Journal of Community & Public Health Nursing
Open Access

Postpartum depression; Maternal mental health; PHQ-9; PHQ-2; Maternal health disparity

Introduction

Practitioners must consider the target population and social determinants of health when administering postpartum depression screenings and use tools with high sensitivity in that population. Women in the United States most at risk for postpartum depression (PPD) are disproportionately impoverished racial/ethnic minorities. The prevalence of PPD increases from affecting 1 in 8 mothers in the nation compared to 1 in 3 mothers in low-income communities. Edinburgh postnatal depression scale is the most widely used screening tool for women of depression.

Given the vast effects of PPD on the entire family and the disproportionate distribution of PPD among women from lower socioeconomic backgrounds, clinicians should devise a plan to decrease the rate of untreated PPD. Having an appropriate sensitive screening tool for this population is vital in this effort and the Edinburgh scale has not been studied in this specific population. The QI project helps identify other screening tools you can use in the specified population.

Methodology

Postpartum Depression (PPD) can adversely affect the mental and emotional well-being of the mother and, in severe conditions, may lead that mother to harm herself or her child. (American Psychological Association [1]. It can also lead to issues in child development and infant and mother attachment [1, 2, and 3]. Studies show that the populations in the United States most at risk for PPD are disproportionately impoverished racial/ethnic minorities. The prevalence of PPD increases from affecting 1 in 8 mothers in the nation to affecting 1 in 3 mothers in low-income communities [2, 3, and 4]. Unfortunately, women from low-income neighborhoods tend to face barriers to accessing quality mental healthcare due to the lack of financial resources and socioeconomic challenges [5, 6, and 7]. Given the vast effects of PPD on the entire family and the disproportionate distribution of PPD among women from lower socio-economic backgrounds, clinicians should devise a plan to decrease the rate of untreated PPD.

A needs assessment was completed in the summer and fall of 2020 at a home visiting clinic in Baltimore city. Between July 1st, 2020, and September 30th, 2020, there were 189 postpartum clients. 20 of 189 were in their first month postpartum and had an Edinburgh postnatal depression scale administered, finding three of 20 were positive. Seven of 189 clients had a positive PHQ-2. Looking at referrals, there were 26 mental health referrals for postpartum depression. Reviewing these numbers, a gap was noted between the number of clients who screened positive and the number of postpartum depression referrals. At the practice site, women are currently screened with the PHQ-2 and are given referrals to mental health services as needed. The previous flow process can be seen in (Figure 1). This process is not was not being monitored, and many women were not being screened for PPD. Referrals were placed when a CHW believed there may be a need for one. This led to low numbers of screenings being done and possibly led to missed cases of PPD. This quality improvement project aimed to implement an evidence-based screening and referral process for postpartum depression for women from low-income areas. This was done using the PHQ-2 followed by a PHQ-9, if positive, monthly until 12 months postpartum. The goal was to increase PPD screening to 100% of all clients contacted and have 100% of postpartum women enrolled in the program who were positively screened for postpartum depression have a direct referral for mental health services (Figure 2).

Figure 1: Process map- current postpartum depression screening process.

Figure 2: Desired postpartum depression screening process.

Evidence Review

A review and synthesis of the evidence were completed to support the practice change. The evidence review table can be seen in (Table 1).

Table 1:Evidence review table.
Level of Evidence                                                 Type of Evidence
I (1)        Evidence from systematic review, meta-analysis of randomized controlled trials (RCTs), or practice-    guidelines based on systematic review of RCTs.
II (2)       Evidence obtained from well-designed RCT and/or reports of expert committees.
III (3)     Evidence obtained from well-designed controlled trials without randomization.
IV (4)     Evidence from well-designed case-control and cohort studies
V (5)       Evidence from systematic reviews of descriptive and qualitative study
VI (6)     Evidence from a single descriptive or qualitative study
VII (7)    Evidence from the opinion of authorities

The evidence synthesis table can be seen in (Figure 3). Although the majority of sources recommend the routine screening of postpartum women for PPD, De Albuquerque concluded the risk of postpartum depression extends past six weeks up to one year; therefore, it is essential to develop a screening strategy that expands through this period [4]. This coincided with The American College of Obstetricians and Gynaecologists recommended screening for postpartum depression for up to 12 months after delivery. Therefore, the recommendation for the practice change is that screening is done monthly until 12 months postpartum.

Figure 3: Meleis' transitions theory.

