Chronic depression is one of the most significant risk factors for the development of antepartum and postpartum depression (Schaffir, 2018). Pregnant women without chronic depression or depressive symptoms are primarily receiving depression screening during the first trimester and then 6 weeks postpartum (Redshaw & Henderson, 2013). These two time points yield an approximate 10-month gap between screenings. In addition, antepartum and postpartum depression education is lacking within the prenatal period (Redshaw & Henderson, 2013). Antepartum (prenatal) depression is depression occurring during pregnancy, and it relates to poor self-care, reduced motivation to ask for help, and a negative outlook on the benefits of obstetrical care (Schaffir, 2018). Women with antepartum depression may have concerns about their parenting skills, a difficult time interacting with others, and may feel withdrawn (Schaffir, 2018).
The American College of Obstetricians and Gynecologists (2018) recommends that pregnant women be screened at least once during the antepartum phase of pregnancy by their health care provider. Research has proven that diagnosing antepartum depression can be difficult if women are only screened once throughout pregnancy and that multiple evaluations during pregnancy can show differences in the rates of diagnosis of depression and anxiety (Biaggi et al., 2016).
Women without continued antepartum depression intervention had antepartum depression remain the same over the second and third trimester (Wilusz et al., 2014). With interpersonal psychotherapy, antepartum depression and depressive symptoms decreased (Bledsoe et al., 2018; Field et al., 2013). This therapy focused on education of depressive symptoms and their correlation with postpartum depression (Bledsoe et al., 2018; Field et al., 2013). Antepartum depression is a significant risk factor for postpartum depression (Redshaw & Henderson, 2013).
Postpartum depression is depression occurring within a few weeks to months after pregnancy (Abdollahi et al., 2016). Postpartum depression is one of the most prevalent emotional issues during a woman's lifespan and affects up to approximately 82% of new mothers (Abdollahi et al., 2016). Undiagnosed and untreated postpartum depression can lead to postpartum psychosis, including maternal suicide and infanticide (Spinelli, 2019). Infanticide is child murder in the first 1 year of life (Spinelli, 2019).
Maternal Risk Factors
Maternal risk factors also play a significant role in development of antepartum depression. Risk factors of antepartum depression include: multi-parity, non-White race (Jacoby et al., 2015; Kim & Dee, 2018), physical or mental health problems, residing in a medically underserved area, low socioeconomic status, unplanned pregnancy (McCarter-Spaulding & Shea, 2016; Redshaw & Henderson, 2013;), obesity (Jacoby et al., 2015), and adolescence (Torres et al., 2017).
Women of non-White race or adolescents also had a degree of decreased health literacy and a need for specialized education on antepartum and post-partum depression. The highest prevalence of decreased health literacy was among African American and Hispanic women (Pao et al., 2019). Health literacy is the ability to comprehend medical language and concepts, either through auditory means or visually (Jansen et al., 2018). People with less education tend to have lower health literacy, although those with more education can also have low health literacy (Jansen et al., 2018). Most women at risk for having low health literacy were also affected by health disparity (Braveman, 2014).
Health disparity is a health difference that has a basis in social, economic, and environmental factors (Braveman, 2014). Health disparities adversely affect the health of people who have encountered obstacles related to social status, economic status, gender, age, mental health, and religion (Braveman, 2014). The highest occurrence of health disparity was among American Indian, Native Alaskan, Hispanic, and African American women (Agency for Healthcare Research and Quality [AHRQ], 2011).
Antepartum Maternal Depression Screening and Education
The Edinburgh Postpartum Depression Scale (EPDS) is the most common antepartum and postpartum depression screening tool used by health care providers (Alhasanat et al., 2017; Bascom & Napolitano, 2016; Farr et al., 2014; Fritz, 2015). The EPDS has been deemed valid, reliable, and feasible (Goyal et al., 2015; Jesse et al., 2015; Stringer et al., 2016).
The EPDS is a 10-item Likert scale questionnaire that evaluates emotional experiences over the previous 7 days (Shrestha et al., 2016). A total score ≥13 is considered an indicator of possible depressive symptoms (Shrestha et al., 2016). Participants' level of understanding of the terminology of each question, the stigma of depression, and individuals' fear of admitting they have depression may influence total score (Shrestha et al., 2016). The EPDS is given to pregnant women within the first trimester, though antepartum depression usually develops later in pregnancy (Wilusz et al., 2014).
The fact that many women present with depression or anxiety at several time points during pregnancy suggests that only one screening during pregnancy is not enough to adequately identify antepartum depression (Marchesi et al., 2009). Antepartum depression has a high probability of becoming postpartum depression, which might have significant implications for early discovery during pregnancy (Koutra et al., 2014). These circumstances make antepartum depression one of the most under-recognized and under-treated conditions (Marcus, 2009).
Some studies have suggested that pairing education with the depression screening process may be beneficial (Mukherjee et al., 2017; Wilusz et al., 2014). Screening for antepartum stressful life events can help identify women at risk for postpartum depression symptoms (Mukherjee et al., 2017). Combining the two interventions may also make the process more efficient, and hopefully sustainable. Pregnant women state that they will receive referrals for mental health assessments, in which they do not always follow through (Sword et al., 2008).
