This is a post by Science & Sensibility's regular contributor, Walker Karraa, MFA, MA, CD(DONA)

The recently published study, 'Reducing Postpartum Depressive Symptoms Among Black and Latina Mothers: A Randomized Controlled Trial' (Howell et al., 2012) has garnered attention among birth and perinatal mental health professionals. The intention of this post is to (a) present the evidence given in the study; and (b) encourage community discussion, exploration, and solution-driven strategies for childbirth education practices that address postpartum depressive symptoms in communities of color.

Study Breakdown: Objectives and Rationale

The objective of the randomized controlled study was to 'estimate the effectiveness of a behavioral educational intervention to reduce postpartum depressive symptoms among minority mothers' (p. 942).

The rationale for the study itself included the current quantitative data demonstrating the public health problems presented by the high prevalence of postpartum depressive symptoms in American women, and the subsequent negative effects of depressive symptoms on maternal quality of life, mother-infant attachment, and the impact of those symptoms on the social, cognitive, and emotional development of children (cited studies: Gaynes et al., 2005; Howell, Mora, Horowitz, & Leventhal, 2005; Martin et al., 2006; Zayas, Cunningham, McKee, & Jankowski, 2002). Most relevantly, rationale for a study examining African American and Latina mothers specifically was based in evidence of three previous studies that have demonstrated 'the burden of postpartum depressive symptoms is especially high in low-income black and Latina women' (p. 942; cited studies: Das, Olfson, McCurtis, & Weissman, 2006; Howell et al., 2005; Lewis-Fernandez, Das, Alfonso, Weisman, & Olfson, 2005).

In this study, Howell, et al., (2012) offered that the rationale for generating a behavioral educational intervention was also rooted in previous research findings that 'situational factors such as postpartum physical symptoms, overload from daily demands, and poor social support play a major role in the generation of depressive symptoms' (p. 942, cited studies: Howell et al., 2005; Howell, Mora, DiBonaventura, & Levanthal, 2009; Howell, Mora, & Levanthal, 2006).

Methods: How Did They Do the Study?

• Recruitment: 540 self-identified black and Latina mothers recruited to participate during their postpartum hospital stay at a 'large tertiary inner-city hospital located in East Harlem in New York City' (p. 943). Inclusion criteria included participants who self-identified as black or Latina, 18 years or older, with neonates weighing 2,500g or higher, with 5-minute Apgar score of >7.
• Randomization: Randomization of groups occurred through approved procedure of computerized randomization of participant number. Research coordinators were blinded to the assignment of the study arm of those who would receive the intervention and the control arm that received enhanced usual protocol.

Intervention: What did they do?

For the group assigned to the intervention, the following 2 steps were taken:

Step 1:

'The in-hospital component of the intervention involved a 15-minute review of an educational pamphlet and partner summary sheet by the mother with a Masters-trained bilingual social worker' (Howell, et al., 2012, p. 943)

What was in the pamphlet?

'The pamphlet represented each potential trigger of depressive symptoms as a 'normal' aspect of the postpartum experience and provided specific suggestions for management. For example, the prevalence of moderate or heavy vaginal bleeding immediately postpartum was depicted by eight of 10 female silhouettes colored red; only one of 10 was red 3 months postdelivery. Simple 'to do' statements (rest; use pads) were listed between the two rows of figures. A separate page was dedicated to social support and 'helpful organizations' were listed' (Howell, et al., 2012, p. 943).

What was the 'partner summary sheet'?

The partner summary sheet spelled out the typical pattern of experience for mothers postpartum, i.e., it was designed to 'normalize' the feelings and behaviors experienced and enacted by most mothers postpartum and stressed the importance of social support for the patient. The social worker reviewed the patient education pamphlet and partner summary sheet with the patient during her postpartum hospital stay and answered questions (Howell, et al., 2012, p. 943).

Step 2:

A phone call 2 weeks post-delivery by a social worker was placed to each mother in the intervention group to assess symptoms, symptom management skills, and to review the 'to-do' lists in the pamphlets.

Istock/aabejon

Results: What Did They Find?

The authors compared the group of mothers who did not receive the intervention to the intervention group and published the following results:

• Positive depression screens were less common among the intervention group compared with the non-intervention group at 3 weeks (8.8% compared with 15.3%, P=.03), 3 months (8.4% compared with 13.24%, P=.09), and 6 months (8.9% compared with 13.7%, P=.11).
• Analysis for up to 6 months follow-up demonstrated that:

'Mothers in the intervention group were less likely to screen positive for depression compared with enhanced usual care (odds ratio 0.67, 95% confidence interval 0.47-0.97)' (Howell, et al., 2012, p. 948).