Screening can be done using many depressions screening tools, including the patient health questionnaires [5]. O’Connor noted that screening instruments could identify pregnant and postpartum women who need further evaluation and need treatment for depression, screening can reduce the prevalence of depression in a population, and that the PHQ-2, if positive, should be followed by a PHQ-9. This is

recommended in practice guidelines. Flynn validated that the PHQ-9 and Edinburgh postnatal depression scale (EPDS) are equally effective in detecting MDD in perinatal and postpartum women [6].

Given that the target population of this practice change is lowincome black and Hispanic women, further research was conducted to ensure the population characteristics were considered. Hansotte, Payne & Babich found that financial barriers, stigma, not being familiar with PPD, and negative experiences with mental health professionals kept women from low-income backgrounds from seeking care after a positive result. Therefore, it is essential to use all resources to mitigate these barriers. Home health visitors can help screen and treat clients effectively in this population [s]. found that the PHQ-9 screening tool has good internal consistency and structural validity and is recommended for screening for depression in Latina women. Despite a possible language barrier using the patient health questionnaire translated into Spanish with this target population can be effective. Four studies concluded that the PHQ is an appropriate tool for black and Hispanic postpartum women to identify postpartum depression.

Theoretical Framework

The practice theory used for this project was Meleis' Transitions Theory (Figure 4). The goal of the transition theory is to help people go through healthy transitions to enhance healthy outcomes [9]. This theory can be applied to childbirth and the development (or not) of postpartum depression. The theory notes that the transition experience occurs before the event and has a fluid ending point, indicating why mothers should be monitored for depression before, during, and after delivery. In addition, this theory identifies 'change triggers,' and childbirth can be a developmental or situational trigger. Properties of the transition regarding postpartum depression can include disconnectedness and a lack of awareness. These properties can predispose the mother to postpartum depression. 'Conditions of the change' include community, societal and personal factors. Conditions such as low social-economic level decreased access to care, and increased risk factors for postpartum depression can affect the mother and put her at risk for postpartum depression. In the transitions theory, interventions facilitate and inspire healthy processes and outcomes. This can be done with an intervention that mobilizes support and provides resources, which will lead to patterns of response to receiving help and improved emotional wellbeing. The Complex Innovation Implementation Framework was used to guide this evidence-based practice change. Incorporating this theory into this practice change, management support was garnered and can be seen in the implementation team that included several of the organization's management team members [10]. The strategies and tactics used in this implementation plan incorporated key determinates, including champions and implementing policies and practices at the organization to help ensure implementation effectiveness. Practices and procedures were also re-designed for this implementation plan.

Figure 4: Conceptual framework for complex innovation implementation.

The organization that implemented this change caters to women in underserved areas in Baltimore City. The Census Bureau and Baltimore City have identified women in these areas as living in an area that needs additional resources. Many of these women were on Medicaid or did not have any health insurance. They also offer services to undocumented immigrants that have issues with access to healthcare. Therefore, the effect of this evidence-based practice change was geared toward reaching the most vulnerable populations. These women received these services free of charge. There were two Nurses, three case managers, and 12 Community Health Workers (CHW) that served 272 postpartum women in the organization (Figure 5).

Figure 5: Data collection tools.

The evidence-based intervention being changed focused on the postpartum depression screening and referrals process. The CHW performed monthly visits on every postpartum client. During their visit, the CHW completed a PHQ-2 questionnaire. This questionnaire was to be completed every month until 12 months postpartum. If positive, with a score of two or more, a PHQ-9 was completed. If scored a four or above on the PHQ-9, indicating mild depression, the CHW then provided the mother with a direct referral for mental health services. In this process, the nurse reviewed all referrals and questionnaires, and the case manager kept track that if a client had a positive screening, she had received a mental health referral using the data management spreadsheet and disposition log.

Structure measures included staff being trained on the new process map for postpartum depression and referral. During the educational meeting, demonstrations were given on conducting the interview, filling out the PHQ, and putting in a referral. Feedback from staff indicated that the demonstrations were the most helpful part of the training.

The goal was to have 100% of all eligible women screened for postpartum depression until 12 months postpartum. Tactics to help the process measure included audits on Tuesdays after meeting with the data expert. Once the data was evaluated, individual feedback was given to staff on the specific data they turned in. Another goal was to have 100% of all positive screening tools to have a mental health referral. Chart audits were conducted to help achieve this goal as well.

Data collection was conducted weekly via chart audits and data was entered into the data management system for evaluation. Data reports were run on the numbers each week on all clients who have completed screening. A manual review of mental health referrals was conducted weekly for each positive PHQ for postpartum depression. To protect patient privacy, no directly identifiable data were collected, and each client was given a number. This is a non-human subject quality improvement project therefore, IRB approval was not indicated (Figure 6).

