Medicine, Nursing and Health Sciences
JANE FISHER & KAREN WYNTER
Jean Hailes Research Unit
School of Public Health and Preventive Medicine
Monash University

 Launched in 2009.
 Objectives are to:
“improve prevention and early detection of antenatal and postnatal depression and provide better support and treatment for expectant and new mothers experiencing depression”.
(Austin et al., 2011)
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In the first three years the main focus has been to:
 Implement screening using the Edinburgh Postnatal Depression Scale during pregnancy and four to six weeks postpartum;
 Train midwives, maternal, child and family health nurses, general practitioners and Aboriginal health workers in screening and first-line treatment;
 Build referral pathways to care;
 BUT, as yet little national focus on prevention.
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Prevention strategies include:
 Indicated: current symptoms;
 Targeted: at risk of developing symptoms;
 Universal: offered to all women
(Mrazek et al, 1994; Lumley and Austin, 2001; Lumley et al 2004)
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Universal prevention strategies:
 Implemented in primary care;
 Accessible and non stigmatising;
 Provide a mental health promoting milieu;
 Address potentially modifiable risk factors using evidenceinformed approaches.
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RISKS FOR POSTNATAL DEPRESSION
Systematic reviews conclude:
 past history of psychopathology, including depression during pregnancy;
 coincidental adverse life events;
 poor marital relationship;
 low social support.
(Scottish Intercollegiate Guidelines for Postnatal Depression and Puerperal Psychosis, 2001)

RISK FOR POSTNATAL DEPRESSION
Less consistent evidence for:
 unintended or unwelcome pregnancy;
 longer time to conception;
 operative childbirth;
 not breastfeeding;
 personal coping style;
 unemployment;
(Scottish Intercollegiate Guidelines for Postnatal
Depression and Puerperal Psychosis, 2001)

Prediction of maternal psychological functioning
• Antenatal prediction of postnatal depression through screening during pregnancy?
• Low positive predictive values;
• No test met criteria for routine use antenatally.
(Austin and Lumley, 2003; Austin 2003)

UNIVERSAL ANTENATAL INTERVENTIONS TO
REDUCE PND
Universal antenatal interventions to prevent postpartum mood disturbance:
 Additional antenatal classes, including men with practical key messages
(Gordon et al, 1960; Midmer et al, 1995);
 Continuous ante- to postnatal midwife care (Shields et al, 1997;
Waldenstrom et al, 1999, Biro et al, 1999);
 Information about depression, help seeking and recovery (Hayes et al,
2001).
(Austin 2003; Austin 2004)

UNIVERSAL POSTNATAL INTERVENTIONS TO ‘REDUCE
DEPRESSION’
Seven universal trials of postnatal interventions:
 Postnatal hospital stay
• Debriefing
(Priest et al, 2003);
• Midwife listening (Lavender et al, 1998);
 Changes to postnatal care :
• Earlier postnatal visit to a GP
(Gunn et al, 1998);
• 10 X 3 hour home visits of increased practical and emotional support
(Morrell et al,
2000);
• Information pack ± invitation to new mothers group
(Reid, 2002);
• Enhanced postnatal care by trained home visitors (MacArthur et al, 2002);
• Enhanced postnatal care and community education
(Small et al, 2007).
(Austin, Lumley and Mitchell, 2004)

PREVENTION OF POSTNATAL MENTAL HEALTH
PROBLEMS:
Why were most interventions unsuccessful?
Methodologically robust studies, so the findings are perplexing:
 Aimed to reduce depression, rather than anxiety, which is prevalent and problematic;
 Did not distinguish between new onset or recurrent conditions;
 Modifiable or non-modifiable risk factors?
 Addressed low social support by providing increased professional support;

NEGLECTED BUT POTENTIALLY MODIFIABLE RISK
FACTORS
Infant behaviour:
• Prolonged crying;
• Resistance to soothing;
• Dysregulated sleeping and feeding;
• Irritability;
(Fisher, Feekery and Rowe-Murray, 2002; Fisher, Rowe and Feekery, 2004)

NEGLECTED BUT POTENTIALLY MODIFIABLE RISK
FACTORS
Partner behaviours:
• Being unavailable through long hours in employment and independent leisure;
• Rigid gender stereotypes about the division of labour;
• Limited participation in unpaid workload of infant care and household tasks;
• Lack of sensitive emotional support;
• Criticism and coercive control;
(Fisher, Feekery and Rowe-Murray, 2002)

NEGLECTED BUT POTENTIALLY MODIFIABLE RISK
FACTORS
Occupational fatigue:
• Increased, but unrecognised, workload of infant care and household tasks;
• Frequently interrupted sleep;
• Insufficient sleep;
Contributes to:
• Irritability, poor concentration, reduced functional efficiency.

