Now More Than Ever, Screening Vital For Postpartum Depression

With incidents of depression increased by the pandemic, it is even more important than ever that risk managers working with physician practices and perinatal units have established policies, protocols and practices to screen for and follow up on the potential of postpartum depression. 

Facts about postpartum depression in peripartum mental illness

• Approximately 70 to 80% of new mothers experience some negative feelings or mood swings during the first few days after giving birth. 
• Perinatal mood and anxiety disorders greatly compromise parenting, which reinforces the underlying mental health condition and adversely affects the child’s physical and emotional development.
• Estimates are that 7% to 20% of pregnant women are affected by depression during and after pregnancy. 
• With approximately 4 million live births occurring annually in the United States, this equates to approximately 600,000 women experiencing postpartum depression.
• Perinatal depression can affect individuals of all backgrounds, however, low socioeconomic status, poor access to education and healthcare, adolescent age, African-American race and recent immigrant status are thought to lead to a postpartum depression rate of up to 25% in these population demographics. 
• Women with a history of depression, anxiety or serious mood disorders such as bipolar are 30% to 35% more likely to develop perinatal depression.
• Women who have experienced depression with previous births are 10% to 50% more likely to experience it with subsequent births.
• Perinatal mood and anxiety disorders can be successfully treated with a variety of approaches including social support, lifestyle modifications, talk therapy and medications.(1)

Especially with the added stresses of the coronavirus pandemic, mental health issues during pregnancy and the postpartum period need to be addressed by practitioners and organizations that deliver perinatal care.(2,3) Even before the pandemic, however, the required screening, follow up and treatment lagged significantly behind the need. “Although 13% of surveyed women with a recent live birth reported depressive symptoms during the postpartum period, one in five did not report a health care provider asking about depression during prenatal visits and one in eight reported they were not asked about depression during postpartum visits.”(4)

While mental health disorders during the entire pregnancy are important maternal health issue, a comprehensive approach to addressing postpartum depression has become a major focus of obstetrical care. The approach to identifying and managing postpartum depression is needed on two levels — one from the individual practitioner and the other from every perinatal unit. The first level is to modify the approach to timing and frequency of postpartum care that enables early recognition of postpartum depression. The second is the recommendation for universal postpartum depression screening before maternal discharge on every perinatal unit.(5)

Postpartum care

The American College of Obstetricians and Gynecologists (ACOG) has called for the following approaches to postpartum care:

• “Postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs.

All women should have contact with their obstetrician–gynecologists or other obstetric care providers within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.”(6)

• “…All (obstetrical providers) … complete a full assessment of mood and emotional well-being (including screening for postpartum depression and anxiety with a validated instrument) during the comprehensive postpartum visit…Clinical staff in obstetrics and gynecology practices should be prepared to initiate medical therapy, refer patients to appropriate behavioral health resources when indicated, or both.”(7)

Because of the increased emphasis on mental health issues during postpartum visits and the potential for unfamiliarity for some practitioners, guidelines have been issued by ACOG District II for scripts that practitioners can use to address these issues with patients.(8)

In addition to changing the frequency and approach to perinatal practitioners’ care, universal screening for postpartum depression should become standard practice for every perinatal unit. Some electronic records include admission questions regarding the patient’s mental health status, including a brief suicide screen. However, the most common, evidence-based tool for this screening is the Edinburgh Postnatal Depression Scale (EPDS).(9) The scale is a 10-question survey administered to every patient before discharge. Scoring is straightforward and should become a routine part of nursing care on the unit. (10) In addition to administration and scoring of the EPDS, protocols for both in-house and community follow up and referrals should be developed. These protocols should include notification of in-house social and case workers as well as notification and referral to obstetrical, pediatric (11) and community mental health providers.

There are many additional resources that address evidence-based approaches to screening and follow up. The Council on Patient Safety in Women’s Health Care has developed a comprehensive bundle for peripartum mental health issues.(12) Postpartum Support International also offers extensive resources for screening, additional training and certification.(13)

Risk managers should assess the nature of screening and follow up in provider practices and perinatal units through meetings and queries of departmental chairs and perinatal nursing leadership. Assurance that there are up-to-date policies, protocols and practices with respect to postpartum depression screening and follow up will improve patient safety and mitigate risks associated with this serious condition.

1. https://www.mhanational.org/issues/position-statement-49-perinatal-mental-healthhttps://www.mhanational.org/issues/position-statement-49-perinatal-mental-health. Accessed September 3, 2020
2. Questions of the potential effect on the baby, change in antenatal appointments, visitation in hospital, potential increased patient and family anger due to restrictions, frustrated birth plans, seeking more out of hospital birth settings, possible restrictions of support people such as doulas, separation of newborn from new mothers, issues of dress and PPE throughout the unit.  See https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics.
3. Rasmussen SA, Jamieson DJ. Caring for Women Who Are Planning a Pregnancy, Pregnant, or Postpartum During the COVID-19 Pandemic. JAMA. 2020 Jul 14;324(2):190-191.
4. Bauman BL, Ko JY, Cox S, et al.  Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression — United States, 2018. MMWR Morb Mortal Wkly Rep 2020;69:575–581.
5. https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/perinatal-depression-preventive-interventions#bootstrap-panel–8 (Accessed September 10, 2020)
6. Optimizing postpartum care. ACOG Committee Opinion No. 736. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e140–50.
7. Screening for perinatal depression. ACOG Committee Opinion No. 757. American College of Obstetricians  and Gynecologists. Obstet Gynecol 2018;132:e208–12.
8. Perinatal Depression Screening: Tools for Obstetrician-Gynecologists American College of Obstetricians and Gynecologists, District II/NY 152 Washington Avenue Albany, New York 12210
9. Cox, J.L., Holden, J.M. and Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.
10. http://www.perinatalservicesbc.ca/Documents/Resources/HealthPromotion/EPDS/EPDSScoringGuide_March2015.pdf
11. Earls MF, Yogman MW, Mattson G, et al; AAP Committee on Psychosocial Aspects of Child and Family Health. Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics. 2019;143(1):e20183259
12. https://safehealthcareforeverywoman.org/council/patient-safety-bundles/maternal-safety-bundles/maternal-mental-health-depression-and-anxiety/
13.  https://www.postpartum.net

Larry Veltman, MD, FACOG, CPHRM, DFASHRM, is an obstetrician/gynecologist and a member of ASHRM since 1988. He serves on the ASHRM Board (2018-2020) and is a well known speaker, author, and consultant in the area of perinatal safety and risk management.