Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Caring for Women With Postpartum Depression in Saudi Arabia: Nurses' and Midwives' Opinions About Their Roles

Zyad T. Saleh, PhD, MSc, RN; Rami A. Elshatarat, PhD, MSc, RN; Inas A. Ebeid, PhD, MSc, RN; Mohammed S. Aljohani, PhD, MSc, RN; Majed S. Al-Za'areer, MSc, RN; Abdullah D. Alhujaili, MSc, RN; Naif S. Al Tarawneh, PhD, MSc, RN; Ahmad H. Abu Raddaha, PhD, MSc, RN

Abstract

The current cross-sectional study was conducted to investigate nurses' and midwives' opinions about their roles in caring for women with postpartum depression (PPD) in Saudi Arabia. Convenience sampling was used to recruit 181 nurses and 141 midwives. A self-administered questionnaire was used to collect data. Participants lacked experience assessing and managing PPD and providing health education and counseling to mothers about PPD. Moreover, participants underestimated the importance of their roles in preventing PPD risk factors, and detecting, assessing, and managing PPD. Findings show significant differences between nurses' and midwives' opinions, with more frequency of agreement among nurses than midwives regarding their roles in caring for women with PPD. Continuing health education programs for nurses and midwives are recommended to improve knowledge, skills, and awareness of their roles in assessing and managing PPD. [Journal of Psychosocial Nursing and Mental Health Services, 58(7), 42–51.]

Abstract

The current cross-sectional study was conducted to investigate nurses' and midwives' opinions about their roles in caring for women with postpartum depression (PPD) in Saudi Arabia. Convenience sampling was used to recruit 181 nurses and 141 midwives. A self-administered questionnaire was used to collect data. Participants lacked experience assessing and managing PPD and providing health education and counseling to mothers about PPD. Moreover, participants underestimated the importance of their roles in preventing PPD risk factors, and detecting, assessing, and managing PPD. Findings show significant differences between nurses' and midwives' opinions, with more frequency of agreement among nurses than midwives regarding their roles in caring for women with PPD. Continuing health education programs for nurses and midwives are recommended to improve knowledge, skills, and awareness of their roles in assessing and managing PPD. [Journal of Psychosocial Nursing and Mental Health Services, 58(7), 42–51.]

Postpartum depression (PPD) is one of the most common psychological problems affecting women after delivery. PPD affects between 10% and 20% of women globally (O'Hara & Wisner, 2014). In fact, this prevalence is underestimated because many women do not seek professional help (Hansotte et al., 2017; O'Hara & Wisner, 2014). Moreover, many PPD cases remain undiagnosed and untreated (Alhusen & Alvarez, 2016). For example, approximately two thirds of major depressive episodes among pregnant women in America went undiagnosed from 2005 to 2009 (Ko et al., 2012).

Unfortunately, there are no published national statistics for PPD in the Kingdom of Saudi Arabia (KSA). Previous studies have shown the prevalence of PPD is between 17.8% (Alasoom & Koura, 2014) and 33.2% (Alharbi & Abdulghani, 2014), which is higher than the global prevalence. Furthermore, actual prevalence of PPD in the KSA may outweigh reported prevalence because many women in the KSA feel discomfort with psychiatric health care settings and sharing psychological symptoms with non-family members (Alamoudi et al., 2017). This social stigma regarding mental illness also extends to many other developed countries, such as Australia (Thorsteinsson et al., 2018). Thus, social stigma may worsen women's health status and lead to the development of additional health complications (Thorsteinsson et al., 2018).

Early identification and recognition of depression symptoms during pregnancy and after delivery are important approaches for prevention and management of PPD (Langan & Goodbred, 2016). Nurses and midwives can play a key role in early identification of risk factors, and screening, assessing, and managing PPD (Registered Nurses' Association of Ontario [RNAO], 2018). However, several studies conducted in different countries show that nurses and midwives have insufficient knowledge, experience, and competency in screening, assessing, and managing PPD. Nurses and midwives also underestimate the importance of their roles and responsibilities regarding assessment and management of PPD. This ambivalence indicates that nurses and midwives may become unable to fulfill their roles and responsibilities in assessing and managing PPD (Jones et al., 2011; Skocir & Hundley, 2006).

