a systematic review of systematic reviews of interventions to improve maternal mental health and...
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Midwifery 29 (2013) 389–399
Contents lists available at SciVerse ScienceDirect
Midwifery
0266-61
http://d
n Corr
E-m
j.mcneil
journal homepage: www.elsevier.com/midw
A systematic review of systematic reviews of interventionsto improve maternal mental health and well-being
Fiona Alderdice, BSSc, PhD (Chair in Perinatal Health and Well-being)n, Jenny McNeill, BSc, MSc, PhD(Lecturer in Midwifery Research), Fiona Lynn, BA, MSc, PhD (Improving Children’s Lives Research Fellow)
School of Nursing and Midwifery, Queens University Belfast, Medical Biology Centre, Lisburn Road, UK
a r t i c l e i n f o
Article history:
Received 5 August 2011
Received in revised form
24 May 2012
Accepted 27 May 2012
Keywords:
Maternal mental health
Well-being
Midwifery
Review
38/$ - see front matter & 2012 Elsevier Ltd. A
x.doi.org/10.1016/j.midw.2012.05.010
esponding author.
ail addresses: [email protected] (F. Alde
[email protected] (J. McNeill), [email protected] (F.
a b s t r a c t
Objective: to identify non-invasive interventions in the perinatal period that could enable midwives to
offer effective support to women within the area of maternal mental health and well-being.
Methods: a total of 9 databases were searched: MEDLINE, PubMed, EBSCO (CINAHL/British Nursing
Index), MIDIRS Online Database, Web of Science, The Cochrane library, CRD (NHS EED/DARE/HTA),
Joanne Briggs Institute and EconLit. A systematic search strategy was formulated using key MeSH terms
and related text words for midwifery, study aim, study design and mental health. Inclusion criteria
were articles published from 1999 onwards, English language publications and articles originating from
economically developed countries, indicated by membership of the Organisation for Economic
Co-operation and Development (OECD). Data were independently extracted using a data collection
form, which recorded data on the number of papers reviewed, time frame of the review, objectives, key
findings and recommendations. Summary data tables were set up outlining key data for each study and
findings were organised into related groups. The methodological quality of the reviews was assessed
based on predefined quality assessment criteria for reviews.
Findings: 32 reviews were identified as examining interventions that could be used or co-ordinated by
midwives in relation to some aspect of maternal mental health and well-being from the antenatal to
the postnatal period and met the inclusion criteria. The review highlighted that based on current
systematic review evidence it would be premature to consider introducing any of the identified
interventions into midwifery training or practice. However there were a number of examples of
possible interventions worthy of further research including midwifery led models of care in the
prevention of postpartum depression, psychological and psychosocial interventions for treating
postpartum depression and facilitation/co-ordination of parent-training programmes. No reviews were
identified that supported a specific midwifery role in maternal mental health and well-being in
pregnancy, and yet, this is the point of most intensive contact.
Key conclusions and implications for practice: This systematic review of systematic reviews provides a
valuable overview of the current strengths and gaps in relation to maternal mental health interventions
in the perinatal period. While there was little evidence identified to inform the current role of midwives
in maternal mental health, the review provides the opportunity to reflect on what is achievable by
midwives now and in the future and the need for high quality randomised controlled trials to inform a
strategic approach to promoting maternal mental health in midwifery.
& 2012 Elsevier Ltd. All rights reserved.
Introduction
Pregnancy is characterised by physiological, social and emo-tional changes and demands which can impact on maternal well-being. Empirical studies suggest that 15–25% of women experi-ence high anxiety or depression during pregnancy (Ross and
ll rights reserved.
rdice),
Lynn).
McLean, 2006; Lee et al., 2007; Figueiredo and Conde, 2011) andthat anxiety and depression levels are higher during pregnancycompared with the postpartum period. Both antenatal anxietyand depression have been found to be associated with poorobstetric and neonatal outcomes (Mancuso et al., 2004; Marcusand Heringhausen, 2009; Dunkel-Schetter and Glynn, 2010;Dunkel-Schetter, 2011). In addition to short term morbidity,maternal mental illness can have an adverse impact on familyfunctioning, and the cognitive, emotional, social and behaviouraldevelopment of infants (Dennis and Hodnett, 2007; Talge et al.,2007).
Additional, associated text wordsMidwife/ves / certified nurse midwifeCommunity midwife/vesAntenatal care / services(Supportive) Intervention(s)Prevention(s)Cost evaluationCost effectiveness / economic evaluationLiterature reviewSystematic reviewPre-existing mental illnessWell-being / wellbeing / wellnessPostpartum psychosis
Mental healthMental disordersStress, psychological / AnxietyStress disorders, post-traumaticMood disorders
MeSH termsMidwiferyMidwifery / Obstetric nursingCommunity Health NursingPregnancy / Pregnant womenPrenatal careCare, postnatalStudy aimEvidence-based practiceHealth promotionCosts and cost analysisCost-Benefit AnalysisStudy designReviewMeta-AnalysisMental healthDepressionDepression, postpartum
Fig. 1. Search terms.
