Maternal Health Needs and Interest in Screening for Depression and Health Behaviors During Pediatric Visits

doi:10.1016/j.pedhc.2011.11.008

Journal of Pediatric Health Care

Volume 27, Issue 4, July–August 2013, Pages 267-277

https://doi.org/10.1016/j.pedhc.2011.11.008 Get rights and content

Abstract

Introduction

Our aims were to assess postpartum health care barriers; health status (including depression and health behaviors); missed opportunities to discuss maternal health at health visits; acceptability of maternal screening in pediatric settings; and association of these variables with income level and race/ethnicity.

Method

A mail survey was used with names randomly drawn from birth files and balanced for race/ethnicity and income level.

Results

The adjusted response rate was 27.6%, with 41% reporting one or more health care barrier(s), 22% screening positive for depression, and 30% screening positive for alcohol abuse. Women of lower income were eight times more likely than those of higher income to have health care barriers (adjusted odds ratio = 8.15; 95% confidence interval: 3.60, 18.44). Missed discussions of postpartum depression or behavioral health during pediatric or other health care visits ranged from 26% to 79%. Acceptability of discussing topics, including depression, smoking, and alcohol use at pediatric care visits generally exceeded 85%.

Discussion

Postpartum women experienced income-associated barriers to health care and generally had favorable views about maternal screening in pediatric settings.

Section snippets

Purpose

Our aim was to determine the occurrence of barriers to health care, postpartum health needs, and acceptability of screening in pediatric settings in a mid size Texas community and to examine if disparities occurred by income status (indexed by Medicaid or private insurance coverage for childbirth) or race/ethnicity (White/Anglo, African American, or Hispanic). To do so, we replicated portions of the study by Kahn and colleagues (1999) using a mail survey and extended this earlier work by

Design and Sample

A cross-sectional survey of mothers residing in a central Texas county was conducted by mail during the summer of 2010. For the survey, names and addresses of women having a live birth between August 23, 2009, and January 22, 2010, were obtained from the state public health agency. The sampling frame was delimited to mothers who were at least 18 years of age, had a singleton term birth, resided in the county of interest, and were White/Anglo, African American, or Hispanic. To derive a sample

Characteristics of Respondents

Using source of coverage for delivery as an index of income level, 35.9% of the women in the sample were of lower income (Medicaid coverage) and 64.1% were of higher income (private insurance). The racial/ethnic composition of the sample was 46.2% White/Anglo, 25.5% African American, and 28.3% Hispanic. Race/ethnicity was not associated with women’s income level. Other respondent characteristics are described in Table 1. On average, women of lower income were younger and less likely to have

Discussion

In recognition of the potential impact of maternal health upon infant health, growth, and development, we examined the occurrence of maternal barriers to health care; their postpartum health needs, especially those related to depression and health behaviors; missed opportunities in health care settings to discuss maternal health; and acceptability of maternal screening in pediatric settings. We also sought to expand on the earlier work of Kahn et al. (1999) by determining if disparities

Clinical Implications

Although our findings are preliminary, they are consistent with pediatric experts and national organizations that strongly advocate family-centered models of care that integrate parental behavioral health screening and referral services in pediatric primary care (Earls, 2010, National Association of Pediatric Nurse Practitioners, 2011). Although primary care providers cannot meet all of their clients’ needs, family-centered approaches bridge research and practice, particularly given the clear

Lorraine O. Walker, Luci B. Johnson Centennial Professor, School of Nursing, The University of Texas at Austin, Austin, TX.