There is a lack of published resources discussing the history and background of specialized nursing and midwifery programs in the KSA, as well as the differences in education, job description, and responsibilities for nurses and midwives who manage mental illness during pregnancy and the postpartum period. In the KSA, nurses and midwives have important roles in providing direct care for women in different health care settings. In the KSA and several Arab countries, midwifery is an important health discipline with significant responsibilities in improving health care for women, particularly during the third trimester of pregnancy, labor, and early stages of the postpartum period (Al-Dossary, 2018; Aldossary et al., 2008). Although there are many students who graduate from Saudi midwifery programs and foreign midwives who work in perinatal health care settings, including hospitals and primary health care (PHC) centers, there is a shortage of midwives in the KSA. Consequently, nurses in the KSA help midwives provide perinatal and neonatal care. However, most of those nurses are not qualified and are not well trained in caring for women during the perinatal period. In addition, the majority of foreign midwives and nurses are not familiar with the KSA's culture and needs, and do not understand the Arabic language, which increases the challenges of improving maternal health care. Therefore, the vision of the Saudi Ministry of Education (2030) is to develop postgraduate programs for nurses in the KSA (Al-Dossary, 2018; Alamoudi et al., 2017). Recently, several universities have established master's programs in midwifery, maternity, and mental health nursing, with the hope that graduates will contribute to improving quality of care and reducing costs of maternity health services for women, neonates, and families throughout the KSA (Al-Dossary, 2018).

The literature has shown that clinical guidelines have been developed in many countries. For example, the Canadian practice guideline contains valuable recommendations for nurses, midwives, and other health professionals to enhance their knowledge and awareness of recent strategies in screening, assessing, and managing PPD. This guideline also describes the effectiveness of nurses', midwives' and other professionals' roles in providing health education and counseling, cognitive-behavioral therapy, and interpersonal psychotherapy to reduce the risk factors of PPD and improve the outcomes of PPD treatment (RNAO, 2018). To enhance nurses' and midwives' ability and readiness to perform their roles, curricula of nursing and midwifery programs should cover cultural aspects and social behaviors toward management of PPD, symptoms and complications of PPD, screening instruments, and description of nurses' and midwives' roles in assessing and managing PPD and referring women with PPD to mental health services (Elshatarat et al., 2018; RNAO, 2018).

To the current researchers' knowledge, there are no structured tools that have been used to screen for PPD, and there is no clinical guideline to assess and manage PPD in most of the KSA's health care settings. Moreover, there are no job descriptions or policies that regulate the role of nurses and midwives in assessing and managing PPD. Thus, the results of the current study may help nursing administrators develop job descriptions, standards, and policies to regulate nurses' and midwives' roles in assessing and managing PPD.

Study Significance and Objectives

To the current researchers' knowledge, there are no published peer reviewed studies conducted in the KSA or other countries investigating the roles of nurses and midwives in assessing and managing PPD. The current study aims to identify the following: (a) participants' experience in caring for women with PPD; (b) participants' exposure to health education and their plans to participate in continuing health education about PPD; (c) participants' opinions about the assessment and management of PPD; and (d) the difference between nurses' and midwives' opinions about the assessment and management of PPD.

Method

Design

A descriptive, cross-sectional study was performed to investigate nurses' and midwives' opinions about their roles and experience in assessing and managing PPD in the KSA.

Sample and Setting

A convenience sampling method was used to recruit participants from governmental and private hospitals, and from different PHC centers in Madinah City, northwest KSA. Inclusion criteria were certified female nurses and midwives who: (a) had an Associate's degree or higher; (b) had an active license from the Saudi Commission for Health Specialties; (c) held full-time work positions in the selected perinatal health care settings; and (d) were able to read, write, and understand English.

G-POWER version 3 was used to determine minimum sample size for chi-square analysis by using a medium effect size of 0.3, alpha of 0.05, and power of 80% (Cohen et al., 2013). Based on this power analysis, the calculated sample size was 293. To minimize the risk of type 1 error, a sample of 312 participants (181 nurses and 141 midwives) was recruited.

Ethical Issues and Data Collection Procedure

Formal approvals to conduct the current study were obtained from the Ethical Committee for Health Research at Al-Ghad International Colleges for Applied Medical Sciences, the Director of the Medical Research Ethics Committee in the Government of Health in northwest KSA, and the medical and nursing directors at selected hospitals and PHC centers.

Written informed consent forms were signed by all participants. Consent forms and explanation sheets about the study's purpose, inclusion and exclusion criteria, and additional information about the study were attached to the distributed questionnaire. Participants were informed that participation in the study was voluntary and their personal information would remain confidential and anonymous.

