both groups. The most important person for detection is chosen because of the regular contact with women and the most appropriate person for treatment is

According to this, participants in 2011 group feel more responsible to take care for women's mental health in antenatal (education in antenatal classes), intrapartum (support during birth, debriefing) and postpartum period (detection, referrals, consultations). There were statistically significant differences between the groups particularly in the awareness of their role in support during labour (t= -2,778, df = 7,135, sig.= 0,027), their role in detection of PND (t= -2,953, df = 9,511, sig.= 0,015) and their role in discussing PND with woman in

**PND SCREENING TESTS THAT YOU KNOW**

**know any Beck C.T.'s EPDS csale**

**yes, it makes diagnosys**

**I don't**

**any**

**applicable**

group of participants. Expected answers are in blue fields.

chosen on the basis of the professional knowledge about PND.

antenatal classes (2Î =11,476, df = 1, sig.= 0,001).

2011

2003

Total

2011

2003

Total

**not**

Total **there isn't**

**I don't know**

**euro5** Total

**yes, but it doesn't make diagnosys**

> Approach to management of perinatal mental health issues is affected by the perception of cause. Doctors usually consider postnatal mood disorders pathological and treat them with

Mood Disorders in the Puerperium and the Role of the Midwife: Study on Improvement

*International journal of mental health nursing,* 12(2), pp. 130-8.

systematic review", *Acta Psychiatr Scand,* 107(1), pp. 10-7.

*MIDIRS Midwifery digest*, 61,pp. 18-9.

study, *Nurs Res*, 41(3), pp.166-70.

depression, *JOGNN,* 27(1), pp.39-45.

implications, MCN, 27(5), pp.282-7.

testing, *Nurs Res,* 49(5), pp.272-82.

screening scale, *Nurs Res,* 50(3), pp.155-64.

depression, *JOGNN,* 21(4), pp.287-93.

*Nurs Res,* 42(1), pp.42-8.

24(9), pp.819-25.

45(5), pp.297-303.

company.

12.

McGraw Hill.

DC: Task Force.

APA.

of Midwives' Knowledge About Post-Natal Depression After an Educational Intervention 313

[5] Altschuler, L., Cohen, L., Moline, L., Kahn, D., Carpenter, D., Docherty, J. (2001). *The*

[6] APA (1994) *Diagnostic and statistical manual of mental disorders IV* 4th ed. Washington:

[7] APA. (2000). *Diagnostic and statistical manual of mental disorders IV* 4th TR. Washington,

[8] Appleby, L., Gregoire, A., Platz, C., Prince, M. and Kumar, R. (1994) "Screening women for high risk of postnatal depression", *Journal of psychosomatic research,* 38(6), pp. 539-45. [9] Armstrong, K. and Edwards, H. (2003) "The effect of exercise and social support on

[10] Austin, M. P. and Lumley, J. (2003) "Antenatal screening for postnatal depression: a

[13] Barnett, B., Morgan, M. (1996). Postpartum psychiatric disorders – who should be admitted and to which hospital? *Aust N Z J Psychiatry*, 30(6),pp. 709-14. [14] Beck C.T., A. T., Ward, C. H., Mendelson, M., Mock, J. and Erbaugh, J. (1961). An inventory for measuring depression, *Arch gen psychiatry,* 4, pp.561-71. [15] Beck C.T. (1992) The lived experience of postpartum depression: a phenomenological

[16] Beck C.T.(1993). Teetering on the edge: a substantive theory of postpartum depression,

[17] Beck C.T. (1995a) Screening methods for postpartum depression, *JOGNN*, 24(4), pp.308-

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[19] Beck C.T. (1996). A meta-analysis of predictors of postpartum depression, *Nurs Res,*

[20] Beck C.T. (1998). A check list to identify women at risk for developing postpartum

[21] Beck C.T. (2002) Theoretical perspectives of postpartum depression and their treatment

[22] Beck C.T., Gable, R. K. (2000). Postpartum depression screening scale: development and

[23] Beck C.T., Gable, R. K. (2001). Further validation of the postpartum depression

[24] Beck C.T., Reynolds, M. A. and Rutowsky, P. (1992). Maternity blues and postpartum

[25] Benner-Carson, V. (2000) *Mental health nursing* 2nd ed. Philadelphia: W.B. Saunders

[26] Berg, M., Lundgren, I., Hermansson, E., Wahlberg, V. (1996). Women's Experience of The encounter with the Midwife during Childbirth. *Midwifery*, 12, pp.11-15. [27] Bick, D. (2003). Strategies to reduce postnatal psychological morbidity: the role of

midwifery services*. Dis manage health outcomes*, 11(1), pp.11-20.

