Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Review Article, J Womens Health Issues Care Vol: 5 Issue: 4

Strategies to Improve Identification of Postpartum Depression, Follow up and Continuity of Care among Women

Sharon Puchalski1* and Toni Tortorella2
1William Paterson University, 300 Pompton Rd, Wayne, 07470 New Jersey, USA
2Bergen Community College, 400 Paramus Rd, Paramus, 07652 New Jersey, USA
Corresponding author : Sharon Puchalski, DNP, WHNP-BC
William Paterson University, 300 Pompton Rd, Wayne, 07470 New Jersey, USA
Tel: 201-602-0290
Fax: 973-285-9848
E-mail: [email protected]
Received: May 20, 2016 Accepted: June 07, 2016 Published: June 12, 2016
Citation: Puchalski S, Tortorella T (2016) Strategies to Improve Identification of Postpartum Depression, Follow up and Continuity of Care among Women. J Womens Health, Issues Care 5:4. doi:10.4172/2325-9795.1000239


Postpartum depression (PPD) is a serious mental health disorder, characterized by severe feelings of sadness that occurs in a significant number of women with symptoms generally appearing in the first 2 months to one-year postpartum. As with many mental health disorders PPD is multifactorial, including such influential factors as race, ethnicity, gender, age, social constructs and community. Women in lower socioeconomic strata experience depression in higher numbers than their counterparts in upper socioeconomic groups. Additionally, women with lower levels of education are more prone to develop PPD. It is critical to understand how healthcare providers can intervene to address PPD. The Centers for Disease Control (CDC) (2016) reported postpartum depressive symptoms in 1 out of 10 women.
Although New Jersey led the nation as the first state to enact a law addressing postpartum depression in 2006, there is little empirical evidence that significant changes have occurred in relation to the diagnosis and treatment of PPD. The law provides funding for education, screening, and the program “Speak Up When You’re Down”. There needs to be an increased commitment to addressing this issue to improve the health of women. In addition to the mandated screening for PPD, advanced practice nurses (APNs) and other health care providers need to provide follow-up for those women identified as being at high risk in order to provide the appropriate support as dictated by the situation.

Keywords: Postpartum depression; Screening


Postpartum depression; Screening


Inter-professional collaboration among APN’s and other healthcare providers is necessary to address the benefit of perinatal and postpartum depression screening, education, and follow up for pregnant women. Depression screening and treatment is imperative to population health, is vital to improve the Nation’s Health, and plays an important role in health prevention and protection of pregnant women [1]. Pregnant women represent a vulnerable population and they are at an increased risk of complications from postpartum depression [2,3]. The prenatal period represents an opportunity for healthcare providers to screen women for depression, educate pregnant women, and address the importance of follow up for women who are identified as high risk.
It is estimated that PPD has an occurrence rate between 3% and 20% of all women who have given birth [4]. The CDC (2016) stated that postpartum depressive symptoms were experienced by approximately 1 in 10 women [2]. According to American College of Obstetrics and Gynecology (ACOG) (2013), all pregnant women are to be screened for depression during and after pregnancy [1]. PPD has significant consequences for the well-being of mothers and their children including but not limited to the inability to care for themselves and/or their infants, disconnect from their infant, and worrying that she may harm the baby or herself [2]. State and national legislation has addressed the importance of identifying and treating PPD. Despite the 2006 legislation in New Jersey mandating universal screening, education and referral for postpartum depression, increasing exposure and public awareness, PPD remains largely undetected, and subsequently undiagnosed, and untreated [3,5,6].
Environmental issues can add benefit or stress to the human system and therefore needs to be included when evaluating the mental health risk of woman. Kozhimannil et al. reported significant racial and ethnic disparities and suboptimal treatment in PPD care among low-income women [6]. The awareness of PPD in this population to initiate and continue care needs to be advanced. Marketing materials should be bilingual. Spanish language magazines and newspapers, TV and radio stations, should carry PSA’s aimed at educating women and countering cultural beliefs that perpetuate the ideas that PPD makes them bad mothers and that this is not a biological problem [7,8].