To collect data, a coauthor (I.E.) interviewed participants in a private room at the selected settings, explained the purpose of the study, and answered any questions about the study. Data were collected using a structured self-report questionnaire. Participants were asked to return the completed questionnaire to the coauthor or drop it in the mail box at the head nurse's office at each of the selected settings.

Instruments

The study questionnaire was adopted from a previous Slovenian study (Skocir & Hundley, 2006). This questionnaire includes six items related to participants' demographic, employment, and health data; two items related to participants' experience in caring for women with PPD; and four items about who they think the most appropriate person is to detect and treat PPD, the preferred place to treat women with PPD, and the separation of newborn babies from their mothers with PPD. To identify nurses' and midwives' opinions regarding their roles in caring for women with PPD, eight items were used to assess participants' agreement regarding their roles in screening for PPD, providing education and counseling about PPD, and referring women with PPD to professional help. Participants' responses were expressed by strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree (Skocir & Hundley, 2006). The validity and reliability of the adopted questionnaire is documented in a previous study (Skocir & Hundley, 2006).

In addition to the previous instrument, two items were adopted from a previous American study (Segre et al., 2010) to identify participants' willingness to participate in continuing education and on screening, assessment, and management of PPD.

Pilot Study

Two senior mental health researchers were asked to review the questionnaire to assess its validity and suitability to address the aims and objectives of the current study. A pilot study was then conducted to assess the reliability and clarity of the questionnaire. A total of 15 nurses and 10 midwives were recruited from the study's selected settings. Participants reported that the instrument was clear and easy to understand. Moreover, internal reliability analysis was between 87.9 and 92.1 for all subscales in the study. Participants in the pilot study were excluded from the main data analysis of the current study.

Data Analysis

SPSS version 21 was used to analyze collected data. Chi-square analyses were used to identify significant differences of the proportions between nurses' and midwives' opinions regarding their roles in caring for women with PPD. Participant responses were re-coded to not agree (0) and agree (1) for each item of the subscale. Not agree (0) includes neither agree nor disagree, disagree, and strongly disagree, and agree (1) includes strongly agree and agree. The significant p value was pre-set as < 0.05.

Results

Most participants were nurses, married, non-Saudi, and working in a PHC center. Nurses' and midwives' mean ages were 31.3 (SD = 12.7) and 26.4 (SD = 8.9), respectively. Mean professional experience for nurses (5.6 [SD = 5.1] years) was higher than midwives (2.6 [SD = 0.83] years) (Table 1).

Demographic Characteristics of Participants (N = 324)

Table 1:

Demographic Characteristics of Participants (N = 324)

Approximately 86.1% of nurses (n = 156) and 87.4% of midwives (n = 125) had experience in caring for women with PPD or who were suspected to have PPD. Among them, 71.8% of nurses and 68% of midwives provided routine care for those women (Table 2).

Participants' Experience Managing Postpartum Depression (PPD) (N = 324)

Table 2:

Participants' Experience Managing Postpartum Depression (PPD) (N = 324)

Table 3 shows that more than one half of participants had exposure to professional education about PPD. Only 20.4% of nurses and 16.1% of midwives had exposure to continuing education about PPD management within the previous 12 months. Approximately two thirds of participants answered strongly agree or agree to willingness in participating in continuing education about the assessment, screening, and management of PPD.

Participants' Exposure to Health Education and Future Plans to Participate in Continuing Health Education about Postpartum Depression (PPD) (N = 324)

Table 3:

Participants' Exposure to Health Education and Future Plans to Participate in Continuing Health Education about Postpartum Depression (PPD) (N = 324)

Nurses (mean = 5.62 [SD = 2.3]) and midwives (mean = 5.5 [SD = 2.9]) believed that partners are the most appropriate persons to detect PPD symptoms. Most nurses (80.4%) and midwives (86.0%) reported that direct personal contact was the reason for this response. Nurses (mean = 6.1 [SD = 2.3]) and midwives (mean = 5.7 [SD = 2.2]) said that psychologists and psychiatrists are the most appropriate persons to manage and treat PPD. Participants said that qualification and professionalism are the rationale for their choice. Nurses (48.6%) and midwives (40.6%) said that the most appropriate setting for PPD treatment is at home, with the help of a partner, family, friends, and community nurses. Approximately one half of nurses (48.6%) and one third of midwives (36.4%) disagreed with separating mother and child, with supportive people and environment being the most frequent reasoning against separation. On the other hand, 23.2% of nurses and 35.7% of midwives believed that the mother and child should be separated “if the mother endangers her child.” Approximately 14% of participants said that women were aware of the possibility of PPD occurring after childbirth. One third of participants said that women could recognize PPD symptoms. Only one fifth of participants said that women know where to seek help for PPD treatment (Table 4).

