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Postpartum Nursing Care in the Home

Depression in young mothers potentially can hamper baby's development.

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Laughter, we've been told, is the best medicine.

For new moms diagnosed with postpartum depression, laughter isn't required; a home visit from the nurse will do just fine, according to a new study.

Researchers found when nurses visited new mothers diagnosed with postpartum depression to teach them how to bond with their babies, symptoms of depression decreased and interaction between mother and baby improved.

The study appeared in the May/June 2013 issue of the Journal of Obstetric, Gynecologic, & Neonatal Nursing, published by Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN).

CARE Intervention

The research, led by June Andrews Horowitz, PhD, RN, PMHCNS-BC, FAAN, from the William F. Connell School of Nursing at Boston College, began back in 2004 when new mothers who delivered at Brigham and Women's Hospital and Massachusetts General Hospital, both in Boston, were being recruited for the study.

Then, new mothers were screened using the Edinburgh Postnatal Depression Scale tool. Those who were considered high risk for depression (674) were invited to speak with an advance practice psychiatric nurse for further screening. Once all diagnostic and logistical criteria were met, the study enrolled 134 women with postpartum depression.

"Often symptoms of postpartum depression include being less talkative, slowed down, sluggish and not wanting to interact," Horowitz explained. "We have all felt that way, but when you're depressed it's persistent, and if you just had a baby, and you're not really there and picking up on cues the baby is giving, development may be affected."

For instance, when a baby smiles if no one is smiling back at the baby, the baby isn't rewarded for smiling.

Nurses in the study used the Communicating and Relating Effectively (CARE) intervention with which they assisted the mothers in recognizing their infant's engagement cues and responding appropriately. Visits were held in the mothers' homes at 6 weeks and 3, 6, and 9 months postpartrum.

During the hour-long visits, the nurses would show the mothers how to teach their baby a particular task and look for behavioral patterns. At the 3-month visit, nurses would show the mother how to engage with the baby using a rattle, Horowitz explained.

That may seem like an easy game, but when depressive symptoms are present even play can seem like a task. After the nurse showed the mother what to do, it was her turn. Putting the moms in charge empowered them and helped build a rapport.

"Being told 'teach your baby' made them realize they can teach their baby," Horowitz said. "That kind of attention, monitoring and positive participation you can give moms who are depressed improves their symptoms and outcomes for the baby."

Videotapes of the sessions were studied closely to determine how well the mother and baby were bonding. What may have looked simple to a layperson - a mom sticking her tongue out at her baby - was carefully coded and examined by the researchers viewing the tapes to interpret their relationship.

Study vs. Control Groups

The home visits differed for new mothers in the control and study groups, Horowitz explained.

"For the control visits, the nurses would ask them the questions on the depression scale and do modeling, but they wouldn't talk about other things that didn't have to with the baby cues. In the study group, the nurses would answer questions about breastfeeding and educate them. It was really hard for the nurses not to educate as much to the control group."

A funny thing happened in Phase III of the study when focus groups were held. Both groups improved. There was little difference in the outcomes between the study and group groups. Postpartrum depression symptoms were less severe and baby interactions were great improved.

Women in the control group were shocked they weren't the ones receiving the CARE intervention.

In the study's conclusion, Horowitz et al write "qualitative findings indicated presence of the nurse, empathic listening, focused attention and self-reflection during data collection, directions for video-recorded interaction, and assistance with referrals likely contributed to improvements for both groups."

The researchers can assume CARE works well. It improved outcomes for the ones who received it, but the women who didn't receive it did well too. The study proved just having a nurse there to listen is a great tool.

Nurse-Led Care

That's what women who deliver babies at Martin Health System in Stuart, Fla., have known since its Mother-Baby Home Visit program began 25 years ago.

The home visits began under the guidance of Lorna Sinclair, BA, RNC-OB, director of maternal/child outpatient services, and nearly 4,500 visits each year visits have been conducted, including some women who were visited as babies now getting the education as new moms.

For the program, nurses visit babies of mothers, within three days of discharge. Nurses provide assistance and support with breastfeeding, assess and weigh the baby, follow up on care for babies with jaundice, assess the house to ensure its baby safe.

"The whole key is prevention," Sinclair says. "We're intervening when needed and out there monitoring. Re-admission rates are down, while breastfeeding rates are above state and national averages.

If Mom is suffering from or at risk for postpartum depression, the nurse will make a referral to the primary physician and to an appropriate community agency with specialized practitioners and counselors

"We have a wonderful Post Partum Depression referral program. We set up a multiagency task force to connect women with counselors and psychiatrists if needed," she said. Area pediatricians are also aware of the program and are encouraged to screen mothers for postpartum depression during baby wellness checks. There is an online component of the program too with resources at http://www.martinpostpartumsupport.org/.

Inspired by Home

The program is fully subsidized and free to new families. About 99% of women who deliver at Martin take advantage of the program. Children Services Council of Martin and St. Lucie Counties, the Martin Health Foundation, and private donations fund the program.

Sinclair says there are two must haves - "registered nurses who are experienced in maternal health care and ones who have a good knowledge of what community resources are available."

Sinclair, who has been at Martin since 1984, was raised and educated in Scotland, where home visits are common.

"In the UK, you're still under the care of midwife 28 days after you've had your baby. After that, you're under a preventive medicine specialist until the child is 5. That is a broad standard of care throughout Europe in one form or another.

Breaking the Stigma

Sinclair and Horowitz agree it would be ideal if nurse-home visits were mandated for all new mothers. In fact, only a few states (Illinois, New Jersey) even require hospitals to screen for postpartum depression before discharge despite it affecting about one in eight new mothers.

The stigma appears to be going away and more women are seeking treatment. However, one misperception exists. Postpartum depression strikes any pregnancy. A woman, who may have had no problems with her first baby, may develop depression with subsequent children or in hind sight may realize she did have postpartum depression with her first child, Horowitz said.

"There was one woman who had really serious postpartum depression and didn't have treatment for her first pregnancy. She did take medication during her second pregnancy because the risks of depression were so serious. She would say 'I feel much better and I'm here this time. I wasn't here for my first baby.'"

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When postpartum depression is caught early, it's very treatable, Horowitz said.

"Supportive therapy works well, and some studies suggest possibly better than medication. Treatment doesn't have to be expensive. A visit from a nurse who gives voice to how women are feeling is great. A visit to the pediatrician where he or she asks the mom about crying, mood, just paying attention to how she is doing takes 18 seconds."

Having a support system helps greatly too. Nurses can educate partners and other family members about the symptoms before and after the baby comes. More research and more mentions of postpartum depression in popular culture are helping to raise awareness.

"We still have a lot of work to do, but 20 years ago, you never heard about it. You would see very little written about it in the professional literature. It was only since 1987 there has been a tool to screen it.

"Nurses can teach family members about the symptoms - depressed mood, irritability, anxiety, feeling numb as if they're not feeling connected to the baby or anyone around them. This doesn't just affect the mothers. It affects the family and possibly the baby's development."

Stacey Miller is a freelance writer.




     

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