Perinatal Mental Health: Implications of Perinatal Mental Illness and Treatment

Perinatal Mental Health: Implications of Perinatal Mental Illness and Treatment

Kayla Acklin, ABD, LPC, NCC

The United States spends more than any other nation in the world on perinatal healthcare; however, it currently and consistently ranks near the bottom on most standard measures of perinatal health to include mental health and wellness (Creanga et al., 2014; Lu, 2010; MacDorman et al., 2016). Some argue that in the culture of the United States, women are viewed and treated as “wrappers” for babies and are not useful once the baby has been born (Verbiest et al., 2016, p. S5). Following this argument, perinatal care in the United States can be characterized as infant-centered care rather than woman-centered (Creanga et al., 2014; Davis-Floyd & Cheyney, 2019). In contrast, a system based on woman-centered care, postpartum services would include coordinated care that includes maternal health and healing along with family wellness and function (Verbiest et al., 2016, p. S5). Researchers have noted that women receiving mainstream care have reported feelings of dissatisfaction with the emotional aspects of care (Gamble & Creedy, 2007).  The issue of lack of support and emotional care during the perinatal period has been identified by others as a problem to be solved (Shah, 2012).

The current system of perinatal health care in the United States is characterized by greater access, higher utilization, and less fragmentation which creates opportunities to identify mental health problems sooner and respond appropriately (Leight, et al., 2010; Verbiest et al., 2016). This is a strength; however, limitations continue to exist in this system. Specifically, in the later stages of pregnancy, women attend visits with their healthcare provider weekly to ensure the health and wellbeing of the mother and infant. Despite more frequent contact and opportunities to identify mental health problems, women with psychiatric disorders in the perinatal period are less likely to receive mental health treatment (Leight, et al., 2010; Verbiest, et al., 2016). This gap in services could be related to the sharp decrease in care and attention provided to women in the postpartum period. Once the baby is born, women typically do not see their healthcare provider until six weeks have passed (Creanga et al., 2014; Davis-Floyd & Cheyney, 2019; Leight, et al., 2010; Verbiest et al., 2016). During this large gap in services, mental health problems can escalate quickly before health care providers have an opportunity to assess women and connect them with appropriate services. During this time period, infants attend several appointments depending on the individual needs of the child and family (Creanga et al., 2014; Davis-Floyd & Cheyney, 2019; Leight, et al., 2010; Verbiest et al., 2016). For example, the infant will visit with their pediatrician and may also visit a lactation consultant if the mother has chosen to breastfeed. With the focus on the infant, the mother may develop a mental health problem that goes unnoticed and untreated leading to negative consequences for the mother, the infant, and the family (Creanga et al., 2014; Davis-Floyd & Cheyney, 2019; Leight, et al., 2010; Verbiest et al., 2016). Mothers often experience difficulty in acknowledging their distress due to stigma, lack of understanding by healthcare professionals, poor recognition of the difference between depression and normal adjustment, and difficulty accepting help (Buist, 2011).

Perinatal mental illness may result in the children experiencing increased behavioral and neurocognitive delays and disorders throughout childhood and into adulthood (Buist, 2011). Additionally, traumatic birth experiences can cause disruption in mother-infant bonding leading to impaired child development due to resulting attachment issues (Simpson & Catling, 2016). Untreated perinatal mental illnesses have been shown to result in suffering for mothers; strained familial relationships; negative effects on children’s emotional social, and cognitive development; and maternal suicide (Buist, 2011; Hanzak, 2016; Simpson & Catling, 2016). In sum, perinatal mental illness and complications have a global affect on women, children, and families. Additionally, the stigma related to perinatal mental illness has an effect on professionals which may lead to hesitation related to conversations around perinatal mental health (MPhil, 2014; Noonan et al., 2018). These two factors collide in a way that women suffering with perinatal mental illness are not able to express their distress and professionals are not comfortable facilitating conversations around perinatal mental health which then leads to increased complications for women and their families because they are going undiagnosed and untreated.