Participants' Opinions about Managing Postpartum Depression (PPD) According to the Study Questionnaire (N = 324)Participants' Opinions about Managing Postpartum Depression (PPD) According to the Study Questionnaire (N = 324)

Table 4:

Participants' Opinions about Managing Postpartum Depression (PPD) According to the Study Questionnaire (N = 324)

There are significant differences between nurses' and midwives' opinions regarding their roles in providing education for women about PPD (χ2 = 12.1, p = 0.01), assessing and screening for PPD (χ2 = 38.2, p < 0.001), managing support groups (χ2 = 9.4, p = 0.003), and providing psychotherapeutic counseling (χ2 = 23.1, p < 0.001). Nurses were more in agreement than midwives in these activities as major roles and responsibilities to prevent PPD risk factors and management of PPD. Providing psychosocial support during labor was more frequently cited by midwives (74.1%) than nurses (44.9%) as one of their roles in caring for women during the perinatal period and as a method for preventing PPD (χ2 = 5.0, p = 0.027) (Table 5).

Relationship Between Nurses' and Midwives' Opinions about Prevention of Postpartum Depression (PPD) Risk Factors and Management of PPD

Table 5:

Relationship Between Nurses' and Midwives' Opinions about Prevention of Postpartum Depression (PPD) Risk Factors and Management of PPD

Discussion

PPD is on the rise in the KSA, which is possibly related to lack of awareness about PPD and of professionals' knowledge and competence in assessing and managing PPD (Alharbi & Abdulghani, 2014; Elshatarat et al., 2018). Women, particularly new mothers, require a special kind of psychosocial support, exposure to health education, and counseling about mental illness with more attention on recognizing PPD symptoms, alternative treatment options, and how to seek health care services and counseling (Langan & Goodbred, 2016; Stuart-Parrigon & Stuart, 2014). Furthermore, nurses and midwives who have direct contact and take care of women in the perinatal period should have enough knowledge, self-confidence, and skill to perform their roles.

Nurses and midwives in the current study, and previous studies, said that caring for women with PPD or suspected PPD is limited to regular care, such as measuring vital signs, routine care after childbirth, and providing health education and counseling for new mothers about PPD (Iþýk & Bilgili, 2010; Jones et al., 2012; Kang et al., 2019). Lack of knowledge and experience in assessing and managing PPD and how to provide health education for women about PPD may be the reasons why most nurses and midwives reported low readiness to take a major role in managing PPD (Jones et al., 2012; Kang et al., 2019).

Lack of knowledge and low self-confidence were reported for the same sample (i.e., nurses and midwives) in Elshatarat et al. (2018) and previous studies (Jones et al., 2012; Skocir & Hundley, 2006). These factors may explain the interest of nurses and midwives in participating in future educational and training programs about assessing, screening, and managing PPD. Therefore, conducting health education programs is important to improve nurses' and midwives' knowledge about screening for PPD symptoms and how to educate women about PPD, develop a plan for detecting PPD, and seek health care services.

In the current study, participants believed that a woman's husband and/or family members are the most appropriate persons to detect early symptoms of PPD. Participants said that the closest people to a new mother are her husband and family, and that they have direct contact with the mother during the prenatal and postnatal periods. Thus, women's husbands and close family members can identify mood changes in women with PPD; however, the literature has shown that women and their family members have difficulty recognizing the psychiatric manifestations of PPD. Because PPD symptoms overlap with other feelings of discomfort (e.g., fatigue, difficulty sleeping, lack of energy and concentration, mood disturbances), women and their family members may think these manifestations are normal after childbirth (Alhusen & Alvarez, 2016; Norhayati et al., 2015). To increase the likelihood of early detection of PPD symptoms, nurses and midwives should focus on providing health education to new mothers and their family members about characteristics of PPD and clinical manifestations, and how to detect symptoms of PPD. This education is required as part of continuing health education for perinatal nurses and midwives to improve their knowledge, self-confidence, and skills to perform these teaching responsibilities (Alhusen & Alvarez, 2016; Coates & Foureur, 2019).

