Abstract
In the US, postpartum depression (PPD) is an intricate and multiple factor that affects a mother, her child, and her family. Depression in the postpartum period has been linked to poor parental bonding, child abuse, and neglect. Furthermore, poor bonding has been found consistently with more cesarean births than vaginal. For years, researchers have been searching for a correlation between obstetric method of delivery and incidence of PPD. Many theoretical research questions have arrived such as: how does the incidence of PPD vary after cesarean section versus normal delivery? The purpose of this paper is to provide a program based on Beck’s PPD theory to help alleviate, reduce, and treat the symptoms of postpartum depression through education, exercise, and an increase in mother-baby bonding. In following this program’s guidelines educational programs can be implemented to improve nursing care of pregnant women with PPD and provide the basis for mothers in the community to be prepared for self-monitoring for symptoms of depression and know what steps to take if they do experience depressive symptoms.
Evaluating postpartum depression theory about cesarean deliveries, mothers are placed in high-stress situations because they are not in control of their bodies or the situation during cesarean delivery. The risk of higher chances of developing post-partum depression in cesarean deliveries remains a sensitive and controversial subject. According to Hui Xu et. al, when compared with women having spontaneous vaginal or forceps deliveries, women having a cesarean section had more than six times the risk of developing postnatal depression postpartum (2017). Nurses are involved throughout all phases of the patient’s care and can make huge impacts on the well-being of every one that he/she encounters. Cheryl Beck, a nursing theorist, dedicated her life to researching and studying this theory to evaluate mood disorders in pregnant and postpartum women. Using the middle-grounded theory approach, Beck structured her modern theory using a postpartum depression screening in predicting whether a woman will develop postpartum depression based on her postpartum screening score (PDSS), history, and current circumstances using various groups of women in her study (Alligood, 2018).
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Symptoms of postpartum depression including extreme sadness, low energy, anxiety, crying episodes, irritability, and changes in sleep or eating patterns affect about 1 in 9 women, according to the Centers for Disease Control and Prevention (ASA, 2018). Postpartum depression can lead to lower rates of breastfeeding and poor bonding with the baby. After a child is born, regardless of the delivery method, every mother deserves to have bonding sessions with their newborn. The literature suggests immediately begin skin to skin contact to initiate the mother-child bonding moment (Ludington-Hoe, 2015). The first hour of life is considered the best opportunity for bonding. This process is evidenced through socio-emotional, sensorimotor, and physical indicators (Hui Xu et. al, 2017). Both the mother and the father can support positive bonding, beginning during pregnancy. Multiple factors may negatively affect the bonding process. These can include a lack of support, the riskiness of pregnancy, and responding to discussions about bonding in a less than socially desirable way, such as refusing bonding moments in cesarean deliveries by using the excuse of being under anesthesia to deny bonding needs.
In the U.S., nearly one in three women give birth by cesarean section. According to The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, cesarean birth is too common in the United States and has increased greatly since it was first measured in the 1960s (Centers for Disease Control, 2018). It is critically important for all involved in the childbirth process, from parents to staff to educators to be aware of the importance of bonding in cesarean births. Positive bonding and attachment can be supported by encouraging contact and facilitating a positive emotional mood. The beneficial outcomes that result from creating a positive bonding experience support the importance of creating an environment in healthcare today that encourages positive attachment for the infant and parent. The ultimate result is a happier, warmer, healthier baby less stress, and fewer chances of developing depression for mom. The purpose of this paper is to propose a program aimed at preventing or controlling post-partum depression resulting from stress, anxiety, and poor mother-baby bonding associated with the effects of cesarean deliveries.
Overview of the program
The goal of this community-based program is to lower the risks of developing post-partum depression in women who undergo cesarean deliveries. The program will address the need to reduce pregnant mothers’ stress and anxieties associated with cesarean births resulting in postpartum depression. Participants in the program consist of any pregnant woman of various backgrounds at risk for emergency C-section or scheduled for a C-section, those with or suspected mood disorders, including depression, maternity blues, and a history of anxiety must be at least 22 weeks pregnant, and be willing to participate from 24 weeks up to 1-year post delivery. This current program is not intended to replace or precede a midwife or obstetrics’ recommendations and medicine prescriptions; it is proposed to provide additional suggestions for therapeutic purposes only.