F. Alderdice et al. / Midwifery 29 (2013) 389–399390
Women are in regular contact with health-care services duringthe perinatal period and midwives are in a key position to educateand support women about mental health and well-being andidentify women at risk: those experiencing increased stress,women at increased risk of developing mental health problemsor women with existing mental illness. The final report fromMidwifery 2020, identifies the midwife as the key health profes-sional to promote well-being for women with uncomplicatedpregnancies and it outlines a pivotal role for midwives inco-ordinating the journey through pregnancy for all women.The co-ordinating role of the midwife ensures women are referredto other services when appropriate and that holistic care isprovided to optimise each woman’s birth experience regardlessof risk factor (Midwifery 2020 Final Report, 2010). This is furtherhighlighted by the CMACE report (Lewis, 2011), which recom-mends that midwives should be able to refer directly to psychia-try services to avoid women being lost in the system. Howeverclarity is required on what effective interventions exist thatwould enable midwives to offer appropriate support and co-ordination of care within the area of maternal mental healthand well-being. Gaps in knowledge also need to be identified, sothat we provide an evidence based approach to the ongoingresearch and development of the role of midwifery in supportingmaternal mental health and well-being.
This systematic review of systematic reviews was conductedas part of a larger review study on the public health role of themidwife for Midwifery 2020 (McNeill et al., 2010). The reviewexplored the education, support and screening roles of midwivesthrough the reproductive pathway starting before conceptionthrough pregnancy, childbirth and the postnatal period. Lookingtowards 2020, the review explored interventions based on theeveryday role of the midwife, which could be built on overthe next decade to further develop the public health role of themidwife. The Royal College of Midwives (RCM) states that it isappropriate for midwives to gain competence in new skills, inaccordance with NMC requirements, so that they can offerwomen a wider range of choices during maternity care includingnon-invasive therapies (RCM, 2007). Therefore this review alsoincluded interventions that could be conducted by midwives withspecialist training.
In the presence of time and financial constraints, a systematicreview of systematic reviews provides a coherent appraisal andsummary of reviews, allowing the findings of individual reviewsto be compared and contrasted, facilitating a broad scope ofmental health interventions. The specific research aim of thisreview was to identify which non-invasive interventions in theperinatal period would enable midwives to offer effective care towomen within the area of maternal mental health and well-being.
Methods
Search strategy
A total of 9 databases were searched: MEDLINE, PubMed,EBSCO (CINAHL/British Nursing Index), MIDIRS Online Database,Web of Science, The Cochrane library, CRD (NHS EED/DARE/HTA),Joanna Briggs Institute and EconLit. A systematic search strategywas formulated including key MeSH terms and related text wordsunder the headings of Midwifery, Study Aim, Study Design andMental Health (see Fig. 1).
Inclusion criteria were articles published from 1999 onwards,English language publications and articles originating from eco-nomically developed countries, indicated by membership of theOrganisation for Economic Co-operation and Development (OECD).If the review did not clearly state the search strategy or include
search terms and databases accessed they were not deemed eligiblefor inclusion. The key terms for inclusion in the search strategywere discussed and agreed with the study Advisory group and theMidwifery 2020 Public Health Stream working group. Interventionsthat could be used by or co-ordinated by a midwife were broadlyagreed to include education, screening and support. Ambiguity as tothe suitability of inclusion in regard to the role of the midwife wasdiscussed within the project team (which included a midwife and2 others with significant experience of maternity care research). Ifconsensus could not be reached within the study team inclusionwas agreed with the Advisory group.
The following exclusion criteria were applied: reviews relatedspecifically to obstetric interventions in pregnancy, rather thanmidwifery, and those which were not directly related to mentalhealth and well-being of women from antenatal to the postnatalperiod. Reviews of interventions requiring specialist long termprofessional training such as psychotherapeutic interventionswere also excluded unless part of a broader review.
The initial search was conducted in November 2009, with afinal update of the search carried out in October 2010. The initialsearch was conducted as part of a larger review of reviews, thefull methods and results of which can be found in McNeill et al.(2010). A broader literature review on maternal mental health inthe antenatal and postnatal period, beyond the remit of thecurrent review of reviews on the role of the midwife in maternalmental health and well-being, can be found in the NICE guidelines(National Collaborating Centre for Mental Health, 2007).
F. Alderdice et al. / Midwifery 29 (2013) 389–399 391
Data extraction
Data were independently extracted using a data collectionform, which recorded data on the number of papers reviewed,time frame of the review, objectives, key findings and recom-mendations. One review author independently assessed all thepotential studies meeting the inclusion criteria and this wasverified by a second author. Data were then extracted by theprimary author using the data collection form. Any ambiguity ordisagreement was resolved through discussion. Summary datatables (Table 1) were set up outlining key data for each study andfindings were organised into related groups.
Data quality assessment
The methodological quality of the reviews was assessed basedon assessment criteria in Smith et al. (2011). For a review to berated as ‘high quality’ there would be evidence of search strategy,selection and inclusion criteria, assessment of publication biasand heterogeneity noted in methods or results. A review wasrated as ‘medium quality’ if there was evidence of search strategy,selection and inclusion criteria but no assessment of bias orheterogeneity; while a rating of ‘low quality’ was given if therewas evidence of a search strategy but no evidence of the otherquality assessment criteria. One reviewer independently assigneda quality rating to each review and this was then verified indiscussion with the other two reviewers.