Participants in the current study believed that psychologists or psychiatrists are the most appropriate persons to detect and treat PPD. These results are similar to the previous Slovenian study (Skocir & Hundley, 2006); however, findings in the current study and previous studies (Coates & Foureur, 2019; Kang et al., 2019) revealed that nurses and midwives underestimated their roles in detecting and managing PPD. For example, in the current study, nurses' and midwives' perception that they have responsibility in detecting and managing PPD ranged between 3.6 and 4.5 (of 7). The literature has documented that nurses and midwives are the closest professionals to mothers during the perinatal period and thus, can be the first to identify PPD symptoms (Langan & Goodbred, 2016; Segre et al., 2010). In addition, nurses and midwives can have effective roles in caring for mothers with PPD and providing teaching and counseling for women about management of PPD (Coates & Foureur, 2019; Langan & Goodbred, 2016; Logsdon et al., 2010). However, the literature has confirmed that lack of knowledge about PPD may result in diminished self-confidence and competency to detect, assess, and manage PPD (Coates & Foureur, 2019; RNAO, 2018). Consequently, nurses and midwives perceived that they are not ready and are unable to fulfill their roles in screening, assessing, and managing PPD (Coates & Foureur, 2019; Kang et al., 2019; RNAO, 2018). Therefore, further education about PPD for all perinatal nurses and midwives is important.

In Arabic societies, most new mothers with symptoms of depression after childbirth do not seek health care services or consult medical or psychiatric specialists. In addition, the Saudi population, as well as other Arab people, still believe that mental illness is related to violence, magic, effects of the evil eye, and evil spirits (Alamoudi et al., 2017; Alharbi & Abdulghani, 2014; Eloul et al., 2009). Thus, the social stigma of being depressed or labeled a “sad woman,” as well as beliefs about the cause of mental illness, may result in undiagnosed and untreated PPD. In addition, these factors are considered major challenges for nurses and midwives when they provide health education about PPD and refer women with PPD to psychiatrists (Kang et al., 2019; RNAO, 2018). Therefore, nurses and midwives should provide health education to women during the prenatal and postnatal periods about etiological factors of PPD, treatment of PPD, serious complication of untreated PPD, and how to seek professional help to manage PPD. Nurses and midwives also have to remind women that mental illness is nothing to be ashamed of, and that sharing feelings with health professionals is the first step toward feeling better and is considered a sign of strength and an effective method of treating PPD and preventing serious complications (Dunkel Schetter & Tanner, 2012; Patel et al., 2012).

The literature has indicated that PPD can be treated at home with the help of family members, counseling, cognitive therapy, and psychosocial support (Alhusen & Alvarez, 2016; RNAO, 2018). Less than one half of participants in the current study and approximately two thirds of participants in the previous Slovenian study (Skocir & Hundley, 2006) believed that women with PPD should be treated at home with the help of their partner, family members, and community nurses. Approximately 40% of participants in the current study and most participants in the previous Slovenian study were against the separation of mothers with PPD and their children (Skocir & Hundley, 2006). Approximately one quarter of participants in the current study and the previous Slovenian study (Skocir & Hundley, 2006) struggled with the decision about the separation of mothers with PPD and their children. To the current researchers' knowledge, there are no clinical guidelines or criteria to help professionals make decisions regarding the separation of mothers and their newborn children. This lack of direction may explain why nurses and midwives in the current study do not know best practice regarding this issue. A previous study by Pope and Mazmanian (2016) recommended keeping newborn babies with their mothers if there is no contraindication. In addition, the study showed the positive effects of breast feeding in improving the mother's maternal health and reducing the severity of PPD, especially in the presence of psychosocial support (Pope & Mazmanian, 2016). On the other hand, other studies have shown negative effects of PPD on mother–baby relationship and attachment. Furthermore, PPD may lead mothers to neglect caring for their children. This problem can be exacerbated when the mother has severe PPD, and she becomes a danger to her baby. For example, in some cases, mothers may physically harm, abuse, or kill their children (Arora et al., 2017; Porter & Gavin, 2010). Further research is needed to examine the effects of separation on the health status of mothers and children. Moreover, developing clinical guidelines is important for helping health professionals decide what is best practice regarding the separation of new babies and mothers with PPD.