Teaching plans should focus on the importance of coordinated care that is flexible for the pregnant woman to ensure unified and quality care (Sword et al., 2008). Strategies of implementation focus on the connection between primary care and mental health services (Sword et al., 2008). These strategies may enhance the likelihood that pregnant women seek mental health care, receive an assessment, and obtain appropriate treatment (Sword et al., 2008).
The desired goal of antepartum depression education involves the inclusion of pregnant women within the edification process, decision making, and to empower them to ask questions (Guo et al., 2018; Náfrádi et al., 2018). Patient-centered obstetric care involves the woman in every aspect of decision making regarding her treatment (Guo et al., 2018). Education is needed for the pregnant woman to make an informed decision (Guo et al., 2018). Health care providers should also consider the pregnant woman's health literacy during teaching lessons (Guo et al., 2018).
Acknowledging Health Literacy During the Edification Process
When planning teaching sessions, it is imperative for health care providers to speak at the health literacy level of the pregnant woman (Náfrádi et al., 2018). Health literacy is the degree to which an individual can comprehend necessary health information and make informed health decisions (Náfrádi et al., 2018). Health literacy involves a variety of skills that improve one's health by enhancing their ability to make healthier lifestyle choices (AHRQ, 2011). These skills include communication, interaction with others, writing, reading, and critical analysis (AHRQ, 2011; Buchbinder et al., 2011). Nurses frequently overestimate a pregnant woman's health literacy level by mainly relying on a pregnant woman's educational level to measure her health literacy (Parnell, 2014).
Postpartum depression affects the entire family, so it is imperative to provide care with a holistic approach, including all family members (Habel et al., 2015). The Health Belief Model suggests that interventions of individuals with depression should also target friends and family, and provide information on help regarding the treatment process (Castonguay et al., 2016). Not only did women desire more health care provider support (Feeley et al., 2016), significant others did as well (Karraa, 2013). Significant others play critical roles within a mother's decision making about how she will manage her symptoms of depression (Henshaw et al., 2015; Wojnar & Katzenmeyer, 2014). In addition, the more the significant other accepts the postpartum depression treatment, the more the mother may accept receiving treatment (Henshaw et al., 2016).
Barriers to Antepartum Maternal Depression Screening and Education
Concerning discussion of depression, most women report that prenatal care providers discussed depression with them at hospital birth and not antepartum (Farr et al., 2014). Health care providers stated that the main barriers to screening and educating pregnant women are proper maternal depression education training, literacy levels, stigma, privacy of screening and location, and referrals to follow-up resources (Tabb et al., 2015). Training for health care providers should focus on signs and symptoms of postpartum depression and the importance of timely mental health care follow up for pregnant women (Goyal et al., 2015; Ko et al., 2017).
Although there are barriers, constant observation and actions to encourage proper screening, referral, and treatment are needed to decrease post-partum depressive symptoms among U.S. women (Ko et al., 2017). Goyal et al. (2015) concluded that postpartum depression education should be initiated at the first prenatal appointment, then continued throughout pregnancy and combined with well-baby visits throughout the first postpartum year.
Implications for Practice
Given the rising prevalence of maternal depression during pregnancy, the current review is relevant to medicine and nursing practice. Findings may lead to standardization of maternal depression screening and education in each trimester during the antepartum phase of pregnancy. Physicians and nurse practitioners play a pivotal role in the assessment and treatment of pregnant women. Prompt maternal depression screening and diagnosis are needed to initiate appropriate treatment. Overall, training of physicians and nurse practitioners on prompt diagnosis and treatment of maternal depression may decrease the incidence of maternal depression, psychosis, and infanticide.
Discussing the importance of maternal education during each prenatal visit is key to the self-identification of symptoms. Pregnant women need appropriate education to be able to self-identify signs of depression. Even with standard screening each trimester, pregnant women need to able to identify the symptoms of maternal depression to receive prompt screening, diagnosis, and treatment.
Sharing this information with women of childbearing age, pregnant, or not pregnant, will enhance the knowledge of maternal depression, as well as the understanding that chronic depression and anxiety are common antecedents of maternal depression. Enhanced self-identification of symptoms may also increase additional depression screenings in between the set standardized screenings, leading to prompt treatment of maternal depression throughout pregnancy and postpartum.
Pregnant women are receiving antepartum depression screening primarily in the first trimester (Redshaw & Henderson, 2013). Antepartum depression may occur throughout pregnancy and can be difficult to diagnose if women are only screened once throughout pregnancy (Biaggi et al., 2016; Redshaw & Henderson, 2013). Antepartum depression has a high probability of becoming postpartum depression, which might have significant implications for early discovery during pregnancy (Koutra et al., 2014).
Maternal depression education for pregnant women is lacking within the prenatal period, which may attribute to lack of health care provider education training, literacy barriers, stigma, privacy of screening and location, and referrals to follow-up resources (Redshaw & Henderson, 2013; Tabb et al., 2015). The self-identification of depressive symptoms may lead to pregnant women receiving additional maternal depression screening, thus leading to prompt diagnosis and treatment.
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