Results
The search identified 2,497 abstracts which were screened forrelevance to the area of maternal mental health and well-beingand use of a review methodology. Full text was obtained for 194reviews and 32 were identified as examining interventions thatcould be used or co-ordinated by midwives in relation to someaspect of maternal mental health and well-being from theantenatal to the postnatal period and had a documented searchstrategy. Full details of the search stages can be found in Fig. 2.
The 32 reviews were organised under antenatal and postnatalheadings which are identified in Fig. 2. Six more generic reviewscovered more than one mental health issue and they have beenintroduced into one of seven sections below where they providethe most data. Eight of the reviews also included a meta-analysis.The key findings of these reviews can be found in Table 1.
Antenatal
Antenatal screening for mental health problems
A Cochrane review by Austin et al. (2008) on antenatalpsychosocial assessment for reducing perinatal mental illnessdid not support the use of screening tools to identify mentalillness in pregnancy. The Edinburgh Postnatal Depression Scale(EPDS) is widely used to screen for postnatal depression symp-toms and a cut off score of 9–10 is often used to indicate womenwho are at risk of postnatal depression. Two small studies werefound, both of which had significant methodological limitations,there was no evidence that using these screening instruments ledto improved maternal mental health as measured by the EPDS.
Interventions to treat antenatal depression and anxiety
Three reviews were identified that explored treatments forantenatal depression and anxiety (Dennis et al. 2007; Beddoe and
Lee, 2008; Dennis and Allen, 2008). Dennis et al.’s (2007) Cochranereview of psychological and psychosocial interventions for thetreatment of antenatal depression found only one trial whichexamined the efficacy of interpersonal psychotherapy for thetreatment of depressed pregnant women. While the psychotherapygroup had a reduction in EPDS scores immediately post-treatmentin comparison to a parenting education group, the trial was toosmall to draw any conclusions. It was also conducted by a trainedtherapist and, therefore, beyond the everyday role of the midwife.
Dennis and Allen (2008) conducted a high quality reviewlooking at interventions other than non-pharmacological/psycho-social/psychological interventions delivered by a professional orlay person. One small three arm trial (two others did not have themethodological quality required for inclusion) looking at massageand depression-specific acupuncture sessions was identified andneither treatment was found to be effective in reducing depres-sive symptoms.
A review by Beddoe and Lee (2008) suggests that there is someevidence from a number of poorly designed studies that pregnantwomen have health benefits from mind–body therapies, for exam-ple, psycho-education, relaxation, yoga and meditation in conjunc-tion with conventional prenatal care. Existing studies suggest thatthese interventions could reduce perceived stress and anxiety,increase birth weight and shorten labour (Beddoe and Lee, 2008).However, the evidence is limited by small sample size and lack of acontrol group and should be interpreted with caution.
Postnatal
Postnatal screening for mental health problems
One review of postnatal screening for mental health problemswas identified (Hewitt and Gilbody, 2009; also reported in Hewittet al. 2009) and a further general review provided data in this area(Matthey, 2004). Hewitt and Gilbody (2009) identified fourscreening studies in their review, all using the EPDS. Two of thestudies looked at EPDS threshold scores at 6 weeks and twolooked at EPDS scores at 16 weeks. The meta-analysis showed asignificant reduction in the EPDS which suggests a reduction inrisk of postnatal depression. However, they noted that the use of aformal screening instrument to identify postnatal depression wasconfounded in a number of studies, as the screening interventionwas included with enhancement of care, such as counselling orinterviewing training. Hewitt and Gilbody (2009) conclude thatthere is insufficient evidence that the EPDS is effective in thepostnatal detection of postnatal depression and the subsequentimprovement in maternal and infant health and well-being.Matthey (2004) provides evidence on detection and treatmentof postnatal depression (including anxiety) and suggests bothanxiety and depression should be assessed in new mothers andfathers. However, the review was rated as low quality as it lackedreporting of selection and inclusion criteria, assessment of pub-lication bias and heterogenity.
Interventions for the prevention of postpartum depression
Of the eight reviews in this area (Ciliska et al., 2001; Austin,2003; Bick, 2003; Ogrodniczuk and Piper, 2003; Dennis andCreedy, 2004; Lumley et al., 2004; Dennis, 2004a; Boath et al.,2005), the Cochrane review by Dennis and Creedy (2004) pro-vided the highest quality data. Within this review, study meth-odological quality was good and all but one involved anintervention from a health professional. The review summarisedthe results of 15 trials involving 7,697 women that were con-ducted in four countries in a wide variety of circumstances.
Table 1Included reviews of mental health and well-being (n¼32).
Author (s) (year) Number of papersincluded (daterange)
Intervention Mental health outcomes Main results/findings Meta-analysis(yes/no)
Qualitylevel
AntenatalScreening for mental health problems
Austin et al. (2008) 2 (–2008) Antenatal psychosocial assessment Psychiatric symptomology No significant effects on depression,
anxiety
No High
Anxiety and depression scores Trend towards raised level of clinical
awareness of risk factors.
Interventions for treating antenatal-depression and anxiety
Beddoe and Lee (2008) 12 (1980–2007) Mind–body interventions during
pregnancy
Perceived stress, mood and perinatal
outcomes
Studies included psycho-education
(3) relaxation (7) and yoga and
medication (2)
No Low
High heterogeneity in design, small
sample size, poor quality—results
inconclusive
Dennis and Allen (2008) 1 (1966–2007) Non-pharmacological/psychosocial/
psychological interventions for the
treatment of antenatal depression
Antepartum/postpartum depression One small trial including massage
therapy and acupuncture. Results
inconclusive.