The therapeutic program consists of an initial screening between 24-28 weeks of pregnancy. 6 weeks of low to moderate exercise such as yoga as tolerated, 3-4 times a week, and at least 30 minutes a day. Education will be provided through means of meetings or classes on bonding with the newborn, stress relieving factors intra and post-partum, and managing anxiety and depression with immediate visits from researching staff post-delivery to encourage and assist with first-hour bonding. The mothers will follow up post-delivery after three months and 1 year for further evaluation of postpartum depression.
The expecting mothers were notified by flyers in several OBGYN offices and community health clinics. The initial meeting began with an information session and discussions about the program, its risks, and benefits. Informed consent was obtained at this time. Expecting mothers discussed their willingness to participate and follow up as needed including the inclusion of a nursing research staff to assist with bonding during the hour of delivery. The initial assessment includes filing out a PHQ-2, followed by the PHQ-9 for those with a score of 2 or higher (CDC, 2013). They were introduced to the Edinburgh Postnatal Depression Scale (EPDS) and Postpartum Depression Screening Scale (PDSS) which they will be completing at their 3rd and 12th month postpartum.
Between the 24th and 28th weeks, mothers will be attending a structured exercise program selected by the community-based clinic, which they will attend 3 times a week, on Mondays, Wednesdays, and Fridays or Saturdays for 30 minutes. The exercise program contains Yoga and one other low-moderate exercise activity, mother’s choice, swimming or dancing. There will also be a 4-hour class on a Saturday during the 32-36 weeks where the mothers learn about early bonding and its effects. They will practice skin-to-skin contact using dolls and learn methods to relieve and alleviate stress and anxiety.
After delivery, one assigned staff will be available to assist mothers with skin-to-skin contact and other methods of bonding with newborns. Researching staff will be available for questions after hospital discharge to help with the ongoing support of the mothers and their new babies. At the three-month post-partum meeting, mothers will complete the PDSS and the results will be discussed with patients. At that time referrals will be made as needed and other assistance will be provided as necessary.
The 12-month follow-up will consist of another PDSS form completion, parents will reflect on the program and their progress at this time. Each and everyone will be asked to reflect on their experience, the staff availability for support, and whether their needs and expectations were met. Parents will be asked whether they think the program helps to reduce their anxiety, stress, and depression levels and increase their involvement with their birthing experience and bonding moments. The program will come to an end after the last meeting.
Overview of the theory
Cheryl Beck has focused her research on postpartum mood disorder and anxiety for at least two decades. In 1993, Beck published her middle-range theory on postpartum depression, titled Teetering on the Edge. Beck completed a literature review on postpartum depression (PPD), and she realized that there was limited qualitative research available on her research topic. Her main goal was to produce research where pregnant women of all backgrounds were included in PPD research and treatment (Marsh, 2013). Beck believes theory is the foundation of nursing and is essential to the profession. As a profession, nursing applies conceptual frameworks to guide practice by describing and predicting specific behavior. It is through the use of guided phenomena that one can expand concepts via research; ultimately, advancing knowledge regarding concepts, experience, and application to practice (Marsh, 2013). It is with this belief that Beck developed this theory by addressing postpartum depression on mother-child interactions, postpartum panic, posttraumatic stress disorders, and birth trauma to tease out differences among post-partum mood disorders (Alligood, 2018).
Multiple analysis was conducted to differentiate predictors of postpartum depression relating to infant temperament, mother-infant interactions, and mothering multiples (Alligood, 2018). Beck discovered women dealing with postpartum depression had difficulties coping with the problem of loss of control through the four-stage process she used in her research on teetering on the edge. The four stages were, encountering terror, dying of self, struggling to survive, and regaining control (Marsh, 2013). Stage one includes anxiety attacks, obsessive thinking, and fogginess. Stage two entails alarming unrealness, self-isolation, and contemplating and attempting self-destruction. The third stage includes feelings of battling the systems, where they feel everyone is against them, praying for relief, and seeking solace at support groups. The last stage discusses unpredictable transitioning, mourning a loss of time, and a guarded recovery (Alligood, 2018).