Postpartum depression (PPD) is a major public health issue that leads to significant negative consequences for the mother, child, family, community and broader society. Knitzer et al. reported the following data on maternal depression: “12% of all women experience PPD in a given year, for low-income women, the estimated prevalence doubles to at least 25%, estimated rates of depression among pregnant and postpartum women range from 5-25%, and low-income mothers of young children, pregnant and parenting teens report depressive symptoms in the 40-60% range” [7]. Dr. Lucy Puryear, President of Postpartum Support International (PSI) found over 30% of Latinas suffer from postpartum depression that continues to be the number one complication of pregnancy [8]. Lara, Letechipia and Hochhausen examined the prevalence and associated risk factors of perinatal depressive symptoms in Latinas in the United States and Mexico, and reported 32.4% for pregnant Latinas and 36.8% for Mexicans [9]. Chaudron et al. found increased depression rates among Hispanic women and Latinas are less likely to be identified as depressed [10]. The study concluded the lifetime prevalence of maternal depression at 37% in Hispanics, 12% above the general population. Demissie et al. discussed the negative impact that PPD has on Latina’s and all mothers including poor parenting behaviors, negative maternalinfant bonding and attachment, and inadequate care to their child [11]. Further undesirable effects on the infant include problems with behavior, developmental, physical and cognitive delays, and poor sleep patterns. Hayden et al. found that Hispanic women felt that they must cope and recover self-reliantly when faced with postpartum depression [12].
State and national legislation has addressed the importance of identifying and treating PPD. Primary Sponsor, NJ Governor Richard J. Codey introduced S213 on 1/10/2006 that requires certain licensed health care professionals providing prenatal care to offer information and screen for PPD. On 4/13/06, New Jersey became the first state in the U.S. to pass a law mandating universal screening, education and referral for postpartum depression [13]. Clearly, the work championed by Mary Jo Codey in the early 2000’s needs to continue, and expand, to encompass those populations of women who are underserved by the mainstream healthcare system and continue to suffer with PPD. Kozhimannil et al., (2011) concluded that PPD care necessitates both clinical and policy consideration [6]. In March 2010, The Affordable Care Act required insurers to cover preventive care and screenings, which comprises screening for postpartum depression. This advance in policy-making, requiring mandatory screening for PPD, includes additional research into the cause, screening, and treatment of PPD [14].


Despite the increased exposure and public awareness, PPD remains largely undetected, and subsequently undiagnosed, and untreated [6,15]. Social determinants of health including low income and education levels, cultural beliefs and role expectations presents an opportunity for health care providers to be active in all aspects of policy to promote women’s health and advocate on this important issue. The following recommendations require the involvement of vital stakeholders, state policymakers and legislators. PSI released a Spanish language DVD “MADRE SALUDABLE, FAMILIA FELIZ” in January 2012 to educate Latina women about PPD [16]. Considering the successful implementation of “Speak Up, When You’re Down”, a recommendation to incorporate this DVD into the postpartum depression screening for Latina women is warranted. This DVD addresses the unique cultural beliefs and role expectations in this underserved, at risk population. A second recommendation is to employ a licensed Mental Health clinician with the language skills, cultural sensitivity, and clinical competence at Hospitals to implement a multidisciplinary approach to PPD screening and management. The Mental Health clinician will immediately evaluate any patient with a positive Edinburgh Postnatal Depression Scale (EPDS) or other postpartum depression screening and provide a follow-up phone call to all patients who deliver at 6 and 12 weeks and facilitate treatment as needed. A final recommendation would incorporate an inter-professional collaboration among Obstetricians, Pediatricians, APNs, and Mental Health clinicians across healthcare settings to provide education, screening and treatment for the first postpartum year. Additionally, those providing the education, screening, and treatment for women should provide the necessary services in the language of comfort for the woman and her family. Efforts must continue to screen and educate women about PPD to assist with early diagnosis and treatment while delivering highquality care, improving continuity of care, and helping to eliminate societal disparities that exist.


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