No High
Maternal mortality
Dennis et al. (2007) 1 (1966–2006) Psychosocial and psychological
interventions for treating antenatal
depression
Antepartum/postpartum depression Interpersonal psychotherapy
compared to a parenting education
programme was associated with a
reduction in the risk of depressive
symptoms immediately post-
treatment
No High
Maternal mortality
PostnatalPostnatal screening for mental health problems
Hewitt and Gilbody (2009) 4 (–2007) Antenatal and postnatal identification
of depressive symptoms (all used
EPDS)
Reduction in EPDS score postpartum
and cost effectiveness
Meta-analysis showed beneficial effect
of using the EPDS in reducing EPDS
scores (OR 0.61 CI 0.48–0.76). Difficult
to interpret as 2 out of 4 studies also
included enhancement of care.
Yes High
Interventions for the prevention of postpartum depression
Austin (2003) 5 (1995–2001) Targeted antenatal group interventions Depression scores, DSM-IV depression
classification
One study showed significant effects
on depression scores for primaparous
women
No Medium
Bick (2003) 12 (1990–2002) Care provided by midwives (and other
care workers) to prevent or reduce
postnatal psychological health
problems
Depression scores, questions on
psychological health
5/12 studies showed positive effects on
preventing postnatal depression
No Medium
Boath et al. (2005) 21 (1966–2003) A broad range of interventions for
preventing postnatal depression,
including psychological and social
support interventions
Postnatal depression 9/21 studies showed positive short
term effect of intervention on
preventing postnatal depression.
Evidence of effect in one trial for
extending specialist midwifery care.
Varying study quality.
No High
Ciliska et al. (2001) 20 (1980–1998) Home visiting in the prenatal and
postnatal period
Not specified in methods range of
maternal and infant outcomes
reported
No negative effect of home visiting
reported. Positive effects reported
include physical and mental health,
development of healthy habits and
knowledge and service utilisation of
mother and baby. Results inconclusive.
Varying study quality.
No High
Dennis (2004a) 29 (1966–2003) Non-biological interventions for the
prevention of postpartum depression
Postpartum outcome assessment Interventions include interpersonal
psychotherapy, cognitive-behavioural
No High
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therapy, psychological debriefing,
antenatal classes, intrapartum support,
supportive interactions, continuity of
care, antenatal identifications and
notification, early postpartum follow-
up, flexible postpartum care,
educational strategies, relaxation with
guided imagery. There was insufficient
evidence to recommend any particular
intervention.
Dennis and Creedy (2004) 15 (1966–2004) Psychosocial and psychological
interventions for preventing
postpartum depression
Postpartum depression/psychosis Women receiving psychosocial
interventions were equally likely to
develop depression as those receiving
standard care
Yes High
Maternal mortality (RR 0.81, CI 0.65–1.02).
Identifying mothers at risk assisted
prevention of postpartum depression
(RR 0.67, CI 0.51–0.89)
Interventions with only postnatal
component more beneficial than
those also incorporating antenatal
component (RR 0.76, CI 0.58–0.98)
Individually based interventions
more effective than group based (RR
0.76, CI 0.59–1.00)
No preventive effect of psychological
debriefing (RR 0.57 CI, 0.31–1.04)
Lumley et al. (2004) 42 (1980–2003) Non-pharmaceutical and non-
hormonal interventions to reduce
postnatal depression
Depression characterised by caseness
or probably caseness by diagnostic
interview or standard measure
Postnatal counselling intervention
provided to women with depression or
probable depression will reduce
depressive symptoms and depression
substantially with an NNT of 2 or 3.
Community postnatal midwifery care
had a NNT of 14. Continuity of care,
doula support in labour, nurse support
in labour, postnatal debriefing by a
midwife, interventions to enhance
mother–infant intervention could not
be recommended as strategies for
reducing postnatal depression.
Yes High
Ogrodniczuk and Piper (2003) 19 (1990–2003) Interventions for preventing
postpartum depression
Postpartum depression Results were mixed No Medium
13/19 studies were midwifery based
and several provided support for the
role of midwife based interventions
for women both in the antenatal and
postnatal period
Postnatal debriefing
Gamble et al. (2002) 3 (1982–2000) Postnatal debriefing and non-directive
counselling
Postpartum psychological morbidity High variability in studies in terms of
design, definition of debriefing and
measurement of outcomes. Overall no
evidence of effect.
No Medium
Gamble and Creedy (2004) 19 (1966–2003) Content and process of postpartum
counselling
Description of interventions Most studies recommended an
interpersonal approach to counselling
but findings descriptive rather than
evaluative
No Low
Maternal outcomes Descriptions of intervention general
and non-specific
Lapp et al. (2010) 9 (–Feb 2010) Postnatal interventions for PTSD PTSD symptoms after childbirth Six RCTs and one pilot RCT study of
debriefing, one case report on CBT and
No High
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Table 1 (continued )
Author (s) (year) Number of papersincluded (daterange)
Intervention Mental health outcomes Main results/findings Meta-analysis(yes/no)
Qualitylevel
one pilot study of eye movement
desensitisation and reprocessing.