The literature explores many treatment approaches related to perinatal mental illness and the effectiveness of the treatments. In order for these treatments to be effective, women need to be able to access them. According to Price et al. (2010) elevated symptoms and symptom severity are significant factors related to help-seeking behaviors. Further, relational comfort or discomfort can greatly affect help-seeking behaviors and symptom disclosure. When the relationship between women and their healthcare provider is uncomfortable, and the provider does not facilitate conversation related to mental health then women are more likely not to disclose their symptoms. Alternatively, when the relationship between women and their health care provider is comfortable, and the provider facilitates conversation related to mental health then women are more likely to disclose their symptoms. Therefore, creating a relationship of trust and eliminating stigmatizing behaviors on the part of the health care provider are powerful first steps to early detection of perinatal mental illness, and providing recommendations for entry into treatment (Kingston et al., 2015). Olde et al. (2006) suggests that a psychosocial approach to identification and treatment is beneficial for women. First, crisis management should be provided to women who are acutely upset following their birth. Next, provide all women with an opportunity to speak with a mental health professional following birth to assess risk for perinatal mental illness. Finally, refer women who meet criteria for perinatal mental illness to an appropriate treatment provider.

Buist (2011) suggests that planning and collaboration are necessary components of early identification and risk management. Further, this researcher asserts that the 5 E’s of risk be implemented as follows: early identification, estimate risk, engage, educate, and enable the mother to keep her baby’s physical and emotional needs in mind. Early identification of perinatal mental illness is vital in regard to the timeliness of treatment and reducing long-term negative outcomes, and can be accomplished via continual observation, open communication, and the use of screening tools. Estimation of risk can be accomplished by understanding the biopsychosocial risk factors for perinatal mental illness, family history of mental illness, and available supports. To gain this understanding, providers need to have open lines of communication and encourage conversations related to mental health in the perinatal period. Engage refers to helping the woman to understand that taking care of her mental health is vital for the health and wellbeing of herself and her infant. Again, open lines of communication and conversations related to mental health are important for meeting this component. Educate refers to helping women and their families understand what perinatal mental illness looks like and how it can develop. Finally, enable the mother to keep her baby’s physical and emotional needs in mind refers to helping the mother understand the importance of early identification and early intervention related to perinatal mental illness. All of these components require providers to establish a trusting relationship with women and their families along with facilitating conversations related to mental health often (Buist, 2011).

Treatment of perinatal mental illness can include individual psychotherapy, group therapy, guided self-help, and medication therapy. The level of functional impairment is an important factor to consider when making decisions related to treatment approach. For example, a woman experiencing severe perinatal mental illness such as a psychotic episode would be an inappropriate candidate for guided self-help groups. Further, a combination of treatments may be required for some women such as using both psychotherapy and medication therapy. Talking therapies and counseling constitute an important part of the treatment of perinatal mental illness, and cognitive behavioral therapy (CBT) has been shown to be an effective approach. Further, various types of groups have been explored by researchers and show promising results (Edozien & O’Brien, 2017; Hanzak, 2016).

            Guided self-help or peer support groups can be helpful for women who want to establish connections with others who share similar experiences, and can be beneficial for women with subclinical symptoms. These types of groups help women to build resilience, and feel supported. In particular, women who experience loss such as miscarriage benefit from these types of groups. These groups are deliverable in a variety of community settings making them accessible for women. It is important that health care providers be familiar with groups available in their community so that they can refer women who could benefit from them (Edozien & O’Brien, 2017; Price, 2010). Butler-OHalloran & Guilfoyle (2015) explored these groups more closely and found that women benefitted from these groups due to the validation and support experienced along with the feeling of safety in disclosing difficulties.  The researchers discovered that between discharge from the hospital and joining a group was an isolating time for mothers because they did not feel as though they could speak about their struggles with anyone due to a fear of being perceived as a bad parent. Women in these groups reported that they were able to speak openly about their difficulties which then lead to the discovery that they were not the only ones struggling with motherhood which helped to increase their confidence and to feel reassured that they were good parents. It was suggested that bringing mental health professionals to the groups as guest speakers would be beneficial so that if women felt that they needed an increased level care, they would be familiar with some of the providers in the community.