Implications

Here the authors noted that implications were that behavioral education could address and modify risk factors that have been shown to correlate with postpartum depressive symptoms. Increasing mothers' knowledge about triggers, and the 'to-do' list of management of those triggers, followed by the phone contact with trained social worker provided an intervention that demonstrated significance in reduced postpartum symptomatology for this study. Authors noted that implementing visual modalities in educational materials assisted mothers' understanding of the triggers, and the range of 'normal' symptoms that could be addressed with behavioral strategies, and re-examined in a timeframe of normalcy.

Limitations

The authors noted that limitations included potential lack of generalizability, as the study took place in one site; they suggested future research in multiple settings would be indicated.

Food for Thought

How does the study inspire ways in which you might most effectively address postpartum symptoms, their triggers, and education with your clients? What are some ways you might use this information in your childbirth education classes?

And lastly, perhaps deeper still, can we truly engage this topic without discussing the role of racism plays in creating barriers to treatment, stigma, and lack of access to care for women of color? What are the steps childbirth and doula organizations can take toward addressing this issue? I would suggest position papers on perinatal mental health and racial disparities would be first line action items for organizations to implement publicly. Outreach to public health and mental health professionals from the organizational level, would further support birth professionals to gain the knowledge and tools needed to acknowledge and address these issues, and become active participants in substantive social change for the future of childbearing women. How many of our organizations are listed in educational pamphlets on postpartum depression as 'helpful organizations'?

Walker Karraa, MFA, MA, CD(DONA)

Walker is currently the President of PATTCh, a not for profit founded by Penny Simkin and Phyllis Klaus - dedicated to the Prevention and Treatment of Traumatic Childbirth. Walker is a doctoral candidate at Institute of Transpersonal Psychology, a certified birth doula, writer, and maternal mental health advocate. She holds an MA degree in Clinical Psychology from Antioch University Seattle, and a BA and MFA degree in dance from UCLA. Walker is a contributor to the Lamaze sites, www.givingbirthwithconfidence.org and www.scienceandsensibility.org. She lives in Sherman Oaks, California with her husband, and two children.

References

Das, A., Olfson, M., McCurtis, H., & Weissman, M. (2006). Depression in African Americans: Breaking barriers to detection and treatment. Journal of Family Practice, 55, 30-39.

Gaynes, B., Gavin, N., Meltzer-Brody, S., Swinson, T., Gartlehner, G., Brody, S., & Miller, W. (Ed.). (2005). Perinatal depression: Prevalence, screening accuracy, and screening outcomes (Summary, evidence report/technology assessment No. 119). Rockville, MD: Agency for Healthcare Research and Quality.

Howell, E. A., Balbierz, A., Wang, J., Parides, M., Zlotnick, C., & Leventhal, H. (2012). Reducing postpartum depressive symptoms among Black and Latina mothers: a randomized controlled trial.Obstetrics & Gynecology, 119(5), 942-949. doi:10.1097/AOG.0b013e318250ba48

Howell, E. A., Mora, P. A., Horowitz, C. R., & Leventhal, H. (2005). Racial and ethnic differences in factors associated with early postpartum depressive symptoms. Obstetrics & Gynecology, 105, 1442-1450.

Howell, E., Mora, P., Chassin, M., & Levanthal, H. (2010). Lack of preparation, physical health after childbirth, and early postpartum depressive symptoms. Journal of Women's Health (Larchmont), 19, 703-708.

Howell, E., Mora, P., DiBonaventura, M., & Levanthal, H. (2009). Modifiable factors associated with changes in postpartum depressive symptoms. Archives of Women's Mental Health, 12, 113-120.

Howell, E., Mora, P., & Levanthal, H. (2006). Correlates of early postpartum depressive symptoms. J Maternal Child Health, 10, 149-157.

Lewis-Fernandez, R., Das, A., Alfonso, C., Weisman, M., & Olfson, M. (2005). Depression in US Hispanics: Diagnostic and management considerations in family practice. Journal of American Board of Family Practice, 18, 282-296.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2006). Births: final data for 2004. National Vital Statistical Report, 55, 1-101.

Zayas, L., Cunningham, M., McKee, M., & Jankowski, K. (2002). Depression and negative life events among pregnant African-American and Hispanic women. Women's Health Issues, 12, 16-22.

Published: May 24, 2012

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