Overall inconclusive evidence of
effective interventions.
Rowan et al. (2007) 8 (1990–2006) Postnatal debriefing interventions Maternal mental health problems No overall evidence of effect. 2/8
studies showed evidence of effect (one
midwife-led counselling, the other
midwife-led debriefing).
Methodological quality variable.
No Medium
Treatment of postpartum depression
Bledsoe and Grote (2006) 11 (1997–2004) Treatment for women with depression
during pregnancy and postpartum
period
Depressive symptomatology Meta-analysis of treatment v control
effect size for all interventions 0.673
(po0.001). However the effect size
was greatest for medication with
psychological therapies. None of the
3 counselling and educational
interventions had a significant effect
Yes Medium
Boath and Henshaw (2001) 30 (1964–2000) Treatment of women with postnatal
depression
Self-reported depression and
depressive symptomatology
Result inconclusive. Studies of varying
quality and design.
No Medium
Dennis (2004b) 21(1966–2003) Non-biological interventions to treat
postpartum depression
Postpartum depression up to one year
postpartum
A range of interventions were
identified IPT, CBT, peer and partner
support, non-directive counselling,
relaxation massage therapy, infant
sleep interactions, infant mother
relationships therapy, maternal
exercise. The results were inconclusive
and the studies of varying quality.
No High
Dennis and Hodnett (2007) 10 (1966–2006) Postnatal psychosocial and
psychological interventions
Postpartum depression Psychological and psychosocial
interventions were effective in
decreasing depressive
symptomatology, however measured,
within the first year postpartum (RR
0.70, CI 0.6–0.81)
Yes High
Maternal mortality
Daley et al. (2007) 5 (–2006) Exercise Postpartum depression Results inconclusive. Studies of varying
quality.
No Low
Daley et al. (2009) 5 (–2008) Exercise Postnatal depression Exercise reduced postnatal depression
(RR �0.8, CI �0.64 to �0.35).
Significant heterogeneity reduces the
integrity of the findings
Yes High
Freeman (2006) 4 (1965–05) Omega-3 fatty acids Major depressive disorder Two studies showed no evidence of
effect
No Low
Two pilot studies showed potential
efficacy
Stevenson et al. (2010) 6 (1950–2008) Group cognitive behavioural therapy
(CBT)
Postnatal depression 3/6 studies showed that group CBT was
effective in reducing depression when
compared to routine primary care,
usual care or waiting list initiatives
No High
Parental training programmes to improve maternal mental health
Barlow et al. (2003) 26 (1970–2002) Group-based parenting programmes Psychosocial Health (anxiety,
depression, social support, self-esteem,
relationship with partner)
Meta-analysis of five outcomes Yes High
Parenting programs effective in
improving depression (Mean
difference �0.26, CI �0.40 to �0.11)
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Effective in improving anxiety/stress
(mean difference �0.4, CI �0.6 to
�0.2)
No evidence of effect in improving
social/support
Effective in improving self-esteem
(MD �0.3, CI �0.5 to 0.1)
Effective in improving relationship
with partner (MD �0.4 CI �0.7 to
�0.2)
GenericAustin and Priest (2005) Number unclear
(1995–2005)
Detection and treatment of perinatal
mood and anxiety disorders
Perinatal outcomes impact on
offspring
Studies reporting treatment effects and
impact of depression and anxiety on
offspring were outlined. Overall review
findings inconclusive due to limited
quality assessment
No Low
Borja-Hart and Marino (2010) 6 (2003–2008) Omega-3 fatty acids Reduction in antenatal, perinatal and/
or postpartum depression, as
measured by depression scales (EPDS,
HAM-D, BDI, MADRS)
All studies showed a positive effect on
depression scores, with 3/6 reporting a
statistically significant positive effect
on depression scores compared to
placebo. However, study limitations
included small sample size, variable
doses of omega-3 fatty acids, short
study durations and lack of a control
group.
No Low
D’Souza and Garcia (2004) 9/48 (1990–2003) Disadvantaged childbearing women Perinatal outcomes Findings inconclusive. Promising
interventions include:
No Low
Subgroup: mental health problems Professional or lay social support to
help in treatment of postpartum
depression
Parenting programmes
Community based postnatal are
delivery specially trained
community midwives
Leis et al. (2009) 6 (1989–2005) Home based interventions to prevent
and treat postnatal depression
Maternal reports of health status 4/6 studies showed evidence of
treatment effect. The four studies
looked at psychological treatments
No High
Matthey (2004) Number unclear
(2002–2003)
Instruments for detecting postnatal
depression
Detection and treatment of postnatal
depression
Inconclusive in relation to screening
and treatment of postnatal depression.
No Low
Summary of treatment strategies
Morrell (2006) 37 (1966–2005) Prevention and treatment of postnatal
depression
Maternal reports of health status Inconclusive due to methodological
and reporting limitations of studies
No Medium
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Number of abstractsscreenedn=2,497 Number of abstracts
filtered outn=2,303
Duplicates (n=451)Non-English (n=22)Non-OECD (n=59)Not a review (n=194)Not a midwifery-ledintervention (n=1,577)
Number of full textobtainedn=194
Total number of eligible studies n=32
Antenatal screening for mental health problems (n=1)Interventions to treat antenatal anxiety and depression (n=3)Postnatal screening for mental health problems (n=1)Interventions for the prevention of postpartum depression (n=8)Postnatal debriefing (n=4)Treatment of postpartum depression (n=8)Parent training programmes (n=1)Generic (n=6)
Not a systematic review(n=57)Not a midwifery-ledintervention (n=105)
Number of ineligiblestudiesn=162
Fig. 2. Search results and filtering process.
