Health care providers have long been concerned with identifying and treating depression in new mothers but it has been difficult to predict which women are most at risk. This difficulty has been exacerbated by shorter hospital stays, a initial focus on infant rather than maternal health, and practice patterns that splinter the care of mothers and newborns among a variety of health professionals.
While the literature often provides conflicting evidence about the etiology and prevalence of this phenomenon [31
], the clinician is faced with a woman who is in distress, who is often not able to identify the nature or source of the difficulty, and who is looking to the primary care provider for help. Whether one views the etiology of this distress from a biomedical or sociological perspective, the problem of early identification and intervention remains. Failure to diagnosis and treat PPD may result in the inability of a mother to provide adequate infant care [32
] and increase the risk for infant cognitive and emotional delay [33
None of the mothers in this study who score ≥ 12 on the EPDS reported being diagnosed with or treated for depression. None reported seeing a mental health specialist and none were taking antidepressant drugs, a finding similar to a previous study [34
]. Despite the predictive value of self-identified emotional or mental health issues in relation to early postpartum depression [35
], only 22.2% to 30.8% of women in this study with EPDS of ≥ 12 reported that they had experienced an emotional or mental health problem since discharge from hospital. However, 44.4% to 52.0% identified the need for reassurance and support.
The EPDS was developed as a screening tool, and is not meant to diagnose actual postpartum depression. A recent review of eighteen EPDS validation studies, suggests that when used in a general population such as the sample for TOMIS, the positive predictive value may be less than 50%, emphasizing the need for further clinical assessment of the women who are identified as ≥ 12 [40
]. The TOMIS results also suggest that prenatal distress, while important, is an insufficient predictor of postpartum depression [37
]. Given that this group of distressed mothers rarely identified themselves as having received help for a prenatal mental health problem, and not all of the mothers who identified prenatal mental health problems had scores of ≥ 12 at four weeks post discharge, it is not adequate for primary care providers to assume that a woman's pre-pregnancy or prenatal mental health status is predictive of postnatal depression [39
Perhaps women have normalized the symptoms that professionals associate with depression. While women who identified a need for reassurance and support were, in the main, able to get it, women who identified a need for help with an emotional or mental health problem reported much less success in obtaining assistance. It is unclear how the women themselves differentiated between these two needs but it was evident that somehow they discriminated between common social support needs and the need for help with what they had defined as a mental health issue.
All participants had contact with a physician since their discharge from hospital. All identified contact in relation to their infant's health, but less than 10 % of women in any of the sites identified that this contact had been for their own needs.
Mothers who scored ≥ 12 identified their own health and the health of their newborn infant as less than optimal. This evaluation was in contrast to mothers who scored less than 12, who evaluated both as "good to excellent". Hospital readmission of either mother or infant was not found to be a related to ≥ 12 scores.
Given that mothers with scores of ≥ 12 reported low levels of both confident and affective support, these results lend credibility to the notion that early postpartum depression may be an expression of a woman's sense of being overwhelmed by a major life-changing event. Thrust into the care of a newborn infant, without strong support, mothers may be primed for an emotional response that they identify in a negative way. "Anxiety", "depression", or "stress" may be used to describe the set of responses, but this research shows these women are experiencing significant distress and may be at risk for more serious, long-term difficulties [12
]. These finding are consistent with other studies that have identified worries about ones own health or about an infant's health, and lack of social support as predictors of PPD [44
Although a woman's sense of personal readiness for discharge was not one of the most strongly associated variables with ≥ 12 EPDS scores, it was an important predictor and may be a clue to providers in identifying an "at risk" group while they are still in hospital. It is important to recognize that the message from these mothers was not "I want to stay in hospital" as much as "I don't think I can manage at home". Given that most women (60.0% to 76.9%) said at the time of discharge that they thought they were ready for discharge, women who want to stay in hospital for a longer period need particular attention. We need to understand their reasons for believing that an increased length of stay would be helpful. Does the woman want to stay longer because she is afraid that she or her infant is "sick"? Is the hospital a "safe haven"? What resources-personal, financial, social – would make discharge feel "safer"? What role could primary care providers in the community play in easing the transition home?
A recently published UK study [46
] found that enhanced and flexible community care for postpartum women that focused on the individual needs of each woman. Home visits during the first 4 weeks after the baby's birth were scheduled according to the needs of the mother. Four months after deliver the mother who received this enhanced care were found to be equally physically health and in better mental health than those who received only standard midwifery care. Mothers receiving enhance care reported a significantly different appreciation of the relationship with their midwife that suggests that both affective and confidant support, notably absent in the group of women in our study who scored ≥ 12 on the EPDS was achieved through the provision of these services.
Simple inquiries by care providers about a woman's sense of her own readiness for discharge might alert them to potential distress [27
]. At four weeks post-discharge, only 44.0% to 72.0 % of women at each site thought that their stay had been the appropriate length for them – significantly fewer than at the time of discharge. Policy changes introduced in Ontario after this research was completed provide a choice of a 60-hour stay at the discretion of the mother. Women exercising this option may represent a group at higher risk for depression in the postpartum period. It is unclear if extended hospitalization reduces the risk for PPD. However, it is reasonable to assume that discharging a distressed woman into a community without guaranteeing adequate assistance is a certain prescription for increased risk.