School of Nursing
Online Journal

Post-Partum Depression in New Zealand

Lana Ennis

Introduction

Post-Partum Depression (PPD) is an illness that burdens many New Zealand women (Plunket, 2014); it has an impact on personal relationships, maternal-infant interaction quality and infant’s social and cognitive development. PPD is prevalent throughout society and is a clinical practice issue that needs to be considered by nurses in order to address both postnatal depression and the flow-on effects experienced by those individuals and their children. By using the PICOT model I have brought my question from the broad idea of ‘does depression have an impact on families’ to a refined question of ‘does postpartum depression have an impact on the development of infants aged four weeks to 18 months?’ This has enabled me to find a wide range of literature around my clinical practice issue and discuss what the implications for practice are.

Clinical Issue

PPD affects many New Zealand women following childbirth (Plunket, 2014); it is a disorder that disturbs mood, causes a loss of interest or pleasure in activities they would normally enjoy and may cause unwarranted anxiety and irritability (WebMD, 2012). It is recognised that about 13% of women experience postnatal depression following childbirth (Plunket, 2014); some studies have reported higher rates of PPD in New Zealand, reaching up to 16 percent in some ethnic populations (Suebwongpat, Standfield, Campbell, & Norris, 2008). From my experience working as a nursing student with a psychiatric district nurse, I saw a large number of people effected by depression and recognised the negative impact it had on their family and loved ones. I became extremely interested in one particular client, a new mother, suffering from PPD. As a result the mother-infant relationship and the child’s development were impaired. This is something I wanted to investigate further in order to gain a greater understanding and to develop skills. This will enrich my practice and thereby improve the outcome for other mothers experiencing PPD. I have become aware of just how prevalent PPD is in society; its cause is multifaceted, and with such high numbers of New Zealand women experiencing depression following childbirth I wanted to understand what impact this has on infant development.

PPD is a significant public health problem; as it can have detrimental consequences for the mother, infant and family. PPD is a clinical issue that needs to be addressed in New Zealand. Mothers play a large role in mediating the infant’s experience of the external environment, so it is imperative to explore the effects of PPD on child growth and development. Understanding the impact that PPD may have on an infant’s development will enable nurses to adequately address the problem through changes in practice, in turn this will help address both PPD and improve infant outcomes. By using the PICOT model (below) as discussed by Schneider and Whitehead (2013) I have been able to develop my clinical question; ‘Does postpartum depression have an impact on the development of infants aged four weeks to 18 months?’

Note: PICOT table developed fromSchneider & Whitehead (2013).

Review of the Literature

From the literature I have found a wide range of articles that suggest PPD has an impact on the development of infants. PPD negatively affects interactions between mother and child and consequently the emotional, social and cognitive development of the child suffers (Quevedo et al., 2011). The findings reveal that there are many contributing factors impacting on the outcome of the child’s cognitive and behavioral development. The negative effects on child development are accentuated in relation to the duration and severity of the maternal mood disorder, with the maternal age and parity also playing a role in the infant outcome (Quevedo et al., 2011).

Quevedo et al. (2011) looked at how the duration of maternal depression impacted on infant’s language development. Results showed that children whose mothers experienced persistent and on-going depression scored more poorly on the language scale than those children who were only exposed to depression at one point in time or not at all (Quevedo et al., 2011).

Language is one of the most important developments made by children, as they first need to gain a range of skills and behaviors in order to acquire all the communication skills needed. The cumulative effect of on-going exposure of depression to the infant can influence the quality of the stimulation that the child receives, in turn having an impact on the verbal skills acquired by the child (Brennan, Hammen, Andersen, Bor, Najman, & Williams, 2000). The difference in language ability based on PPD remained significant after controlling for confounding variables such as socio-economic status, sex of the baby and the delivery and health of the baby (Quevedo et al., 2011). Although maternal age and parity were also associated with poorer language development they did not mitigate the effect of PPD (Quevedo et al., 2011).

Another longitudinal study by Kaplan, Danko, Diaz, and Kalinka (2011), supports the findings outlined above, where 154 infants and their mothers who had varied duration of depression were tested at 12 months to understand how PPD impacted on infant’s perception of language, language development and their cognitive development (Kaplan, Danko, Diaz, & Kalinka, 2011). This study found that a greater duration of the depressive episode resulted in poorer learning by the infant; this remained so even with no measurable differences in the severity of depression between the participants.