Figure 6: Data collection tools.

Results

Before implementation, the structure measures of 100% of staff being trained on the new process map for postpartum depression and referral process to mental health services were completed by 18 staff members (three case managers, two nurses, and 13 CHWs were trained). The trend on the run chart showed low screening numbers in the first few weeks of implementation therefore, staff check-ins and re-education were completed in weeks 6, 9, and 13. This resulted in increased screening tools being completed in the subsequent weeks.

At the end of the 14 weeks of implementation, 134 PHQ screening tools were completed for PPD. There were 179 postpartum women enrolled in the program, but only 171 were able to be contacted during the implementation period. Women not contacted were excluded from the results. Fourteen percent (n=24) of postpartum women screened positive for PPD (score of 4 or more). This is a 64% increase in positive PPD screening tools compared to pre-implementation rates. The run chart trends showed increased screening rates every week after completed staff check-ins. During the week of thanksgiving, no screening tools were documented due to the office being closed for three days that week.

The process measure was to have 100% of all eligible women screened for postpartum depression until 12 months postpartum. During implementation, 74.8% of women were screened for PPD using the PHQs. Some identified barriers to reaching this goal included the high turnover of clients, a turnover of one case manager and two CHWs, which increased workloads, the inability to reach clients due to their change in phone numbers and housing, and disconnected phone lines (Table 2).

Table 2:Synthesis table.

I (1)        Evidence from systematic review, meta-analysis of randomized controlled trials (RCTs), or practice-guidelines based on systematic review of RCTs.
II (2)       Evidence obtained from well-designed RCT and/or reports of expert committees.
III (3)     Evidence obtained from well-designed controlled trials without randomization.
IV (4)     Evidence from well-designed case-control and cohort studies
V (5)       Evidence from systematic reviews of descriptive and qualitative study
VI (6)     Evidence from a single descriptive or qualitative study
VII (7)    Evidence from the opinion of authorities

The long-term process measure was to have 100% of women screened positive for postpartum depression to have a direct mental

health referral for services. All 24 women who screened positive had a direct referral, meaning a mental health facility accepted the referral and was in the process of scheduling the intake and first visit. The process in which referrals were to be completed was changed before implementation due to the online platform UniteUs not being functional. Therefore, we created a working relationship with a nearby mental health facility with an electronic referral system. They worked closely with us to ensure all referrals were received and processed. Unfortunately, by the time implementation was complete, we could not assess the disposition of every woman to see if their mental health visit was completed.

Discussion

This quality improvement project's key impact was increased compliance and screening rates for postpartum depression in lowincome women. It was identified that the PHQ was more appropriate in this population. In addition, clients and staff commented PHQ tool was utilized more efficiently than the Edinburgh postnatal depression scale. Therefore, more patients were able to complete it without difficulty. This coincides with the research that identified internal consistency, validity, and better usability of the PHQ with women from lowincome backgrounds with decreased reading levels and in the Hispanic population.

In this population of low-income women in an urban city, PPD rates are expected to be 1 in 3 or 33%. In this quality improvement project, 14% of women screened positive for PPD. Some limitations were identified in the results and included being unable to reach clients due to their change in phone numbers and disconnected phone lines.

These limitations were increased since COVID-19 because CHWs were no longer primarily conducting in-person home visits; instead, all questionnaires were completed via phone. To adjust for this, we did not count women who could not be contacted at all during the implementation periods. Still, inconsistent communication could have been a barrier and affected results.

Conclusion

Women from low-income neighborhoods tend to face barriers to accessing quality mental healthcare due to the lack of financial resources and socio-economic challenges [11,12]. Given the vast effects of PPD on the entire family and the disproportionate distribution of PPD among women from lower socio-economic backgrounds, clinicians should devise a plan to decrease the rate of untreated PPD. This QI project demonstrated that routine depression screening of postpartum women with the PHQ could facilitate timely referral of mental health services. Healthcare providers must also consider the population they serve and their Social Determinants of Health when administering screening tools and implement using tools that are best suited for their patients. Identifying and referring women from high-risk populations for PPD treatment can help decrease the effects PPD has on the mother and family alike. It was determined from this QI project that in the future, continued support of the program with staff education, training, and check-ins may be beneficial to similar clinics. For sustainability at this clinic, case managers have been trained and added to their process to include in their monthly check-in with their CHWs that they are completing PPD screening tools and answering and providing support. Staff education will be conducted yearly and continued access to recorded training videos for new staff or a refresher for current staff.

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