The literature has shown that approximately one quarter of mothers who are diagnosed with PPD had depression symptoms during the prenatal period (O'Hara & Wisner, 2014). Early screening of PPD during the prenatal period and within 1 month after delivery positively impacted early recovery from PPD symptoms and enhanced the effectiveness of mental health interventions (American Psychological Association [APA], 2013; O'Hara & Wisner, 2014). Early identification of risk factors and detection of PPD symptoms are important and should be of high priority for health care providers for preventing and controlling PPD (APA, 2013). Mothers' follow-up visits at obstetricians and gynecologists after childbirth, babies' follow-up visits at pediatric and family health care clinics, and routine immunization visits are the best opportunities for health care providers to screen for PPD. These visits also allow nurses and midwives opportunities for early identification of PPD risk factors, detection of PPD symptoms, education about PPD, and referral of mothers with PPD to appropriate mental health care specialists (Alhusen & Alvarez, 2016; Kang et al., 2019).

Results of the current study show that approximately one half of participants said they strongly agree or agree with their role in assessing, screening, and managing PPD, and referring women to mental health care specialists. The results also show significant differences between nurses' and midwives' opinions, with more frequency in agreement among nurses than mid-wives regarding their roles in assessing, detecting, and managing PPD. These results were expected due to the curricula of nursing programs in the KSA and many other Arab countries, which focus on assessment, treatment, and psychotherapeutic counseling for individuals with depressive symptoms more than midwifery programs. Midwifery programs in the KSA and many other Arab countries focus on assisting obstetricians in assessing women's vital signs and health status, providing psychosocial support, and providing routine care for women during labor and the early stages after childbirth. Furthermore, despite the development of undergraduate nursing and midwifery programs during the previous 2 decades in the KSA, the content of these programs does not focus on the mental and psychological health of women in the perinatal period. This discrepancy is verified by the results of the current study, with approximately 55% of participants having had professional education about PPD.

Implications

Unfortunately, nursing and midwifery programs in the KSA and other countries may not provide detailed information about PPD, which may result in nurses and midwives being unfamiliar with the assessment and management of PPD. Undergraduate curricula should be reviewed and developed by experts in mental and maternity health care to enhance content and improve nursing and midwifery students' ability to assess and manage PPD.

The literature has recommended that all health care professionals, particularly perinatal nurses and midwives who work with new mothers, be trained on screening for PPD and educating women and their families about PPD risk factors, symptoms, treatment, and how to seek professional help. In addition, it is an important strategy to provide widespread education and training programs for professionals in the KSA, including hospitals and outpatient clinics that provide health care for women with PPD, about the assessment and management of PPD (APA, 2013; RNAO, 2018).

Adopting updated clinical guidelines that discuss the assessment and management of PPD is important. Moreover, issuing written job description booklets to regulate nurses' and midwives' roles and activities in assessing and managing PPD is recommended (RNAO, 2018).

Further experimental studies are needed to investigate the effects of health educational programs to improve nurses' and midwives' knowledge, skills, and readiness in assessing and managing PPD. Conducting qualitative studies would also be helpful to understand health care professionals' perceptions about the management of PPD. Moreover, qualitative studies are required to fully understand the perspectives of mothers with PPD and the preferred methods of control and management.

Limitations

There are limitations to the current study. The descriptive, cross-sectional design limits causality between variables. Using a convenience sampling method and conducting the study in one area of the KSA also limits the generalizability of the findings to nurses and midwives in other regions of the KSA.

Conclusion

The current study was conducted to investigate nurses' and midwives' opinions about their roles in assessing and managing PPD. The results of this study and many previous studies indicate that nurses and midwives lack experience and readiness in assessing and managing PPD and providing health education and counseling for women about PPD. Moreover, nurses and midwives underestimated the importance of their roles in preventing PPD risk factors, and detecting, assessing, and managing PPD. Improving health education programs, further developing the curricula of nursing and midwifery programs, and establishing postgraduate programs related to mental and maternal health are recommended strategies to prevent PPD risk factors and manage PPD among women in the KSA.