CHANGE IN MATERNAL DEPRESSION (EPDS)
13
12
11
10
9
8
7
6
5
Admission
* p<.0001
One month Six months

CHANGE IN INFANT CRYING AND FUSSING
160
140
120
100
80
60
Admission One month
* p <.001
Six months

Successful implementation of universal prevention strategies requires:
 Detailed understanding of the views of primary care providers;
 Consultation with primary care providers about content;
 Identification of barriers to implementation;
 Identification of learning needs.
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Aims:
 What are primary care practitioners ’ views, experiences, current practices in relation to postnatal mental health problems?
 What are their specific views about potentially modifiable risk factors for postnatal mental health problems?
 What are their views about adaptations to practice to include new strategies to prevent postnatal mental health problems?
 What learning needs do they identify?
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SURVEY
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MCH nurses in universal service only
MCH line nurses 39
BOTH MCH line and universal service 20
Total
(May 2012)
1012
Responded
325
11
7
Overall response rate = 343/1051=32.6%
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Number of years’ experience
Less than 2 years
2 - 5 years
6 - 10 years
11 - 20 years
More than 20 years n
44
62
62
94
81
%
12.8
18.1
18.1
27.4
23.6
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In your experience, what are the three main contributing factors to mental health problems in parents of infants in your area?
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We know that parents often seek help with a baby who is unsettled
(for example, sleeps poorly, cries inconsolably, is difficult to feed, is difficult to manage).
In your experience, what contributes to unsettled infant behaviour?
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Please imagine that a mother/caregiver presents with a concern regarding her 6 – month old infant, of age-appropriate weight, who wakes every few hours overnight and/or is difficult to settle. She is distressed about this. Please could you tell us briefly what advice you would give her.
MCH nurses have a consistent view that comprehensive assessment of and responses to women’s mental health are integral to MCH services.
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• most (213) would “discuss settling strategies”, but
• many (125) did specify what approach to settling would be taken;
• among the the rest, 25 different approaches were described e.g.:
Controlled comforting
Wrap the infant
Controlled crying Do not wrap the infant
Let the infant cry
Patting the cot
Camping out Do NOT let the infant cry
Stretcher method
Co-sleeping
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 In the absence of clear and specific clinical practice guidelines, nurse are currently offering very varied advice to parents
 No agreement amongst respondents about what sleep patterns are
“normal” for 6 month old infants, or whether / where to refer parents for help with sleep and settling problems.
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How do you ask a woman about her occupation?
Included because:
• increased, but unrecognised, workload of infant care and household tasks;
• rigid gender stereotypes about the division of labour are a common problem for parents in adjusting to new roles;
• primary care practitioners can be agents of social change;
• gender-informed language is part of establishing a mental health promoting milieu.
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 Many MCH nurses use language that names and values this unpaid work
 Some encourage women not to describe their current occupations as
‘not working’ or being ‘just a mother’.
I ask her what she does in 'paid employment.' If she says that she is 'only a mother' as many do, I tell her that she is doing the most important job that there is.
 However, some still ask about “work”.
Do you work normally?
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 Most MCH nurses indicated that fathers are welcome to attend.
 Only 12% reported that fathers are specifically invited.
 Specific group activities implemented to increase fathers ’ participation have not been well attended.
We've tried fathers groups in our area....no interest
 Current content of FTP groups:
• 45% include partner relationships
• 85% include “A settled baby: what does it mean?”
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Willingness to include a session about: n (%) neither willing nor unwilling
…adjustments to relationships, roles and responsibilities after the birth of an infant
…. infant soothing and settling techniques
46 (22.4%)
36 (17.6%) n (%) willing to make this change
138 (67.3%)
148 (72.2%)
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 Less than 1% of MCH nurses indicated that FTP group sessions are currently offered on a Saturday morning.
 Almost 75% acknowledged that offering programs only in conventional office hours was a barrier that prevents fathers from participating.
Willingness to include: n (%) neither willing nor unwilling n (%) willing to make this change
…at least one Saturday session, to increase participation of partners?
63 (30.7%) 78 (38.0%)
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 MCH nurses recognise that in addition to their role in the identification and treatment of current symptoms, they have a role in promotion of mental health and prevention of mental health problems;
 MCH nurses identified the following potential risks for postnatal mental health problems:
 new parents’ lack of relevant knowledge and skills to respond to unsettled infant behaviours; and
 lack of support / the quality of the intimate partner relationship.
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 MCH nurses have diverse views about ways to respond to parents seeking assistance with unsettled infant behaviours. This would be assisted by evidence-informed clinical practice guidance.
 They are interested in future professional development about the prevention of postnatal mental health problems in primary care.
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ACKNOWLEDGMENTS
• Victorian Department of Education and Early Childhood Development
• Anne Colahan
• Karene Fairbairn
• Jennifer Carr
• Municipal Association of Victoria
• Helen Rowe
• Jean Hailes Women’s Research Unit:
• Heather Rowe
• Joanna Burns
• Evaluation Solutions Pty Ltd
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