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Making the Legal and Ethical Case for Universal Screening for Postpartum Mood and Anxiety Disorders in Pediatric Primary Care
2017, Current Problems in Pediatric and Adolescent Health Care
Citation Excerpt :
Of note, however, one study found that all participating mothers connected their own emotional health to their child's well-being, and most believed they had a responsibility to maintain their own emotional health for the benefit their child.58 This, along with other studies about mothers' approval of their children's providers screening for PPD,13 and a general receptiveness to being screened using the EPDS,59 show that there is substantial maternal support for implementing screening in this setting.13,60,61 Support for screening among fathers and other caregivers has not yet been evaluated to the same extent, highlighting a need for further research in this area.
Postpartum depression (PPD), part of a larger spectrum of perinatal mood and anxiety disorders, affects up to 15% of women following the birth of an infant. Fathers may also be affected. PPD not only affects caregivers, but also impacts infants through mechanisms such as inadequate caregiver–infant interactions and non-adherence to safety practices. The negative impact on infants may extend across the life course through adulthood. This article seeks to move the needle toward universal screening for PPD using validated tools in pediatric primary care settings for new caregivers by making the legal and ethical case for this course of action in a manner that is both compelling and accessible for clinicians. Toward this end, we summarize current literature as it applies to provider responsibilities, liabilities and perspectives; and caregiver autonomy, confidentiality, and privacy. We then assess utility by balancing the benefits and burdens of this approach to practices, providers, and caregivers; and take the analysis one step further by looking across multiple populations to assess distributive justice. We conclude that there is a strong ethical case for universal screening for PPD in pediatric primary care settings using validated tools when informed consent can be obtained and appropriate follow-up services are available and accessible. Clinical considerations, practical resources, and areas ripe for future research are also addressed.
Postpartum Depression Screening at Well-Child Appointments: A Quality Improvement Project
2017, Journal of Pediatric Health Care
Citation Excerpt :
In this project, only one patient refused screening. This correlates with the findings of Walker et al. (2013), which indicated that new mothers are open to discussions of PPD with their pediatricians. This high compliance rate supports the use of well-child visits as an optimal time to screen for PPD.
The purpose of this quality improvement project was to implement and evaluate a postpartum depression screening program using the Edinburgh Postnatal Depression Scale (EPDS) during well-child appointments up to 1 year of age at a private, faith-based primary care clinic.
The Plan–Do–Study–Act framework was used in this quality improvement project. The EPDS was administered to mothers ages 19 years and older at their infants' well-child appointments at a faith-based clinic in the Midwest. A score of 10 or higher was considered a positive result. The results were reviewed, and protocol changes were implemented every 2 weeks using the Plan–Do–Study–Act framework.
A total of 35 mothers completed the EPDS during the 9-week implementation period. Of 37 mothers asked to participate, nearly all agreed (97.3%); there was one refusal (2.7%). Staff compliance rate with administering the EPDS was 78.7%; there were 10 missed opportunities (21.3%). There were five positive EPDS results (14.3%). Mothers who screened positive were between the ages of 20 and 44 years. Infant ages were between 2 weeks and 12 months.
Screening mothers at well-child appointments can identify women with postpartum depression. Not doing so is a missed opportunity. The results of this project support the identification of postpartum depression by screening using the EPDS during well-child appointments up to 1 year of age.
Missed Opportunities for Postpartum Behavioral and Psychosocial Health Care and Acceptability of Screening Options
2016, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
Citation Excerpt :
Similarly, in their recent systematic review focused on depression, El-Den et al. (2015) summarized that in numerous studies most women reported that screening for postpartum depression was acceptable. For example, in prior studies in which researchers used a quantitative metric of acceptability of depression screening, which parallels our study method, rates of acceptability ranged from over 80% (Gemmill, Leigh, Ericksen, & Milgrom, 2006) to over 90% (Kahn et al., 1999; Segre, O'Hara, Arndt, S., & Beck, 2010; Walker, Im, & Tyler, 2013). Segre et al. (2010) found that higher-income women preferred clinic-based screening, whereas lower-income women of ethnic minorities preferred home-based screening on the sensitive topic of depression.
To examine occurrence of health care provider discussion of postpartum women's behavioral and psychosocial health, acceptability of screening, and access to a provider with whom to comfortably discuss sensitive topics.
Mail survey during the first postpartum year.
Community dwelling.
Postpartum women (N = 168) from diverse backgrounds.
Using vital records, we drew a random sample that was stratified on race/ethnicity and income from a Southwestern U.S. community. Potential participants were mailed a questionnaire about health care and screening in the areas of depression, diet, physical activity, smoking, and alcohol use during the postpartum period.
Women reported that discussion of depression most often occurred (51%) during health care encounters, and discussion of weight least often occurred (14%). More than 94% of women indicated they would “welcome” or “not mind” screenings for depression, diet, physical activity, alcohol use, or smoking at health care visits. More than 90% welcomed screening during their infants' pediatric health care visits. Most (86%) reported that screening on an electronic device at their health care visits was acceptable. Most (84%) were interested in completing a screening at home on a Web site. Also, 58% of women without health insurance compared with 24% of those with insurance indicated that they lacked a health professional with whom they could comfortably discuss sensitive topics such as depression.