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Demographic Characteristics of Participants (N = 324)

Characteristicn (%)
Nurses (n = 181)Midwives (n = 143)
Education level
  Associate's degree59 (32.6)90 (62.9)
  Bachelor's degree109 (60.2)53 (37.1)
  Postgraduate degree13 (7.2)
Marital status
  Married96 (53)62 (43.4)
  Other85 (46)81 (56.6)
Nationality
  Saudi64 (35.4)40 (28)
  Other117 (64.6)103 (72)
Current employment
  Working in a PHC center123 (68)70 (49)
  Working in a hospital58 (32)73 (51)
Mean (SD) (Range)
Age (years)31.3 (12.7) (20 to 49)26.4 (8.9) (20 to 49)
Professional experience (years)5.6 (5.1) (1 to 32)2.6 (0.83) (1 to 32)

Participants' Experience Managing Postpartum Depression (PPD) (N = 324)

Variablen (%)
Nurses (n = 181)Midwives (n = 143)
Experience managing PPD
  Cared for a woman with PPD58 (32)41 (28.7 )
  Cared for a woman suspected to have PPD98 (54.1)84 (58.7 )
  No experience managing PPD25 (13.9)18 (12.6)
Actions of participants with experience managing PPD(n = 156)(n = 125)
  Provided routine care112 (71.8)85 (68)
  Assessed PPD symptoms41 (26.3)24 (19.2)
  Talked about the help they could offer78 (50)55 (44)
  Referred care recipient to a physician/obstetrician95 (60.9)64 (51.2)
  Referred care recipient to a psychologist/psychiatrist37 (23.7)49 (39.2)
  Notified care recipient's physician/obstetrician85 (54.5)67 (53.6)
  Talked to care recipient's partner71 (45.5)58 (46.4)
  Provided health education51 (32.7)47 (37.6)
  Provided counseling48 (30.8)42 (33.6)

Participants' Exposure to Health Education and Future Plans to Participate in Continuing Health Education about Postpartum Depression (PPD) (N = 324)

Variablen (%)
Nurses (n = 181)Midwives (n = 143)
Participants' exposure to health education about PPD
  Had exposure to professional education (in college or university) about PPD101 (55.8)79 (55.2)
  Had exposure to continuing education about PPD management in previous 12 months37 (20.4)23 (16.1)
Willing to participate in continuing education about detection and assessment of PPD
  Strongly agree25 (13.8)8 (5.6)
  Agree88 (48.6)89 (62.2)
  Neither agree nor disagree17 (9.4)23 (16.1)
  Disagree39 (21.6)18 (12.6)
  Strongly disagree12 (6.6)4 (2.8)
Willing to participate in continuing education about management of PPD
  Strongly agree23 (12.7)28 (19.6)
  Agree91 (50.3)76 (42)
  Neither agree nor disagree44 (24.3)14 (9.8)
  Disagree16 (8.8)15 (10.5)
  Strongly disagree7 (3.9)10 (7)

Participants' Opinions about Managing Postpartum Depression (PPD) According to the Study Questionnaire (N = 324)

Opinion About Managing PPDNurses (n = 181)Midwives (n = 143)
Who is the most appropriate person(s) to detect PPD?aMean (SD)
  Partner5.62 (2.3)5.5 (2.9)
  Other family members and friends4.91 (2.0)4.5 (2.3)
  Nurses and midwives in primary health care (PHC) centers3.8 (1.2)3.9 (1.5)
  Nurses and midwives in maternity hospitals4.0 (1.6)3.6 (2.1)
  Community nurses and midwives4.3 (1.6)4.2 (0.8)
  Obstetricians3.8 (2.1)3.3 (1.7)
  Psychologists and psychiatrists5.18 (2.4)4.8 (2.7)
Reason for choicebn (%)
  Contact32 (17.7)27 (18.9)
  Personal relationship115 (80.4)123 (86)
  Professionalism39 (21.5)35 (24.5)
  Other13 (7.2)24 (16.8)
Who is the most appropriate person(s) to care for women with PPD?aMean (SD)
  Partner4.2 (2.2)4.8 (2.3)
  Other family members and friends3.2 (2.2)4.9 (1.9)
  Nurses and midwives in PHC centers4.5 (1.3)4.3 (1.7)
  Nurses and midwives in maternity hospitals4.1 (1.6)4.4 (2.3)
  Community nurses and midwives4.2 (1.6)4.4 (0.8)
  Obstetricians3.3 (2.3)2.6 (1.2)
  Psychologists and psychiatrists6.1 (2.3)5.7 (2.2)
Reason for choicebn (%)
  Contact27 (14.9)30 (21)
  Personal relationship34 (18.8)39 (27.3)
  Professionalism143 (79)109 (76.2)
  Other28 (15.5)19 (13.3)
What is the most appropriate setting for managing PPD?n (%)
  At home with help from partner, family, friends, and community nurses88 (48.6)58 (40.6)
  In a maternity hospital36 (19.9)20 (14)
  In a psychiatric hospital21 (11.6)32 (22.4)
  In a special psychiatric ward in a maternity hospital24 (13.3)21(14.7)
  In a special maternity ward in a psychiatric hospital12 (6.6)12 (8.4)
Should mother and baby be separated?n (%)
  Yes42 (23.2)51 (35.7)
  No85 (48.6)52 (36.4)
  Do not know54 (30.9)40 (28)
Reason for choicebn (%)
  Will worsen situation25 (13.8)32 (22.4)
  If mother endangers baby64 (35.4)46 (32.2)
  When depression is very severe34 (18.8)36 (25.2)
  If the mother has support38 (21)41 (28.7)
  If there is 24-hour control30 (16.6)23 (16.1)
  Mother and baby belong together22 (12.2)28 (19.6)
  Adaptation to motherhood35 (19.3)21 (14.7)
  Baby as therapy15 (8.3)30 (21)
  Other23 (12.7)17 (11.9)
How aware do you think women are of PPD?n (%)
  They know the possibility of PPD after childbirth exists24 (13.3)20 (14)
  They know how to recognize symptoms54 (30.9)58 (40.6)
  They know where to seek help35 (19.3)32 (22.4)

