Postpartum Depression: The Preventive and Interventional Roles of Nurses
Postpartum depression is widely recognized as a significant health threat to the mother and the rest of the family, and thus to society, but the biggest threat is to the lifetime health prospects of the newborn infant. Given the health significance of postpartum depression, recent research about the risk factors for this condition, and recommendations for interventions, were examined. While a direct causal link between depression and child neglect does not appear to exist, or be statistically strong, there is a significant indirect causal link. The essential connection seems to be difficulty bonding and bonding is essential to the process of maternal-infant attachment. There also appears to be an inverse relationship between the strength of the attachment and the risk of postpartum depression, such that both mother and child benefit from a strong attachment to each other. Nursing professionals can foster the attachment process by taking on various roles with respect to the patient, primarily by establishing a trusting relationship, teaching the patient all they may need to know about first-time parenting, being a technical expert when needed, and if the patient so desires, acting as a surrogate family member in a supportive role. The overall effect of these roles is to reduce the amount of stress pregnancy and first-time parenting causes, thus reducing the risk of postpartum depression.
Postpartum Depression: The Preventive and Interventional Roles of Nurses
Postpartum depression can represent a serious threat to maternal, infant, and family health, and for this reason it has garnered much attention over the past decade. However, the relatively recent attention paid to this condition means that generally-accepted screening and treatment strategies have not been identified (reviewed by Yawn et al., 2012). In the absence of robust general practice guidelines for postpartum depression, nursing professionals may find themselves without reliable guidance. The potential impact of information inconsistency on individual, family, and societal health is probably significant. This essay will examine several recent research articles and what they offer in terms of best practice approaches for treating women at risk for postpartum depression.
Factors Contributing to Postpartum Depression
Prospective mothers often ask their psychiatrist if there is a risk that they might abuse their child (reviewed by Choi et al., 2010). Questions of this nature reveal the popular perception that there is a causal link between maternal mental health and the risk of child abuse. This possibility is supported by exerts in the field, who have claimed the risk factors for postpartum depression are a history of maltreatment as a child or being subjected to poor parenting. Such experiences may increase the chances of mental health problems and reduce the ability of the mother to handle stress, thereby contributing to infant neglect and other forms of abuse.
When Choi and colleagues (2010) investigated the possible causal relationships between various suspected risk factors for child abuse, they found that mothers with a bad parenting experience as a child and who worried about the risk of child abuse were no more likely to abuse their child than mothers without a poor parenting experience. Although Choi and colleagues did not find a direct relationship between depression and abuse, there was a significant relationship between depression and difficulty bonding (p < 0.001), and between difficulty bonding and abusive behavior (p < 0.001). This finding suggests there is an indirect causal relationship between depression and child abuse.
Zauderer (2008) found similar evidence for a causal link between postpartum depression and bonding; however, Zauderer makes a distinction between bonding and attachment, with the latter representing a more complex relationship that begins during pregnancy and develops progressively during the early years of infant parenting. Attachment is believed to be important for the cognitive, social, and emotional development of the child. In contrast, bonding occurs during the period immediately following childbirth, but is believed to be essential to the attachment process.
By presenting a composite 'case study' of postpartum depression, Zauderer (2008) reveals the common experiences of these patients. For example, mechanically caring for the newborn is a common trait arising out of feeling trapped in the stay-at-home parent role and no longer in control of their personal life and body. The immediate outcome of this lack of attachment is a more demanding infant, which in turn aggravates the mother's resistance to meeting the needs of the infant. When this dynamic unfolds, treatment may involve the use of anti-depressant medications, maternal health and nutrition instruction, promoting breast feeding if still possible, encouraging strong family and social support ties, and parenting classes, all in an effort to foster reattachment.
A recent meta-analysis of studies reattachment interventions revealed the importance of informational, instrumental, emotional, esteem/appraisal, and network support for increasing breast feeding prevalence among teen mothers and lengthening the time before weaning (Grassley, 2010). Professional caregivers can therefore play an important role in formal network support by providing information on the importance and methods of breast feeding and other important parenting methods. For example, breast feeding has been proposed to protect the mother against depression and other mood disorders, while increasing attachment to the infant (reviewed by Humphries and McDonald, 2012). In other words, while attachment is essential to the health and well-being of the infant, it is also important to the mental health of the mother.
While breast feeding has been shown to be important to the process of maternal-infant attachment, some caution should be urged in applying this approach to all women. Humphries and McDonald (2012) interviewed six women suffering from mental disorders and discovered that the stress of breast feeding, and the added complication of psychiatric medications, predisposed these women to experiencing unreasonable expectations. For these women, using infant formulas may be a better alternative to breast feeding.
Humphries and McDonald (2012) argue that the process of maternal-infant bonding and attachment is important, but women should be treated as individuals with unique problems. In other words, a one-size-fits-all approach could unintentionally interfere with the bonding and attachment process for some women. The six nursing helping roles proposed by Hildegard Peplau in 1952 could provide a useful guide in how to manage pregnant women suspected of being at risk for suffering from postpartum depression (reviewed by Courey, Martsolf, Draucker, and Strickland, 2008). These roles are stranger, resource person, teacher, leader, surrogate, and counselor. A seventh role, technical expert, was added to this list at a later date.
Stress is widely believed to be a significant risk factor for depression (Choi et al., 2010) and stress reduction can be accomplished by first establishing a trusting relationship with the patient (stranger role) (reviewed by Courey, Martsolf, Draucker, and Strickland, 2008). It this is accomplished, a patient is more likely to pay attention to recommendations, be willing to become informed about the bonding and attachment process, and ask important questions (teacher role). The teacher role is an important component of efforts to reduce the stress experienced by pregnant women as they approach the birth of their first child, by teaching them what to expect, how to manage their new role as parent, and debunking parenting myths.
If the patient has a weak, problematic, or non-existent informal support network, the nurse can step into this role (surrogate role) in an attempt to encourage activities that increase the chances of a successful attachment process (reviewed by Courey, Martsolf, Draucker, and Strickland, 2008). Whether the nurse will assume a surrogate role will depend on the patient and how comfortable they are with leaning on the nurse for assistance. More pragmatically, women in general, but especially young women, may experience unnecessary anxiety about breast feeding simply due to a lack of knowledge and not having anyone else to turn to (technical expert role). For example,…