Townshend et al. (2018) explored the effects of a mindfulness based program, Caring for Body and Mind in Pregnancy (CBMP), on depression, anxiety, general stress, and mindfulness. The researchers found that the program did improve participants’ scores via Wilcoxon Signed Rank Test analysis with pre and post group measures. In particular, CBMP reduced depression, anxiety, and general stress scores while increasing mindfulness and self-compassion scores. Perinatal depression scores prior to program participation were significantly influenced by post program self-compassion t(73) = -2.90, p<.01, R2=.10, a1= -.03, SE=.01, CI= -.05, -.02. In sum, CBMP significantly reduced perinatal depression and anxiety in this sample of women. Self-compassion was a stronger mediator than mindfulness in reducing perinatal depression.

Tandon et al. (2018) explored the effects of the Mothers and Babies 1-on-1 (MB 1-on-1) intervention with prenatal clients. This program is based on a CBT curriculum and delivered in the client’s home. Women who received MB 1-on-1 exhibited decreases in depressive symptoms between baseline and three months postpartum with continued symptom decline exhibited at six months postpartum. Women receiving a higher does of the intervention appeared to exhibit greater symptoms relief, n=20, between baseline (M= 11.0, SD= 8.1) and six months postpartum (M=6.6, SD= 5.9). Further, at the six month postpartum assessment, only 6% of women in the intervention condition met criteria for postpartum depression while 18% of women receiving care as usual met criteria for postpartum depression.

Further studies have sought to investigate cognitive behavioral therapy (CBT) and effectiveness related to treating perinatal mental illness. Ayers, McKenzie-McHarg, & Eagle (2007) used a case study method to analyze the effectiveness of CBT in treating post traumatic stress disorder (PTSD) caused by birth. These researchers found that CBT was an effective treatment leading to symptom relief, and that a combination of reliving, exposure, and cognitive reappraisal techniques is vital for treatment success. Another study by Harvey et al. (2018) found that a nurse-led community model of service provided effective assessment and brief intervention services. This study focused on the value of mental health nurses and what they can provide insofar as mental health services. These researchers suggest that mental health nurses are skilled in establishing a therapeutic relationship and providing care that includes health promotion, assessment, psychosocial interventions, and collaborate well with other service providers. Further, the researchers argue that this model of care fills gaps in service that are not met by the biomedical model and that nurses are more approachable which increases engagement. In this study, nurses were trained in the delivery of CBT, and provided brief intervention for women with symptoms of perinatal mental illness. These new CBT skills along with their knowledge of psychotropic medications was beneficial for women related to making informed decisions regarding their care and facilitating the continuation of treatment. This innovative model was also more economically viable when compared with services provided by psychiatrists. The rate of attendance in the study was excellent with a fail to attend rate at less than 10 percent once women attended one appointment. This can be explained by the easy accessibility of the physical locations of the program along with the welcoming culture established there (Harvey, 2018).

Other researchers have experimented with training midwives to deliver mental health interventions in the perinatal period. These studies have produced mixed results. In a study by MPhil (2014), findings indicated that some midwives may lack the confidence and ability to provide effective care for women experiencing birth as traumatic. All of the midwife participants in this qualitative study noted that learning the counseling skills and delivering the intervention were challenging due to being unfamiliar with counseling techniques and learning to change their approach with women who experienced birth as traumatic. Prior to participating in the study, midwives expressed difficulty caring for distressed women in the postpartum period due to having a limited understanding of trauma and its relationship to the care women received. During the training process, many of the participants expressed that they struggled to adapt and found that the new way of working with women was uncomfortable. Even upon completion of the training, some of the midwives felt that they were not able to gain the knowledge and skills necessary to deliver the intervention. However, some of the midwives were able to gain confidence and skills in implementing the program which helped them to be able to feel more comfortable listening to women’s narratives even if the narrative was distressing. Of the midwives who were able to learn and use the skills, many of them felt as though these new skills gave them confidence in their practice regarding having mental health conversations with women and when discussing distressing births with colleagues (MPhil, 2014).