Relationship Between Nurses' and Midwives' Opinions about Prevention of Postpartum Depression (PPD) Risk Factors and Management of PPD

Role (Strongly Agree or Agreea)n (%)χ2p Value
Total (N = 324)Nurses (n = 181)Midwives (n = 143)
Provide education about PPD160 (49.4)102 (56.4)58 (40.6)12.10.01*
Provide support during labor180 (55.6)74 (44.9)106 (74.1)5.00.027*
Provide debriefing after labor179 (55.2)94 (51.9)85 (59.4)4.60.39
Assess and detect PPD169 (52.2)107 (59.1)62 (43.4)38.2<0.001*
Refer care recipient to obstetrician163 (50.3)95 (52.5)68 (47.6)0.60.51
Refer care recipient to psychologist or psychiatrist129 (39.8)74 (40.9)55 (38.5)0.180.72
Manage support group(s)134 (41.4)86 (47.5)48 (33.6)9.40.003*
Provide psychotherapeutic counseling159 (49.1)105 (58.0)54 (37.8)23.1<0.001*
Authors

Dr. Saleh is Associate Professor, School of Nursing, The University of Jordan, Amman, Jordan; Dr. Elshatarat is Assistant Professor, Dr. Aljohani is Assistant Professor and Head of Department, Mr. Alhujaili is Specialist, Department of Medical and Surgical Nursing, Dr. Ebeid is Assistant Professor, and Dr. Al Tarawneh is Assistant Professor, Department of Psychiatric and Mental Health Nursing, College of Nursing, Taibah University, Madinah, Kingdom of Saudi Arabia; Mr. Al-Za'areer is Director, Medical Simulation Centre, Al-Rayan Colleges, Madinah, Kingdom of Saudi Arabia; and Dr. Abu Raddaha is Associate Professor and Head of Nursing Department, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, Al-Kharj, Kingdom of Saudi Arabia. Dr. Ebeid is also Lecturer, Psychiatric and Mental Health Nursing Department, Faculty of Nursing, Port Said University, Port Said, Egypt, and Mr. Al-Za'areer is also PhD Student, Faculty of Medicine, University of Sultan Zainal Abidin, Kuala Terengganu, Malaysia.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

This publication was supported by the Deanship of Scientific Research at Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia. The authors thank the Research Committee at Al-Ghad International Colleges for Applied Medical Sciences; the Chairman of Medical Research Ethics Committee in the Directorate General of Health Affairs in Madina City with providing the formal approval to conduct this study at the selected governmental health settings; and Dr. Omar A. Al-Smadi for English editing of the manuscript. The authors also thank the nurses and midwives who participated in this study.

Address correspondence to Ahmad H. Abu Raddaha, PhD, MSc, RN, Associate Professor and Head of Nursing Department, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, P.O. Box 422, AlKharj, 11942, Kingdom of Saudi Arabia; email: a.aburaddaha@psau.edu.sa/ supremecurve@yahoo.com.

Received: October 04, 2019
Accepted: April 14, 2020
Posted Online: May 12, 2020

10.3928/02793695-20200506-05

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