Perinatal Mood and Anxiety Disorders (PMAD), is the most under diagnosed obstetrical complication. Left untreated, PMAD can have a permanent negative impact on the affected client and their family. Screening for PMAD is an integral part of the care women should receive during pregnancy and postpartum, yet it is frequently overlooked in the outpatient arena. Additionally, a proportion of women do not access postpartum care, especially at risk are those suffering from mood and anxiety disorders. Unfortunately, the established assessment tools for depression and anxiety have not been validated for use during the immediate postpartum period. A validated screening tool is needed for the immediate postpartum period to connect women identified at risk for PMAD with a behavioral health care provider, social worker, home care and community support prior to discharge.
Purpose:
The purpose of this project is to validate a piloted screening instrument to identify women at risk for or exhibiting symptoms of PMAD during the immediate postpartum period. A secondary purpose was to improve the behavioral health referral process and ensure access to community support.
Methods Section:
This quality improvement project will be exploring the psychometric properties of a screening instrument. The PMAD screening instrument has 4 items that were developed to identify mothers for risk factors for PMAD. The instrument was created based on the risk factors identified by the Office of Women’s Health (National Women's Health Information Center 2001). The screening tool has been piloted with over 50,000 postpartum women during their admission assessment. However, the effectiveness of the instrument, including reliability and validity have not been assessed.
Phase 1:
A content validity index (CVI) was conducted for the PMAD screening tool, including the assessment of each individual item. A panel of three content experts in maternal/child health was asked to review and rate each question on the PMAD Risk assessment tool using a 4- point likert scale for content relevance and clarity. The results were recorded on content validity grid. The range of the scale was as follows: 1=not clear/not relevant; 2= somewhat clear/ somewhat relevant; 3=quite clear/ quite relevant and 4 =very clear/highly relevant. If a question was deemed somewhat clear/ somewhat relevant or not clear/ not relevant the expert was asked to provide a comment explaining how the question could be improved.
Phase 2:
An IRB application has been submitted for expedited review. The hospital statistician was consulted to obtain a power analysis to determine the number of chart reviews required in order to have enough power to have a medium effect size.
After Internal Review Board (IRB) approval a retrospective random chart review will be performed on records from patients who delivered between 2017 and 2018. The 4 screening question responses recorded in the EMR will be reviewed to identify if the mothers had a positive or negative response. Additionally, the negative responses will be reviewed, to identify risk factors that are indicative of PMAD. Exclusion criteria will include those charts with incomplete documentation on their admission assessment.
Phase 3:
Education on consistent use of the PMAD screening instrument will be provided to staff working with mothers postpartum within the hospital. In addition to obstetrical and neonatal nursing staff, an on-line education program including a pre and posttest will be electronically sent to the lactation consultants, providers in obstetrics, pediatrics, behavioral health, social work, and the hospital home care department.
Results:
Phase 1 of this Quality Improvement project has been completed. The PMAD screening instrument was reviewed by 3 content experts, who responded to the relevancy of each of the items, as well as the clarity. The only question that received a low score on clarity from one content expert was, “Have you experienced premenstrual syndrome (PMS)”? The recommendation from the content expert was to change the question to, “Have you experienced severe PMS or premenstrual dysphoric syndrome”? The other two content experts rated this question as very clear, therefore the decision was made to leave the question in the screening instrument. The item content validity (CVI) was .92, with a scale-level CVI of .9725. Phase 2 and Phase 3 data is still pending.
Conclusion:
The preliminary data from phase I of this quality improvement project suggest that the PMAD screening instrument has content validity. The data obtained from phase 2 and phase 3 of this project will provide additional insight into ensuring the effectiveness of the PMAD Screening instrument. Excellent outcomes are reported when women receive appropriate mental health treatment; ultimately benefiting the mother, the infant, and the entire family.
Acknowledgements: The implementation of this quality improvement project is supported by the Maternal-Child Health Nurse Leadership Academy and sponsored by Sigma and Johnson & Johnson