Gamble et al. (2005) further studied midwife-led intervention. In this study, the intervention highlighted the role of midwives in providing postpartum emotional care including increased time to talk with women about their birth in a meaningful way, providing information about the birth, and assisting with the integration of this transformative life event. The researchers note that prior literature asserts that single debriefing sessions within the first few days of birth is likely to be ineffective in reducing symptoms of perinatal mental illness and that these could contribute to an increase in symptoms (Gamble & Creedy, 2004; Gamble et al., 2005). Therefore, it is important for the midwife to talk with the mother more than one time. The participants in this study identified that there is a need for emotional support following a distressing birth experience, and the intervention responded to this need by providing women with a face-to-face session with their midwife and a follow-up phone call. The intervention focused on linking emotional responses with perceived causes of distress to decrease self-blame and increase resilience. The participants in this randomized control trial reported reduced trauma symptoms along with increased confidence regarding future pregnancies. Further, the participants reported that the intervention was helpful. However, there was no significant difference in the number of women diagnosed with post traumatic stress disorder at three months postpartum when examining outcome measures. The researchers found no indication of harm when examining outcome measures; therefore, discussing the birth on more than one occasion will not create problems or contribute to distress.

A review of the literature regarding counseling interventions following a distressing birth experience by Gamble & Creedy (2004) highlights that providing women the opportunity to discuss their birth draws upon Rogerian principles in which active listening and a deep sense of empathy conveyed to the woman serves to affect therapeutic change. Inviting women to tell their birth story and helping them to develop a birth narrative in the context of a humanistic working relationship can help to decrease symptoms. Further, social support from partners can moderate the development of post traumatic stress disorder (PTSD) symptoms.

A qualitative study by Fenwick et al. (2013) echoed these assertions and findings. In this study, participants were provided with psychoeducation within six weeks of giving birth along with consultation with a midwife to review their experiences. Women in the study, again, reported a need for emotional support following their birth. The participants reported that knowing that a midwife would contact them to follow-up and provide space to share their experience and ask questions lead to feeling cared for which had a positive effect on the participants’ wellbeing. Telling the birth story, clarifying any misunderstandings regarding how the birth unfolded, and having the opportunity to ask questions helped the participants to make connections between the events, intense emotions, and subsequent responses. These participants were then able to explore solutions with a midwife with whom they had an established therapeutic alliance. These women reported feeling cared for and that the intervention improved their wellbeing.

Several researchers have proposed and explored integrated behavioral health models related to the perinatal period (Cantwell & Smith, 2008; Laios, Rio, & Judd, 2013; Leight, et al., 2010; Lomonaco-Haycraft et al., 2018). The model developed by Lomanaco-Haycraft et al. (2018) proposes the implementation of a universal screening process along with integrated behavioral health during the perinatal time period within the existing healthcare system. These researchers propose that the universal screening program will serve to identify perinatal mental illness early in pregnancy and monitor the wellbeing of women throughout the perinatal period. Further, any women identified as at risk for the development of perinatal mental illness or those who are affected by it can then be connected with appropriate behavioral health care in the same setting in which they receive healthcare services related to pregnancy. With this model, the behavioral health team and the healthcare team are able to collaborate effectively in order to best meet the needs of the woman. Comprehensive mental health assessment and management, like the above described model, integrated with maternity care has been shown in qualitative studies to be an effective approach to the detection and management of perinatal mental illness; however, further quantitative studies are needed to assess how effective these programs are (Laios, Rio, & Judd, 2013). Cantwell & Smith (2008) assert that there are some key components necessary for these models to work effectively. First, multidisciplinary care plans are needed to ensure that appropriate care is delivered across sectors. Next, all health care and behavioral health care providers must collaborate and communicate effectively regarding the woman’s current state of wellness along with the interventions being provided and how well these interventions are working. Further, Leight et al. (2010) proposes that for assessment to be effective the healthcare team must have a thorough understanding of several factors related to the development of perinatal mental illness including genetic factors, social factors, and behavioral factors. Therefore, taken as a whole, these models assert that integrated behavioral health must include a thorough understanding of factors related to the development of perinatal mental illness; universal screening and assessment; multidisciplinary care plans; and collaboration and communication across healthcare sectors.