Wide gaps exist in postpartum behavioral and psychosocial health care. Most women find a variety of screening settings and methods acceptable.
A systematic review on the acceptability of perinatal depression screening
2015, Journal of Affective Disorders
Citation Excerpt :
Five studies were included that assessed the acceptability of PND screening by a certain healthcare professional or within a certain setting (Table 2). Three publications assessed the views of perinatal women on the acceptability of screening within a paediatric setting (Feinberg et al., 2009; Kahn et al., 1999; Walker et al., 2013). One publication assessed the views of perinatal women on the acceptability of screening by nurses (Segre et al., 2010b), and another assessed the views of nurses on providing screening themselves (Segre et al., 2010a).
Perinatal depression (PND) affects approximately 10–15% of women, worldwide. PND screening, using screening tools, has been undertaken by a broad range of healthcare professionals in different settings. Our objective was to explore the acceptability of PND screening and how acceptability was being assessed.
A systematic literature review of studies that explored the acceptability of PND screening was carried out throughout MEDLINE, PsycINFO, PubMed, CINAHL, Embase, Maternity and Infant Care and Joanna Briggs Institute databases.
Twenty-eight out of twenty-nine publications reported PND screening to be acceptable to most participants. A wide range of terms, questions and statements was used to infer, assess or report on acceptability. There was no uniform, psychometrically tested tool used to measure acceptability across the studies.
Broad inclusion criteria and methodological differences limited comparisons, but are overcome by the comprehensiveness of the data and the lack of uniformity across studies.
Even though PND screening appears acceptable, it is difficult to draw conclusions about PND screening acceptability as studies used different methods to infer, assess or report on acceptability. The lack of a uniform, psychometrically tested tool to measure acceptability is not unique to PND. Nonetheless, the majority of perinatal women and healthcare professionals reported positive attitudes towards PND screening using different tools in different settings, indicating that it may be the responsibility of all healthcare professionals who come into contact with perinatal women.
Postpartum Psychosocial and Behavioral Health: A Systematic Review of Self-Administered Scales Validated for Postpartum Women in the United States
2015, Women's Health Issues
Women's poor postpartum psychosocial and behavioral health may negatively affect them and their infants. Validated postpartum screening scales can help to identify problems early, but currently there is limited knowledge in this area. Thus, we conducted a systematic examination of self-administered psychosocial and behavioral scales validated for postpartum women in the United States in the domains of depression, body image, diet, physical activity, smoking, and alcohol use. We examined the characteristics of included scales, their validation samples, and reported psychometric properties.
Nine databases were searched during October 2014 through February 2015. After meeting inclusion/exclusion criteria, article information was extracted independently by two authors, compared, and differences were resolved through discussions.
The final sample included 23 published articles covering 19 scales. Seventeen were in the domain of depression, and one each in physical activity and dietary domains. None was found in the domains of body image, smoking, or alcohol use. The number of scale items varied from 2 to 35. The majority of scales were originally designed for postpartum women, and validated in one or two postpartum studies with samples of predominantly adult women. If reported, scale reliability coefficients were generally 0.80 or greater and validity coefficients of 0.70 or greater. Five depression scales had favorable sensitivity and specificity using standard cutpoints, but only one was tested across adolescent, low-income, and predominantly ethnic minority postpartum populations.
No U.S.-validated postpartum scales were found for body image, smoking, or alcohol use. Most scales had limited validity testing, and validation was in predominantly advantaged samples. Further scale development and testing are recommended.
Improving postpartum depression screening in pediatric primary care: A quality improvement project
2019, Journal of Pediatric Nursing
Citation Excerpt :
These guidelines suggest screening at all WCC visits, but at least the 1, 2, and 6-month visits (AAP, 2014). Despite those recommendations, there is no standardization among pediatric practices to guide the implementation of PPD screenings; furthermore, the rates of PPD screening in the pediatric setting are low (Evans, Phillippi, & Gee, 2015; Glasser et al., 2016; Walker, Im, & Tyler, 2013). In order to integrate standardized PPD screening in the clinic and determine its potential effect in increasing PPD detection, the project manager developed a QI project with a primary aim of increasing the rates of standardized PPD screening at 1, 2, and 6-month WCC visits.
Despite recommendations for standardized postpartum depression screening in primary care pediatrics, few pediatric healthcare providers are adequately screening mothers for postpartum depression.
To improve standardized screening for postpartum depression in the pediatric primary care setting. Secondary aims were to determine if infant and family characteristics (gender of infant, feeding method, insurance type, income level, ethnicity of infant) were associated with positive postpartum depression screening.
This quality improvement project involved implementing a standardized postpartum depression screening tool into pediatric primary care practice. Independent samples t-test and logistic regression were used for data analysis.
Postpartum depression screening practices improved from 83% to 88% (p = 0.096). Although not statistically significant, infant characteristics of male gender, Medicaid or sliding-scale payment for services, and Hispanic ethnicity were associated with higher rates of positive postpartum depression screens.
Pediatric health care providers can effectively screen for postpartum depression. Certain infant and family characteristics may alert the provider to higher risks for mothers.