[11] Ball, J. (1982) "Stress and the postnatal care of women", *Nursing times,* 78(45), 1904-7. [12] Barnes, S.L. (2002). What midwives need to know about postpartum depression.

*expert consensus guideline series: Treatment of depression in women*. New York:

mothers reporting depressive symptoms: a pilot randomised controlled trial",

medicines (Beck C.T., 2002b), while midwives, according to their philosophy about physiology of pregnancy, birth and the puerperium, might consider mild postnatal mood disorders normal response to the changes that occur in the puerperium and the demands of transition to parenthood. This argument support also the facts from the literature review; depression in postpartum is not more commom than in other periods of woman's life (CRAG, 1996), aetiology is unknown and varies individually, risk factors are therefore inconsistent (Robertson et al., 2004; Skočir, 2004; Wylie et al., 2011) and symptoms similar to normal changes of the puerperium (Yonkers et al., 2001). Some experts even claim that depression in the transition to motherhood is necessity – a kind o »recognition of imperfection« (Raphael-Leff, 1991) and »healthy rersponse to all the loss of the puerperium« (Stewart & Henshaw, 2002). It could be stated that PND as such does not exists and is a product of medicalization of another part of woman's reproductive mental health (as Pre-Menstrual Syndrome - [PMS]). Life changes that demand alteration of lifestyle, social roles and relationships can be stressful for the individuals (Stowe & Nemeroff, 1995). Postpartum period is demanding because of all the situations that need adaptations (Albers & Williams, 2002). And the feelings of loss, anxiety and depression might be considered a normal response to these changes. However it is not clear at which point mother's physical exhaustion and sadness due to adaptation to parenthood convert into pathology. The most certain assumtion is that the causes and the development of postnatal mood disorders are very complex and individual. Therefore it is very important that there is certain continuity of carer who accompanies woman and her family through pregnancy, birth and postpartum and establish a relationship with the family that can be helpful in addressing also mental health issues.

Few interventions to reduce psychological morbidity of postnatal women have been successful, but obvious individualized continuous midwifery care (for example new models of midwifery-led care) have benefits on mothers' postnatal psychological well-being (MacArthur et al., 2002; Yaffe, 2002). This should be considered in development of policies for antenatal and postnatal care provision (Bick, 2003). Midwives, responsible for this role, however need educational interventions (Wheatley et al., 2003; Barnes, 2002) that include theoretical informations and practical counselling skills. Results of the study show similar results as others (Jardri et al., 2010); midwives benefit from educational interventions (Jardri et al., 2010). They perform their role more successfully and feel more confident.

#### **6. References**

medicines (Beck C.T., 2002b), while midwives, according to their philosophy about physiology of pregnancy, birth and the puerperium, might consider mild postnatal mood disorders normal response to the changes that occur in the puerperium and the demands of transition to parenthood. This argument support also the facts from the literature review; depression in postpartum is not more commom than in other periods of woman's life (CRAG, 1996), aetiology is unknown and varies individually, risk factors are therefore inconsistent (Robertson et al., 2004; Skočir, 2004; Wylie et al., 2011) and symptoms similar to normal changes of the puerperium (Yonkers et al., 2001). Some experts even claim that depression in the transition to motherhood is necessity – a kind o »recognition of imperfection« (Raphael-Leff, 1991) and »healthy rersponse to all the loss of the puerperium« (Stewart & Henshaw, 2002). It could be stated that PND as such does not exists and is a product of medicalization of another part of woman's reproductive mental health (as Pre-Menstrual Syndrome - [PMS]). Life changes that demand alteration of lifestyle, social roles and relationships can be stressful for the individuals (Stowe & Nemeroff, 1995). Postpartum period is demanding because of all the situations that need adaptations (Albers & Williams, 2002). And the feelings of loss, anxiety and depression might be considered a normal response to these changes. However it is not clear at which point mother's physical exhaustion and sadness due to adaptation to parenthood convert into pathology. The most certain assumtion is that the causes and the development of postnatal mood disorders are very complex and individual. Therefore it is very important that there is certain continuity of carer who accompanies woman and her family through pregnancy, birth and postpartum and establish a relationship with the family that can be helpful in addressing also mental

Few interventions to reduce psychological morbidity of postnatal women have been successful, but obvious individualized continuous midwifery care (for example new models of midwifery-led care) have benefits on mothers' postnatal psychological well-being (MacArthur et al., 2002; Yaffe, 2002). This should be considered in development of policies for antenatal and postnatal care provision (Bick, 2003). Midwives, responsible for this role, however need educational interventions (Wheatley et al., 2003; Barnes, 2002) that include theoretical informations and practical counselling skills. Results of the study show similar results as others (Jardri et al., 2010); midwives benefit from educational interventions (Jardri

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