F. Alderdice et al. / Midwifery 29 (2013) 389–399396
Antenatal classes focusing on postpartum depression were shownto have no preventive effect. The evidence for interpersonalpsychotherapy and lay support was uncertain. Preliminary evi-dence of the effect of early postpartum follow up suggested thereis no preventive effect on postpartum depression. There waspreliminary evidence to suggest that intensive postnatal nursinghome visits with at risk mothers was protective during the first 6weeks postpartum (Armstrong et al., 1999). The review by Ciliskaet al. (2001), although less rigorously conducted, also supportedthis finding.
Five of the reviews in this area explored a broader evidencebase including, psychological and social support interventions,interpersonal therapy, postnatal stress debriefing, information anddiscussion/education, reconfiguring midwifery and other services,individual home based care, hormonal prevention, antidepressantprevention and dietary interventions (Bick, 2003; Ogrodniczuk andPiper, 2003; Lumley et al., 2004; Dennis, 2004a; Boath et al., 2005).
Dennis (2004a) provided a broad review of 29 non-biologicalinterventions using quasi-experimental and RCT designs andthe conclusions were similar to that of the Cochrane review(Dennis and Creedy, 2004). Lumley et al. (2004) conducted a
broad systematic review and meta-analysis of 42 trials excludingpharmaceutical or hormonal intervention studies. The reviewconcluded that only postnatal interventions for women at riskfor depression have a substantial impact on postnatal depression.Therefore postnatal counselling interventions by a variety ofprofessionals for women at risk of depression were effective butuniversal interventions were considered to be ineffective basedon review evidence. Community postnatal midwifery care alsosignificantly reduced depressive symptoms. However continuityof care, doula support in labour, nurse support in labour, postnataldebriefing by a midwife, interventions to enhance mother–infantintervention could not be recommended as strategies for reducingpostnatal depression.
The review by Boath et al. (2005) included 21 RCTs, too diverseto be meta-analysed and there was no analysis of bias orheterogeneity. Fifteen of the trials looked at psychological andsocial support and included similar trials to that reported inDennis and Creedy (2004) although the two reviews had differentexclusion criteria. One small trial found under the heading ofreconfiguring midwifery and other services looked at an extendedperiod of specialist midwifery care which was associated with asignificantly lowered EPDS score at 4 months postpartum incomparison to controls.
The reviews by Ogrodniczuk and Piper (2003) and Bick (2003)identify a number of midwifery interventions. The review by Bick(2003) included 12 studies and focused specifically on midwiferycare for the prevention or reduction of postnatal psychologicalhealth problems. Bick concluded that significant benefits to postnatalpsychological well-being have been found following the implementa-tion of new models of midwifery-led care although further evidenceis needed to substantiate these findings. Ogrodniczuk and Piper(2003) identified 19 studies looking at interventions for pregnantwomen in general and interventions that targeted high risk women.Of the 19 studies in the review 13 involved some form of midwiferycare either provided directly by a midwife or someone in a midwife-type role. While overall the results were inconclusive, there were anumber of promising midwifery based interventions based onindividually tailored case management by midwives and continuityof care identified. This review did not provide sufficient informationon individual studies to assess overall quality.
The final review in this area was Austin (2003) which speci-fically looked at targeted group antenatal prevention of postnataldepression and identified five studies. One of the studies used amidwife educator to facilitate the group while the four othersused clinical psychologists (n¼3) and another used a psychiatricnurse. Two out of the five interventions reported significanteffects; one small study using interpersonal therapy and theother involved six weekly meetings with a psychiatric nursewhich was found to be effective in primparous women. Overallthe studies were small and methodological problems wereidentified in defining women at risk of postnatal depression.
Postnatal debriefing
Three reviews of postnatal debriefing were identified (Gambleet al., 2002; Gamble and Creedy, 2004; Rowan, Bick and Bastos,2007). A further review by Lapp et al. (2010) which looked at themanagement of post traumatic stress disorder after birth, alsofocused predominantly on debriefing and counselling interventions.Gamble et al. (2002) were specific in their definition of debriefing asa single debriefing session or non-directive counselling session toreduce depression and trauma symptoms in women in the first fewdays following birth. While the implication of included studies wasthat counselling should be offered a few days/weeks after birth, thiswas not always clear. Gamble and Creedy (2004), Rowan et al.(2007) and Lapp et al. (2010) conducted broader reviews in terms of
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definition, reflecting the more generalised definitions of suchinterventions in current research literature. Also, it was noted thatmany existing randomised controlled trials (RCTs) and cohortstudies set up to examine debriefing have used depression as anoutcome rather than PTSD (Gamble et al., 2002). Rowan et al.(2007) identified eight RCTs of debriefing or counselling interven-tion in childbirth settings, seven within the UK. Results of onerandomised controlled trial reported possible short term harm, twotrials indicated a positive association related to a psychologicalintervention, while the others showed that there were no differ-ences in outcomes. Lapp et al. (2010) identified seven debriefing orcounselling interventions after birth; overall, the reviews concludedthat there was insufficient evidence to support the use of formalpostnatal debriefing. Timing of the intervention was not alwaysclear and some studies describe the provision of a counsellingservice any time after birth and even years later (Gamble andCreedy, 2004).