 

 

 

 

 

 

 

 

 

 

 

 

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Perinatal Mental Health: Implications of Perinatal Mental Illness and Treatment

Kayla Acklin, ABD, LPC, NCC

The United States spends more than any other nation in the world on perinatal healthcare; however, it currently and consistently ranks near the bottom on most standard measures of perinatal health to include mental health and wellness (Creanga et al., 2014; Lu, 2010; MacDorman et al., 2016). Some argue that in the culture of the United States, women are viewed and treated as “wrappers” for babies and are not useful once the baby has been born (Verbiest et al., 2016, p. S5). Following this argument, perinatal care in the United States can be characterized as infant-centered care rather than woman-centered (Creanga et al., 2014; Davis-Floyd & Cheyney, 2019). In contrast, a system based on woman-centered care, postpartum services would include coordinated care that includes maternal health and healing along with family wellness and function (Verbiest et al., 2016, p. S5). Researchers have noted that women receiving mainstream care have reported feelings of dissatisfaction with the emotional aspects of care (Gamble & Creedy, 2007).  The issue of lack of support and emotional care during the perinatal period has been identified by others as a problem to be solved (Shah, 2012).

The current system of perinatal health care in the United States is characterized by greater access, higher utilization, and less fragmentation which creates opportunities to identify mental health problems sooner and respond appropriately (Leight, et al., 2010; Verbiest et al., 2016). This is a strength; however, limitations continue to exist in this system. Specifically, in the later stages of pregnancy, women attend visits with their healthcare provider weekly to ensure the health and wellbeing of the mother and infant. Despite more frequent contact and opportunities to identify mental health problems, women with psychiatric disorders in the perinatal period are less likely to receive mental health treatment (Leight, et al., 2010; Verbiest, et al., 2016). This gap in services could be related to the sharp decrease in care and attention provided to women in the postpartum period. Once the baby is born, women typically do not see their healthcare provider until six weeks have passed (Creanga et al., 2014; Davis-Floyd & Cheyney, 2019; Leight, et al., 2010; Verbiest et al., 2016). During this large gap in services, mental health problems can escalate quickly before health care providers have an opportunity to assess women and connect them with appropriate services. During this time period, infants attend several appointments depending on the individual needs of the child and family (Creanga et al., 2014; Davis-Floyd & Cheyney, 2019; Leight, et al., 2010; Verbiest et al., 2016). For example, the infant will visit with their pediatrician and may also visit a lactation consultant if the mother has chosen to breastfeed. With the focus on the infant, the mother may develop a mental health problem that goes unnoticed and untreated leading to negative consequences for the mother, the infant, and the family (Creanga et al., 2014; Davis-Floyd & Cheyney, 2019; Leight, et al., 2010; Verbiest et al., 2016). Mothers often experience difficulty in acknowledging their distress due to stigma, lack of understanding by healthcare professionals, poor recognition of the difference between depression and normal adjustment, and difficulty accepting help (Buist, 2011).

Perinatal mental illness may result in the children experiencing increased behavioral and neurocognitive delays and disorders throughout childhood and into adulthood (Buist, 2011). Additionally, traumatic birth experiences can cause disruption in mother-infant bonding leading to impaired child development due to resulting attachment issues (Simpson & Catling, 2016). Untreated perinatal mental illnesses have been shown to result in suffering for mothers; strained familial relationships; negative effects on children’s emotional social, and cognitive development; and maternal suicide (Buist, 2011; Hanzak, 2016; Simpson & Catling, 2016). In sum, perinatal mental illness and complications have a global affect on women, children, and families. Additionally, the stigma related to perinatal mental illness has an effect on professionals which may lead to hesitation related to conversations around perinatal mental health (MPhil, 2014; Noonan et al., 2018). These two factors collide in a way that women suffering with perinatal mental illness are not able to express their distress and professionals are not comfortable facilitating conversations around perinatal mental health which then leads to increased complications for women and their families because they are going undiagnosed and untreated.