An important element of caregiver stimulation is infant-directed speech, it is effective at maintaining infant attention and facilitating infant learning. However, when produced by depressed mothers it is lacking in pitch modulation and less effective at producing basic learning (Kaplan, Bachorowski, & Zarlengo-Strouse, 1999). This study provided evidence that suggested that the more prolonged exposure to a depressed mother affects the infant’s ability to respond appropriately to speech stimuli and impacts on language development (Kaplan et al., 2011). In addition other studies have also found that children of mothers who experience PPD exhibit lags in cognitive development and vocabulary acquisition (Cornish, McMahon, Ungerer, Barnett, Kowalenko, & Tennant, 2005).

There is a growing body of evidence that links maternal depression following childbirth to poor child development in the cognitive, emotional and behavioural domains. During these early months, the mother’s communicative skills are important for consolidation of particular interactive skills and cognitive processes within the child, with the severity of maternal depression having a greater impact on the infant’s development. Studies found that children with parents scoring high on the Edinburgh Postnatal Depression Scale (EPDS) were less curious and focused in free play and were more likely to be insecurely attached and show restricted levels of joy (Edhborg, Lundh, Seimyr, & Widstrom, 2001).

Young infants are highly sensitive to the quality of care they receive; women demonstrating greater depressive symptoms tend to be less responsive, sensitive and involved parents, resulting in child developmental delays (Edhborg et al., 2001). Edhborg et al (2001) demonstrated these ideas in a play situation where the mother and infant had to perform a structured task. The mother had to be emotionally available to facilitate the child in achieving the task, taking into consideration the child’s individual needs and ability. It was found that those mothers with a higher EPDS score created an environment that was less effective for the child, and therefore had an impact on the infant’s development (Edhborg et al., 2001).

It was discovered that the key difference between those who scored high EPDS compared with those mothers who had low EPDS scores was the maternal emotional availability. Those with high EPDS scores were significantly less effective at facilitating the child’s acquisition of skills and mastery, particularly with structured tasks but also in free play (Edhborg et al., 2001). As a result the interaction between the infant and the mother was interpreted as less joyful and seemed to remain beyond the period of the mother’s depressed mood (Edhborg et al., 2001).

Recommendations and rationale

From the study it is clear that PPD is associated with impaired infant development; this includes poor language acquisition and diminished cognitive and emotional development. These findings are correlated with poor care practices by the primary caregiver as well as negative maternal attitudes which may interfere with secure attachment and coping mechanisms developed by the infant.

From a clinical perspective the findings highlight the importance of early detection and nursing interventions, through routine screening and providing support for those mothers who have screened positive for depressive symptoms. Effective and accurate screening methods for PPD have huge benefits for mothers following childbirth.

It is important to determine the best screening practices for nurses caring for mothers to ensure that mothers get timely evaluation, treatment and support if required. It has been concluded that the use of a standardised screening tool such as the EDPS during well-child visits, is a feasible approach to effective screening (Fergerson, Jamieson, & Lindsay, 2002). It was also found that mothers were receptive to PPD screening via mail and telephone, this could be considered as an alternative form of screening for those women who are difficult to reach or in remote areas (Horowitz, Murphy, Gregory, & Wojcik, 2011).

A number of studies have found that nurse home visits improve the maternal-infant interaction and decrease the severity of PPD. In one particular study a number of mothers were recruited from an obstetric unit where they were screened for PPD (Horowitz, Murphy, Gregory, Wojcik, Pulcini, & Solon, 2013). Over the following nine months they were visited by a registered nurse in their homes, the nurse would teach and support the mother giving them skills to effectively communicate and relate with their infant in order to help improve maternal-infant relationships (Horowitz et al., 2013). The trial found that all those involved had significant increases in the quality of interaction between the mother and child and decreased the severity of depression for those suffering PPD (Horowitz et al., 2013). 