View all citing articles on Scopus

Lorraine O. Walker, Luci B. Johnson Centennial Professor, School of Nursing, The University of Texas at Austin, Austin, TX.

Eun-Ok Im, Marjorie O. Rendell Endowed Professor, School of Nursing, The University of Pennsylvania, Philadelphia, PA.

Diane O. Tyler, Professor of Clinical Nursing, School of Nursing, The University of Texas at Austin, Austin, TX.

: This research was supported by the Luci B. Johnson Centennial Professorship in Nursing.

: Conflicts of interest: None to report.

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ArticleMaternal Health Needs and Interest in Screening for Depression and Health Behaviors During Pediatric Visits

Abstract

Introduction

Method

Results

Discussion

Section snippets

Purpose

Design and Sample

Characteristics of Respondents

Discussion

Clinical Implications

Journal of Midwifery & Women’s Health

American Journal of Obstetrics & Gynecology

General Hospital Psychiatry

Journal of Obstetric, Gynecologic, and Neonatal Nursing

Summary health statistics for the U.S. population: National Health Interview Survey, 2009

Vital and Health Statistics

Family pediatrics: Report of the task force on the family

Pediatrics

ACOG Committee Opinion No. 343: Psychosocial risk factors: Perinatal screening and intervention

Obstetrics & Gynecology

Current estimates from the National Health Interview Survey, 1993

Vital and Health Statistics

Screening and treatment for depression during pregnancy: A cautionary note

Australian and New Zealand Journal of Psychiatry

Data 2010…the Healthy People 2010 database: Objective 26-Substance Abuse

Data 2010…the Healthy People 2010 database: Objective 27-Tobacco Use, Texas

The foundations of lifelong health are built in early childhood

Legal and ethical considerations: Risks and benefits of postpartum depression screening at well-child visits

Pediatrics

Postpartum maternal health care in the United States: A critical review

Journal of Perinatal Education

Maternal depressive symptoms and child behavior problems in a nationally representative normal birthweight sample

Maternal and Child Health Journal

Summary of effects of parental smoking on the respiratory health of children and implications for research

Thorax

Preconception and interconception health status of women who recently gave birth to a live-born infant—Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004

Morbidity and Mortality Weekly Report Surveillance Summary

Racial ethnic differences in rates of depression among preretirement adults

American Journal of Public Health

Incorporating recognition and management of perinatal and postpartum depression into pediatric practice

Pediatrics

Increasing response rates to postal questionnaires: Systematic review

British Medical Journal

Improving women’s health during internatal periods: Developing an evidence-based approach to addressing maternal depression in pediatric settings

Journal of Women’s Health

Article
Maternal Health Needs and Interest in Screening for Depression and Health Behaviors During Pediatric Visits