The literature explores many treatment approaches related to perinatal mental illness and the effectiveness of the treatments. In order for these treatments to be effective, women need to be able to access them. According to Price et al. (2010) elevated symptoms and symptom severity are significant factors related to help-seeking behaviors. Further, relational comfort or discomfort can greatly affect help-seeking behaviors and symptom disclosure. When the relationship between women and their healthcare provider is uncomfortable, and the provider does not facilitate conversation related to mental health then women are more likely not to disclose their symptoms. Alternatively, when the relationship between women and their health care provider is comfortable, and the provider facilitates conversation related to mental health then women are more likely to disclose their symptoms. Therefore, creating a relationship of trust and eliminating stigmatizing behaviors on the part of the health care provider are powerful first steps to early detection of perinatal mental illness, and providing recommendations for entry into treatment (Kingston et al., 2015). Olde et al. (2006) suggests that a psychosocial approach to identification and treatment is beneficial for women. First, crisis management should be provided to women who are acutely upset following their birth. Next, provide all women with an opportunity to speak with a mental health professional following birth to assess risk for perinatal mental illness. Finally, refer women who meet criteria for perinatal mental illness to an appropriate treatment provider.

Buist (2011) suggests that planning and collaboration are necessary components of early identification and risk management. Further, this researcher asserts that the 5 E’s of risk be implemented as follows: early identification, estimate risk, engage, educate, and enable the mother to keep her baby’s physical and emotional needs in mind. Early identification of perinatal mental illness is vital in regard to the timeliness of treatment and reducing long-term negative outcomes, and can be accomplished via continual observation, open communication, and the use of screening tools. Estimation of risk can be accomplished by understanding the biopsychosocial risk factors for perinatal mental illness, family history of mental illness, and available supports. To gain this understanding, providers need to have open lines of communication and encourage conversations related to mental health in the perinatal period. Engage refers to helping the woman to understand that taking care of her mental health is vital for the health and wellbeing of herself and her infant. Again, open lines of communication and conversations related to mental health are important for meeting this component. Educate refers to helping women and their families understand what perinatal mental illness looks like and how it can develop. Finally, enable the mother to keep her baby’s physical and emotional needs in mind refers to helping the mother understand the importance of early identification and early intervention related to perinatal mental illness. All of these components require providers to establish a trusting relationship with women and their families along with facilitating conversations related to mental health often (Buist, 2011).

Treatment of perinatal mental illness can include individual psychotherapy, group therapy, guided self-help, and medication therapy. The level of functional impairment is an important factor to consider when making decisions related to treatment approach. For example, a woman experiencing severe perinatal mental illness such as a psychotic episode would be an inappropriate candidate for guided self-help groups. Further, a combination of treatments may be required for some women such as using both psychotherapy and medication therapy. Talking therapies and counseling constitute an important part of the treatment of perinatal mental illness, and cognitive behavioral therapy (CBT) has been shown to be an effective approach. Further, various types of groups have been explored by researchers and show promising results (Edozien & O’Brien, 2017; Hanzak, 2016).

            Guided self-help or peer support groups can be helpful for women who want to establish connections with others who share similar experiences, and can be beneficial for women with subclinical symptoms. These types of groups help women to build resilience, and feel supported. In particular, women who experience loss such as miscarriage benefit from these types of groups. These groups are deliverable in a variety of community settings making them accessible for women. It is important that health care providers be familiar with groups available in their community so that they can refer women who could benefit from them (Edozien & O’Brien, 2017; Price, 2010). Butler-OHalloran & Guilfoyle (2015) explored these groups more closely and found that women benefitted from these groups due to the validation and support experienced along with the feeling of safety in disclosing difficulties.  The researchers discovered that between discharge from the hospital and joining a group was an isolating time for mothers because they did not feel as though they could speak about their struggles with anyone due to a fear of being perceived as a bad parent. Women in these groups reported that they were able to speak openly about their difficulties which then lead to the discovery that they were not the only ones struggling with motherhood which helped to increase their confidence and to feel reassured that they were good parents. It was suggested that bringing mental health professionals to the groups as guest speakers would be beneficial so that if women felt that they needed an increased level care, they would be familiar with some of the providers in the community.

