Project Team Consisted of: Jeannie W. Connolly RN, CNM, MSN, Roger H. McBride RN, MSN, Barbara C. Woodring EdD, RN.
Purpose: This project was undertaken in partial fulfillment of requirements for participants in the Sigma Theta Tau International, Maternal-Child Nursing Leadership Academy. The primary purpsose of this project was to improve the identification, referral and treatment of depression in women .
Background/Significance: Pregnancy and childbirth can impact the health of reproductive age women especially when there are complications with mother, infant or both. Perinatal depression (PD) is one of the most common complications of pregnancy and affects as many as one in seven women [American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice, 2015]. Perinatal depression (PD) is under-diagnosed and under-treated. Unfortunately, untreated PD can lead to maternal suicide and/or infanticide, and exceeds hemorrhage and hypertension in pregnancy as a cause of maternal mortality.
The perinatal period gives women’s health care providers and Pediatricians the ideal opportunity to screen for, and refer for care of, depression and anxiety . Universal screening is encouraged in both the antepartum and postpartum periods to increase detection, diagnosis, and access to treatment while supporting women to talk about perinatal mood disorders. [United States Preventative Task Force 2016].
Currently, West Florida Hospital includes post partum depression (PPD) screening performed by the Labor and Delivery Nursing staff using the Edinburgh Postnatal Depression Scale (EPDS) prior to discharge. The EPDS is a self-report, evidence based screening tool, no other screening is conducted. The local community has identified the need for more awareness of depression and PPD through discussions in professional/community committees and boards. There are few maternal mental health providers, and limited support now available in the region.
Process/Methods: This is an on-going project that utilizes a defined process of screening, referral, education and support while helping to de-stigmatize, educate, support families and identify barriers to engage women to talk about perinatal mood disorders. Initial buy-in from major stakeholders, including Administration, Maternity Nursing staff, OB/GYN, Pediatricians and Behavioral Health staff was obtained through educational seminars, and community gap analysis. A distinct process of screening with an evidence based tool followed by client-referral for diagnosis and treatment was put into action. As a result, internal protocols for universal screening approaches, providing telephone support, being listened to, validated and understood by Behavioral Health professionals and an Intensive Out-Patient Program(IOP) was implemented. Services for post-partum women were added to an existing IOP. Special elements of support to newly delivered women were initiated offering newborn changing/care area, lactation support/equipment, changing tables, breast feeding area, breast pumps and milk storage fridge to allow inclusion of the baby during IOP sessions if needed. Education packets were developed for the post-partum patient, that incuded step-by-step directions for the screening and referral processes. All post-partum patients seen in the WFH System OB/GYN and Pediatricians offices received the screening packets. An educational program was developed and implemented for the office staff with multiple lunch and learn sessions re: screening/referral process offered. Supplemental educational classes and materials were developed for Maternal-Child and Behavioral Health staff. Knowledge gains and retention were measured by use of a pre and post-test.
RESULTS/FINDINGS
As a result of the educational processes implemented the staff demonstrated a significant increase in the post-test knowledge of post-partum depression, and anxiety and the effects on the health outcomes of mothers, infants and families. Some issues were identified during the project and addessed: 1) telephone contact in Behavioral Health; 2) a physician champion was enlisted to encourage referrals and provide education from ACOG on PD presented at monthly OB/GYN physician’s meetings; 3) patient packets were delivered to out patient offices on a regular schedule.
Total of 321 patients have been screened during the project, there were 20 who could have been referred to BH clinic based on PPDS data. To date no PPD patients have been admitted to the IOP. It was thought that perhaps some women would prefer to seek services outside the WFH system, therefore, we sought resources external to WFH involving community maternal mental health providers and offered these as another source of referral and patient choice.
Since this project continues for several more months, our CNO has shared her opinion that maybe our population does not require or need an IOP or BH interventions as we first thought or they have been declined access to services due to insurance barriers. Several of our patients have been referred to community mental health providers and others have received prescription medication for their depression/anxiety from the OB/GYN providers.
Conclusion: We are encouraged that awareness of PPD has been raised in the community through both lay and professional groups and the staff have retained knowledge from educational offerings. We will continue the data collection and will initiate use of the screening tool at the first prenatal visit, in the third trimester and again post-partum. Striving to normalize perinatal mental health, engage patients and families in recognizing signs and symptoms of PD and provide resources for them. We will continue to perfect the “soft” transition of depressed mothers into appropriate mental health care, share our program with other community facilities and healthcare teams, as well as continue to improve outcomes for moms, babies and families.