Treatment for postpartum depression
There were eight reviews of treatment for postpartum depres-sion of varying quality (Boath and Henshaw, 2001; Dennis 2004b;Bledsoe and Grote, 2006; Freeman, 2006; Dennis and Hodnett,2007; Daley et al., 2007, 2009; Stevenson et al., 2010). One reviewby Borja-Hart and Marino (2010) provided evidence on thebroader area of perinatal depression and three further reviewswere identified that provided information on prevention andtreatment of postpartum depression (Austin and Priest, 2005;Morrell, 2006; Leis et al., 2009). A range of treatment approachesincluding pharmacological, psychological, psychosocial and hor-monal were identified in the review by Boath and Henshaw(2001). However there were limited data presented on theindividual studies in regard to methods and recruitment andreview findings was inconclusive. Dennis (2004b) also conducteda broad review of interventions for interpersonal therapy, supportinterventions, mother–infant interventions and maternal exer-cise. The review identified 21 papers. Definitive conclusions couldnot be drawn due to methodological limitations; lack of RCTs,small sample size or lack of true control group. However Dennisand Hodnett’s (2007) Cochrane review of 9 trials (reportingoutcomes on 956 women) found any psychosocial or psychologi-cal intervention compared to usual postpartum care was asso-ciated with a reduction in the likelihood of continued depression.However, definite conclusions could not be reached about therelative effectiveness of the different treatment approaches due topoor design, diversity of settings and small sample sizes.
The findings of this review are also supported by Bledsoe andGrote (2006); although their review included less rigorous studies.Trials selecting participants based on a clinical diagnosis of depres-sion were just as effective in decreasing depressive symptoms asthose that enroled women who met inclusion criteria based on self-reported depressive symptoms. All interventions were face to faceand provided by a health professional except for one trial thatprovided telephone-based peer support. Psychosocial interventionsincluded peer support and non-directive counselling. A range ofpsychological interventions were included, for example, cognitivebehaviour therapy (CBT), that generally require specialist trainingbeyond the everyday role of the midwife. A Health TechnologyAssessment review by Stevenson et al. (2010) reported on sixstudies of group CBT for postnatal depression. Three studies showedthe treatment to be effective in reducing depression when com-pared to routine primary care but there was no adequate evidenceon which to assess group CBT and how it compared with othertreatments for postnatal depression.
Morrell (2006), in her review of interventions to prevent ortreat postnatal depression, found that the 37 studies identified were
inconclusive. Studies reviewed by Morrell (2006) had variable recruit-ment times ranging between a few days after birth through to 18months postpartum. Leis et al. (2009) review looked at RCT’s of homebased psychological interventions to prevent or treat postnataldepression and the studies overlapped with those reported inMorrell’s review (2006). The review by Austin and Priest (2005)provided more generic reporting of treatment effects but the reviewfindings were inconclusive due to the lack of focus and quality of thereview.
Other interventions that have been used to treat mental illnessinclude exercise, diet and complementary therapies. Daley et al.(2007) found two trials exploring the role of exercise in treatingpostpartum depression. This was later updated with Daley et al.(2009) reviewing five studies looking at exercise interventions withother treatments/no treatment in women with postnatal depression.Due to heterogeneity of included studies, it was unclear whetherexercise reduces symptoms of postnatal depression. Freeman (2006)conducted a review of Omega-3 fatty acids and perinatal depressionand found four studies; two evaluating efficacy in postpartumdepression prophylaxis and two evaluating its use as acute treatment.The included studies were small and the results were inconclusive. A2010 review by Borja-Hart and Marino identified seven studies of theuse of Omega-3 Fatty Acids for the prevention or treatment ofperinatal depression. Only six were reviewed as one trial wasdiscontinued early due to the relapse of depression symptoms. Aswith the review by Freeman (2006) the results were inclusive andlimited by sample sizes, variable dosing and study duration.
Parent training programmes to improve maternal mental health
One high quality Cochrane review was identified by Barlow et al.(2003), which aimed to establish whether parent-training pro-grammes can improve maternal psychosocial health. Twenty-sixstudies were included in the review, with a total of 64 assessmentsof a range of psychosocial outcomes: depression, anxiety, stress, self-esteem, psychiatric morbidity. Data sufficient to combine in meta-analysis existed for only five outcomes (depression, anxiety/stress,self-esteem, social support, and relationship with spouse/maritaladjustment). Meta-analyses showed statistically significant resultsfavouring the intervention group for depression, anxiety/stress, self-esteem, and relationship with spouse/marital adjustment. All of theprogrammes reviewed were successful in producing positive changein maternal psychosocial health in the short term. However, longterm consequences need to be explored and the authors highlightthat there is insufficient evidence to reach any firm conclusionsregarding the role of parenting programmes in the primary preven-tion of mental health problems. D’Souza and Garcia (2004) high-lighted parenting programmes as a promising intervention forwomen with mental health problems in their review of women withmental health problems, as a subgroup of disadvantaged women (9out 48 studies in the overall review). The review included systematicreviews and original studies and included no quality assessment.