Findings indicate that empathetic listening and focused attention by the nurse contributed to participant’s improvements. This has great implications for future practice as results suggest that nurse-led home visits have a positive effect on the outcome of all (Horowitz et al., 2013). Although it would be unrealistic to provide on-going nursing care for all new mothers following childbirth, I recommend the use of an effective initial screening for PPD, from there those mothers who have early signs of depression should be followed up. This will help negate the likelihood that children of postpartum depressed mothers will suffer adverse developmental consequences, and in turn it will improve the outcome for both mother and infant (Edhborg et al., 2001)

Conclusion

PPD has a major impact for both mother and infant. There is a growing body of evidence linking maternal emotional distress with poor infant development. This literature review has found that the severity and duration of PPD has a profound impact on the infant’s language development, perception of language, cognition, emotion and behaviour. The postpartum period is one of the most important stages for infant development so maternal depression needs to be addressed effectively to ensure the best outcome for mother and child.

These findings have important implications for practice; it is clear that PPD has an impact on infant outcomes so enhancing nursing intervention programs aimed at improving the maternal-infant couple is essential for the infant’s development. Initiatives such as effective screening and nurse-led interventions need to be employed with a universal standard. Support can then be provided for those mothers who screen positive for PPD to reduce the effect of PPD on the infant’s development and improve the mental health and emotional wellbeing of mothers and their infants.

References

Brennan, P. A., Hammen, C., Andersen, M. J., Bor, W., Najman, J. M., & Williams, G. M. (2000). Chronicity, severity, and timing of maternal depressive symptoms: Relationships with child outcomes at age 5. Developmental Psychology. 36(6), 759-766. doi: 10.1037//0012-1649.36.6.759

Cornish, A. M., McMahon, C. A., Ungerer, J. A., Barnett, B., Kowalenko, N., & Tennant, C. (2005). Postnatal depression and infant cognitive and motor development in the second postnatal year: The impact of depression chronicity and infant gender. Infant Behavior & Development. 28(4), 407–417.

Edhborg, M., Lundh, W., Seimyr, L., & Widstrom, A. (2001). The long-term impact of postnatal depressed mood on mother-child interaction: A preliminary study. Journal of Reproductive and Infant Psychology, 19(1), 61-71. doi: 10.1080/02646830020032300

Horowitz, J. A., Murphy, C. A., Gregory, K. E., & Wojcik, J. (2011). A community-based screening initiative to identify mothers at risk for postpartum depression. JOGNN. 40(1), 52-61. doi: 10.1111/j.1552-6909.2010.01199.x

Horowitz, J. A., Murphy, C. A., Gregory, K., Wojcik, J., Pulcini, J., & Solon, L. (2013). Nurse home visits improve maternal/infant interaction and decrease severity of postpartum depression. JOGNN. 42(3), 287-300. doi: 10.1111/1552-6909.12038

Kaplan, P. S., Bachorowski, J. A., Zarlengo-Strouse, P. (1999). Child-directed speech produced by mothers with symptoms of depression fails to promote associative learning in four-month old infants. Child Development. 70(3), 560–570.

Kaplan, P. S., Danko, C. M., Diaz, A., & Kalinka, C. J. (2011). An associative learning \deficit in 1-year-old infants of depressed mothers: Role of depression duration. Infant Behavior and Development. 34(1), 35-44. doi:  10.1016/j.infbeh.2010.07.014

Plunket (2014). Postnatal depression. Retrieved from http://www.plunket.org.nz/your-child/welcome-to-parenting/postnatal-depression/

Quevedo, L. A., Silva, R. A., Godoy, R., Jansen, K., Matos, M. B., Tavares-Pinheiro, K. A., & Pinheiro, R. T. (2011). The impact of maternal post-partum depression on the language development of children at 12 months. Child: care, health and development. 38(3), 420-424. doi:10.1111/j.1365-2214.2011.01251.x

Schneider, Z., & Whitehead, D. (2013). Nursing and midwifery research: Methods and appraisal for evidence-based practice (4th ed.). Sydney, Australia: Mosby.

Suebwongpat, A., Standfield, L., Campbell, S., & Norris, S. (2008). Screening for postnatal depression within the Well Child Tamariki Ora Framework. (HSAC Report). University of Canterbury, Christchurch, New Zealand.

WebMD (2012). Postpartum depression health center. Retrieved from http://www.webmd.com/depression/postpartum-depression/postpartum-depression-symptoms