Townshend et al. (2018) explored the effects of a mindfulness based program, Caring for Body and Mind in Pregnancy (CBMP), on depression, anxiety, general stress, and mindfulness. The researchers found that the program did improve participants’ scores via Wilcoxon Signed Rank Test analysis with pre and post group measures. In particular, CBMP reduced depression, anxiety, and general stress scores while increasing mindfulness and self-compassion scores. Perinatal depression scores prior to program participation were significantly influenced by post program self-compassion t(73) = -2.90, p<.01, R2=.10, a1= -.03, SE=.01, CI= -.05, -.02. In sum, CBMP significantly reduced perinatal depression and anxiety in this sample of women. Self-compassion was a stronger mediator than mindfulness in reducing perinatal depression.

Tandon et al. (2018) explored the effects of the Mothers and Babies 1-on-1 (MB 1-on-1) intervention with prenatal clients. This program is based on a CBT curriculum and delivered in the client’s home. Women who received MB 1-on-1 exhibited decreases in depressive symptoms between baseline and three months postpartum with continued symptom decline exhibited at six months postpartum. Women receiving a higher does of the intervention appeared to exhibit greater symptoms relief, n=20, between baseline (M= 11.0, SD= 8.1) and six months postpartum (M=6.6, SD= 5.9). Further, at the six month postpartum assessment, only 6% of women in the intervention condition met criteria for postpartum depression while 18% of women receiving care as usual met criteria for postpartum depression.

Further studies have sought to investigate cognitive behavioral therapy (CBT) and effectiveness related to treating perinatal mental illness. Ayers, McKenzie-McHarg, & Eagle (2007) used a case study method to analyze the effectiveness of CBT in treating post traumatic stress disorder (PTSD) caused by birth. These researchers found that CBT was an effective treatment leading to symptom relief, and that a combination of reliving, exposure, and cognitive reappraisal techniques is vital for treatment success. Another study by Harvey et al. (2018) found that a nurse-led community model of service provided effective assessment and brief intervention services. This study focused on the value of mental health nurses and what they can provide insofar as mental health services. These researchers suggest that mental health nurses are skilled in establishing a therapeutic relationship and providing care that includes health promotion, assessment, psychosocial interventions, and collaborate well with other service providers. Further, the researchers argue that this model of care fills gaps in service that are not met by the biomedical model and that nurses are more approachable which increases engagement. In this study, nurses were trained in the delivery of CBT, and provided brief intervention for women with symptoms of perinatal mental illness. These new CBT skills along with their knowledge of psychotropic medications was beneficial for women related to making informed decisions regarding their care and facilitating the continuation of treatment. This innovative model was also more economically viable when compared with services provided by psychiatrists. The rate of attendance in the study was excellent with a fail to attend rate at less than 10 percent once women attended one appointment. This can be explained by the easy accessibility of the physical locations of the program along with the welcoming culture established there (Harvey, 2018).

Other researchers have experimented with training midwives to deliver mental health interventions in the perinatal period. These studies have produced mixed results. In a study by MPhil (2014), findings indicated that some midwives may lack the confidence and ability to provide effective care for women experiencing birth as traumatic. All of the midwife participants in this qualitative study noted that learning the counseling skills and delivering the intervention were challenging due to being unfamiliar with counseling techniques and learning to change their approach with women who experienced birth as traumatic. Prior to participating in the study, midwives expressed difficulty caring for distressed women in the postpartum period due to having a limited understanding of trauma and its relationship to the care women received. During the training process, many of the participants expressed that they struggled to adapt and found that the new way of working with women was uncomfortable. Even upon completion of the training, some of the midwives felt that they were not able to gain the knowledge and skills necessary to deliver the intervention. However, some of the midwives were able to gain confidence and skills in implementing the program which helped them to be able to feel more comfortable listening to women’s narratives even if the narrative was distressing. Of the midwives who were able to learn and use the skills, many of them felt as though these new skills gave them confidence in their practice regarding having mental health conversations with women and when discussing distressing births with colleagues (MPhil, 2014).

