Even before the pandemic, we were facing a shortage of mental health providers in the United States. One group especially impacted by the inadequacy of our mental health system is women with perinatal mood and anxiety disorders. Over the last decade, clinicians have become more aware of perinatal mood and anxiety disorders and are more often identifying women with this group of disorders; however, there is still a lot of room for improvement. Women who experience psychiatric illness in this setting continue to receive inadequate treatment or receive no treatment whatsoever.
The American College of Obstetricians and Gynecologists (ACOG) recommends that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. Furthermore, ACOG notes, “Although screening is important for detecting perinatal depression, screening by itself is insufficient to improve clinical outcomes and must be coupled with appropriate follow-up and treatment when indicated; clinical staff in obstetrics and gynecology practices should be prepared to initiate medical therapy, refer patients to appropriate behavioral health resources when indicated, or both.” While obstetric providers have clearly increased their ability to identify women with PMADs, there is no way they can address all of the mental health needs of this population.
Although not specifically trained to provide mental health services, nurses and midwives are ideally positioned to identify mental health challenges in perinatal populations. Because they work within the obstetric framework and have frequent contact with obstetric patients, they have the opportunity to form a solid alliance with their patients and can monitor for mental health problems emerging during pregnancy or the postpartum period. Previous studies have also demonstrated that, instead of using mental health providers, it is possible to train people from the community to provide psychological interventions which are effective in reducing the severity of depressive symptoms.
A recent review from Wang and colleagues looked at the effectiveness of nurse- and midwife-delivered psychological interventions for women with perinatal mental health disorders. They focused on intervention studies conducted in the perinatal care setting, including community-based programs (e.g., home services, community clinics, prenatal clinics, neonatal clinics and delivery institutions) and hospital-based programs (for example, obstetric clinics, delivery rooms, and postpartum wards). While some studies they found included care delivered by mental health professions, this review focused only on psychological interventions provided by midwives or nurses.
They identified 12 studies published between 1989–2019. The final analysis included a total of 4,141 women (2,636 in the intervention group; 1,505 in the control group). These trials were conducted in the United Kingdom, Australia, Norway, Iceland, Nigeria, Spain and France. No studies were from the United States.
- Five studies (45%) investigated cognitive behavioural methods (Brugha et al, 2011, 2016; Ingadóttir & Thome, 2006; Prendergast & Austin, 2001; Thome et al, 2012)
- Three studies (28%) used supportive counselling (Glavin et al 2010; Holden et a, 1989; Morse et al, 2004)
- Two studies (18%) used psychoeducation (Gureje et al, 2019; Toohill et al, 2014)
- One study used psychosomatic therapy (Collado et al, 2014).
All studies used the EPDS as an instrument to identify perinatal depression, with eight trials using an EPDS score of 12 or greater as the cutoff score for perinatal depressive symptoms. Most interventions were performed 8–12 weeks after delivery and in the other three studies, it was provided in the second and third trimesters.
In terms of effectiveness, the researchers assessed the interventions’ immediate effects (within 2 weeks) and short-term effects (9–12 weeks) post-intervention . Compared to the control group, women receiving psychological intervention provided by nurses and midwives experienced a reduction in depression symptoms by 36% within 2 weeks (RR: 0.64, 95% CI [0.50–0.83]) and by 25% at 9–12 weeks post-intervention (RR: 0.74, 95% CI [0.65–0.86]).
Subgroup analyses showed that cognitive behavioral approaches and supportive counselling were the most effective in reducing depressive symptoms (RR: 0.63, 95% CI [0.51–0.78] and RR: 0.58, 95% CI [0.42–0.80], respectively). Psychoeducation did not yield statistically significant improvements in depressive symptoms.
Subgroup analysis demonstrated interventions consisting of fewer than four sessions reduced depressive symptoms by 30% (RR: 0.70, 95% CI [0.52–0.95]) and interventions with 6–8 sessions did not significantly improve effectiveness over shorter interventions (RR: 0.66, 95% CI [0.55–0.79]) the symptoms of depression were significantly reduced. Interestingly, psychological interventions with 10–16 sessions did not have a beneficial effect on depressive symptoms (RR 0.85, 95% CI [0.68–1.05]).
The Bottom Line
The findings of this review indicate that psychological interventions provided by nurses and midwives can significantly reduce the severity of perinatal depressive symptoms. This study suggests that by providing appropriate training and relevant knowledge and skills, nurses and midwives can provide a psychological intervention similar in efficacy to those provided by mental health professionals.
We have often observed that women diagnosed with depression during the perinatal period are unlikely, unwilling, or unable to seek mental health services when they are provided outside of the obstetrical setting. Nurses and midwives have multiple contacts with women during the perinatal period, and thus are in a position to detect mental health problems earlier than other professionals. Other studies have demonstrated that nurses and midwives not only provide medical services related to pregnancy and childbirth, but they also attend to women’s mental health issues and provide timely emotional support, which can help increase women’s awareness of depressive symptoms and reduce their risk of depression (Brugha et al, 2011, 2016; Glavin et al, 2010). Furthermore, considering perinatal depression as a possible complication of pregnancy, just like gestational diabetes or hypertension, may help to decrease the stigma of receiving treatment. Thus, if we can provide nurses and midwives with the training needed to deliver psychological interventions, we can further enhance their capacity to effectively care for women with perinatal mental health problems.
How we can translate this information into American obstetric practice is less clear. None of these studies were carried out in the United States. In the US, only 8% of women are cared for by midwives. In the United Kingdom, however, midwives care for most obstetric patients; only high risk patients are seen by obstetricians. Nonetheless, we have seen that the most successful models of perinatal mental health care are those in which mental health services are provided in the obstetric setting.
Ruta Nonacs, MD PhD
Wang TH, Pai LW, Tzeng YL, Yeh TP, Teng YK. Effectiveness of nurses and midwives-led psychological interventions on reducing depression symptoms in the perinatal period: A systematic review and meta-analysis. Nurs Open. 2021 Sep;8(5):2117-2130. Free article.
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