Discussion
The 32 reviews identified in this review were diverse in qualityand in content. Many provided some evidence of effect but findingshave been confounded by poor design and quality of includedstudies. Overall no review identified an intervention in the perinatalperiod that could be definitively recommended in clinical practice.While some reviews identified promising interventions, the samplesof included studies were small and the range of interventions wastoo heterogeneous to establish which intervention would be mosteffective. A number of interventions were highlighted that warrantfurther consideration, for example, midwifery led models of care for
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preventing depression, psychological and psychosocial interventionsfor treating postnatal depression, mind–body interventions in preg-nancy and use of exercise. Facilitation/co-ordination of parent-train-ing programmes was also considered to be promising in preventingmaternal mental health problems. However, more research isrequired on these interventions to ensure a good evidence base toinform training, policy and practice about the relative effectiveness ofthese different treatment approaches.
It is clear from the reviews identified that most of the research inthis field has focused on intervention for depression rather thanstress and anxiety. Also many of the interventions identified wouldrequire additional midwifery training, for example, those involvingpsychological and psychosocial interventions. Those interventionsrelated specifically to midwifery did not appear to be highlyintensive or to differ much from usual care but the reviews high-lighted the importance of tailoring the intervention to the individualneeds of the woman. More measures of maternal well-being shouldbe included in future randomised controlled trials of midwiferymodels of care to further elucidate these findings. In the absence ofclear evidence, the priority is to raise awareness of the importance ofmaternal mental health and the potential role of the midwife inpromoting maternal well-being. A recommendation of this review isfor midwives to avail of the opportunity to inform and influence astrategic research approach to perinatal mental health interventionsand to drive this strategy by building on their core role.
Future research needs to address the major gap in the literatureon effective interventions in maternal mental health and well-beingin pregnancy as this is the point of most intensive contact andprovides considerable opportunity to improve maternal well-being.As the evidence continues to mount in relation to the impact ofmaternal stress and anxiety on the fetus and woman’s health andwell-being in the short and long term (Dunkel-Schetter, 2011),there is an urgency to consider how we can best support women inpregnancy to maximise well-being. This is not just in relation to thescreening and diagnosis of mental ill health antenatally, but moregenerally into the stress and strains in pregnancy and how womencope with them. Consideration needs to be given to what makeswomen anxious in pregnancy and what can be done to support herin routine care (Alderdice and Lynn, 2010). Midwives are ideallyplaced to introduce simple interventions to enhance self care or toeducate women about the symptoms and changes to expect inpregnancy to help relieve stress. However, research is urgentlyneeded in the area of stress reduction interventions in pregnancybefore they can be introduced in practice.
While this reviews of reviews provides an important overview andcoherent appraisal of current knowledge, the reviews included variedin quality and scope, which imposes limitations on interpreting thefindings. Consideration needs to be given to the differences inpopulations in each review and how relevant the population studiedis to the population where the intervention will be implemented. Theconsequence of this diversity is a narrative review with limitedsynthesis, which is a common problem within systematic reviews.This is reflected in this study, with less than a quarter of includedsystematic reviews reporting a meta-analysis. In addition, reviewsmay provide information about the effectiveness of interventions butit is also pertinent to consider how realistic or practical the interven-tions are and the impact on service users. Within the context of thisreview, the intervention would need to align with both the expecta-tions of women and the scope of midwifery practice.
Despite these limitations, a systematic review of reviews canprovide reassurances on the conclusions of individual reviews andhighlight the best quality reviews in a single document with defini-tive summaries to inform clinical practice (Smith et al., 2011) andhelp direct future research strategies. This review highlightedthe lack of effective interventions currently available for useby midwives to support women’s maternal mental health and
well-being. The review also identified the need to focus more onwell-being rather than solely mental illness. It should also be notedthat evidence was identified only for short term outcomes related toimmediate psychosocial well-being and further research is neededto evaluate longer term health outcomes and outcomes related toresources and organisation of care.
Conclusions
This systematic review of systematic reviews provides avaluable summary of the current evidence and gaps in evidencerelated to interventions to improve maternal mental health in theperinatal period. It also provides the opportunity to reflect onwhat needs to be considered by midwives on their potential rolein the field going forward. The review highlighted that based oncurrent systematic review evidence it would be premature toconsider introducing any of the identified interventions intomidwifery training or practice. However there were a number ofexamples of possible interventions in the included reviewsworthy of further research. A major gap in the review literaturewas the lack of reviews exploring a specific midwifery role inmaternal mental health and well-being in pregnancy, and yet, thisis the point of most intensive contact and needs a strategicresearch approach. Midwives play a key role in refocusing aperinatal mental health research strategy to ensure it includeshigh quality randomised controlled trials of interventions that canpromote well-being and reduce stress for all women, in additionto supporting women with mental illness.
Acknowledgements
We would like to acknowledge the NHS Education for Scotlandand the Midwifery 2020 Public Health Group for funding theproject and for providing strategic direction. We would also liketo acknowledge the support and commitment of the Review ofReviews steering group (Mrs Elizabeth Bannon, Prof Debra Bick,Dr Helen Cheyne, Prof Mike Clarke, Mrs Joanne Gluck, Prof BillieHunter, Dr Dermot O’Reilly).
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