Gamble et al. (2005) further studied midwife-led intervention. In this study, the intervention highlighted the role of midwives in providing postpartum emotional care including increased time to talk with women about their birth in a meaningful way, providing information about the birth, and assisting with the integration of this transformative life event. The researchers note that prior literature asserts that single debriefing sessions within the first few days of birth is likely to be ineffective in reducing symptoms of perinatal mental illness and that these could contribute to an increase in symptoms (Gamble & Creedy, 2004; Gamble et al., 2005). Therefore, it is important for the midwife to talk with the mother more than one time. The participants in this study identified that there is a need for emotional support following a distressing birth experience, and the intervention responded to this need by providing women with a face-to-face session with their midwife and a follow-up phone call. The intervention focused on linking emotional responses with perceived causes of distress to decrease self-blame and increase resilience. The participants in this randomized control trial reported reduced trauma symptoms along with increased confidence regarding future pregnancies. Further, the participants reported that the intervention was helpful. However, there was no significant difference in the number of women diagnosed with post traumatic stress disorder at three months postpartum when examining outcome measures. The researchers found no indication of harm when examining outcome measures; therefore, discussing the birth on more than one occasion will not create problems or contribute to distress.

A review of the literature regarding counseling interventions following a distressing birth experience by Gamble & Creedy (2004) highlights that providing women the opportunity to discuss their birth draws upon Rogerian principles in which active listening and a deep sense of empathy conveyed to the woman serves to affect therapeutic change. Inviting women to tell their birth story and helping them to develop a birth narrative in the context of a humanistic working relationship can help to decrease symptoms. Further, social support from partners can moderate the development of post traumatic stress disorder (PTSD) symptoms.

A qualitative study by Fenwick et al. (2013) echoed these assertions and findings. In this study, participants were provided with psychoeducation within six weeks of giving birth along with consultation with a midwife to review their experiences. Women in the study, again, reported a need for emotional support following their birth. The participants reported that knowing that a midwife would contact them to follow-up and provide space to share their experience and ask questions lead to feeling cared for which had a positive effect on the participants’ wellbeing. Telling the birth story, clarifying any misunderstandings regarding how the birth unfolded, and having the opportunity to ask questions helped the participants to make connections between the events, intense emotions, and subsequent responses. These participants were then able to explore solutions with a midwife with whom they had an established therapeutic alliance. These women reported feeling cared for and that the intervention improved their wellbeing.

Several researchers have proposed and explored integrated behavioral health models related to the perinatal period (Cantwell & Smith, 2008; Laios, Rio, & Judd, 2013; Leight, et al., 2010; Lomonaco-Haycraft et al., 2018). The model developed by Lomanaco-Haycraft et al. (2018) proposes the implementation of a universal screening process along with integrated behavioral health during the perinatal time period within the existing healthcare system. These researchers propose that the universal screening program will serve to identify perinatal mental illness early in pregnancy and monitor the wellbeing of women throughout the perinatal period. Further, any women identified as at risk for the development of perinatal mental illness or those who are affected by it can then be connected with appropriate behavioral health care in the same setting in which they receive healthcare services related to pregnancy. With this model, the behavioral health team and the healthcare team are able to collaborate effectively in order to best meet the needs of the woman. Comprehensive mental health assessment and management, like the above described model, integrated with maternity care has been shown in qualitative studies to be an effective approach to the detection and management of perinatal mental illness; however, further quantitative studies are needed to assess how effective these programs are (Laios, Rio, & Judd, 2013). Cantwell & Smith (2008) assert that there are some key components necessary for these models to work effectively. First, multidisciplinary care plans are needed to ensure that appropriate care is delivered across sectors. Next, all health care and behavioral health care providers must collaborate and communicate effectively regarding the woman’s current state of wellness along with the interventions being provided and how well these interventions are working. Further, Leight et al. (2010) proposes that for assessment to be effective the healthcare team must have a thorough understanding of several factors related to the development of perinatal mental illness including genetic factors, social factors, and behavioral factors. Therefore, taken as a whole, these models assert that integrated behavioral health must include a thorough understanding of factors related to the development of perinatal mental illness; universal screening and assessment; multidisciplinary care plans; and collaboration and communication across healthcare sectors.

 

 

 

 

 

 

 

 

 

 

 

 

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