Beck discovered the concept of PPD far beyond the analysis of symptoms and definition of major depressive mood disorders because she experienced working with pregnant women. She discovered that PPD was not a diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (Alligood, 2018). She decided to forego a qualitative study designed to investigate specific social psychological problems of PPD and the social psychological process used to resolve PPD. She did this by receiving the assistance of 12 women participant observation in a PPD support group over 18 months. Continually 12 in-depth taped interviews were conducted with mothers who had attended the support group. Loss of control was found to be the basic social psychological problem in PPD (Marsh 2013).
Use of the Theory to Guide Program Development
Postpartum depression (PPD) affects 10%-15% of mothers within the first year after giving birth (CDC, 2008). The CDC analyzed data from the Pregnancy Risk Assessment Monitoring System (PRAMS) for 2004-2005 which is the most recent data available to assess the prevalence of self-reported postpartum depressive symptoms (PDS) among mothers by selected demographic characteristics and other possible risk factors for PDS (2008). Unplanned caesareans may have a particularly negative psychological impact on mothers because they are unexpected, usually mentally and physically stressful, and associated with a loss of control and unmatched expectations (Science Daily, 2019).
Using what Beck called the “ripple effect” in meeting with the women in different aspects during their pregnancy and post-natal to make the necessary connections for effective treatments (Alligood, 2018). The program will incorporate the postpartum depression theory as a basis to help women suffering from this condition especially those undergoing cesarean sections that feel more uncontrol during delivery and are unable to touch or bond with their babies immediately after birth. Depending on their circumstances, some women may not even see their babies for hours post-delivery which creates an increase in anxiety levels, a sense of loss of control, and feelings of inadequacy. As a caring profession as nursing, we must care for all patients and provide all with a sense of wholeness including psychologically. Stressful events such as giving birth where women may be vulnerable to mood disorders is the perfect time for nurses to step up and intervene, and that is why this program is being created, to help these women achieve a happier and more fulfilling pregnancy and delivery. Identifying the symptoms and risk factors before they appear has a greater chance of preventing and alleviating months of suffering (Alligood, 2018).
Conclusion
The stigma of women being expected to feel, look, and act happy during and after pregnancy has silenced many women from voicing their feelings of depression. Many believe that motherhood is a natural feeling, once given birth it’ll automatically suit a woman’s personality; according to Beck, these are assertions that continue to psychologically affect women (Alligood, 2018). Identifying symptoms early through careful screening using this current program can help treat women appropriately.
The use of Beck’s theory on postpartum depression is a pertinent tool for any provider, whether midwife, family nurse practitioner, childbirth educator, or nurse, to provide the best care to pregnant and postpartum patients. Providers that provide care to potential postpartum depressant patients for any amount of time need to be meticulous in recognizing signs and symptoms of PPD and be familiar with at least the Edinburgh postnatal depression scale (EPDS) and the Postpartum Depression Screening Scale (PDSS). Not only do providers need to be able to recognize PPD but also adequately educate patients regarding PPD and the potential emotions that may be experienced along with methods of seeking help with the appropriate referrals.
References
- Alligood, M. R. (2018). Nursing theorists and their work.
- American Society of Anesthesiologists (ASA). (2018, October 14). Postpartum depression linked to mother's pain after childbirth: New study underscores the importance of managing pain during recovery. ScienceDaily. Retrieved from www.sciencedaily.com/releases/2018/10/181014142700.htm.
- Centers for Disease Control and Prevention. (2013). Depression Among Women of Reproductive Age.
- Hui Xu, et al. (2017). Cesarean section and risk of postpartum depression: A meta-analysis. Department of Epidemiology and Health Statistics, Volume 97, pp. 118-126. Retrieved from: https://doi.org/10.1016/j.jpsychores.2017.04.016
- Marsh, J (2013). A Middle Range Theory of Postpartum Depression: Analysis and Application. International Journal of Childbirth Education. Vol. 28 (4). Pp.50-54.
- Ludington-Hoe, S. (2015). Skin-to-Skin Contact: A Comforting Place with Comfort Food. MCN, The American Journal of Maternal/Child Nursing. 2015. Vol.40(6); pp.359–366. Retrieved from: DOI:10.1097/NMC.0000000000000178.
- University of York. (2019, January 23). Emergency caesareans put new mothers at higher risk of developing postnatal depression. ScienceDaily. Retrieved from www.sciencedaily.com/releases/2019/01/190123105845.htm.
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