Anyone who has had a child, or has supported a new parent, will know that the postnatal period is a time of huge psychological, social and emotional upheaval. Unfortunately for at least 1 in 10 women (and 1 in 25 men) this upheaval during the year after birth is so great that it triggers an episode of depression (Post-Natal Depression; PND). As the saying goes, nothing can really prepare you for it. Or can it?
A Cochrane systematic review and meta-analysis of 20 randomised controlled trials (RCTs) including over 14,000 women suggests that psychosocial and psychological interventions can indeed prevent the onset of a depressive episode (Dennis & Dowswell, 2013). Women who received an intervention were 20% less likely to suffer from PND than women who received usual antenatal care (RR=0.78). So what can we do to ensure that future interventions are even more successful, and that barriers to accessing such interventions can be reduced?
Increasingly, researchers recognise the value of a mixed-methods approach; complementing RCTs with qualitative evaluations (e.g. interviews and focus groups) of users’ experiences of interventions (Midgley, Ansaldo, & Target, 2014).
This new review investigated experiences of participating in interventions to prevent postnatal depression.
Methods
Scope et al. (2017) performed a systematic review of the (published) literature and identified 22 studies reporting users’ (and healthcare professionals’; HCPs) experiences of participating in interventions to prevent PND. The majority of interventions were delivered in the antenatal period followed by a postnatal session.
Their key topics of interest were:
- Helpful and unhelpful parts of the intervention from the perspective of service users and service providers
- What women and HCPs believe they need from an intervention
- Barriers to accessing, delivering or facilitating the delivery of the intervention.
Results
The studies were mostly interview studies (primarily of service users rather than HCPs).
Factors helpful to intervention (12 studies)
- The most common theme was support (n=11 studies) i.e.
- value of peer support in group interventions
- involvement of partner largely helpful
- relationship between user and provider very important
- Five studies reported factors raised by HPCs, which largely related to the benefits of group-based interventions.
Factors unhelpful in an intervention (8 studies)
- Limitations of the group format and negative aspects of involving partners.
What women and HCPs believe they need from an intervention (5 studies)
- Having more time for sharing experiences.
Barriers to accessing/delivering the intervention (3 studies)
- Organisational issues e.g. timing, availability of childcare
- Stigma and fear of accessing service, meant that although some women wanted help, they were reluctant to seek it.
Support from the group, the intervention leader and one’s partner emerged as being particularly helpful in preventive interventions.
Conclusions
I started out by arguing that in order to develop more effective preventive interventions for PND, quantitative evaluations should be complemented by qualitative studies of service users’ and service providers’ experiences of preventive interventions.
The review by Scope et al. (2017) highlights the relatively limited number of studies that have addressed this need and the fact that these studies are often of relatively poor quality.
Nevertheless, the review suggests that one of the most helpful aspects perceived by women participating in PND preventive interventions (and HCPs delivering them) is the support from peers achieved from a group intervention.
Strengths and limitations
Although I believe this is a great idea for a review and has the potential to inform the development of improved interventions in the future, I have some concerns about the methodology of the study:
- Firstly, the authors combined data from very different interventions: from psychotherapy, to alternative and complementary medicine approaches, to the reorganisation of maternity care. The helpful and unhelpful aspects of these interventions are likely to be quite different, as are the barriers to accessing or facilitating them.
- Secondly, although the broad search criteria enabled inclusion of data from a reasonably large sample of service users (n=982) and HCPs (n=43), each of the key research topics of interest were only addressed by a few studies.
- Thirdly, although the authors made a good attempt to assess study quality (something which is challenging in qualitative research), this analysis concluded that the studies were of relatively poor quality. The authors also assessed the certainty of review findings across all studies (categorised as high, moderate, low and very low). Unfortunately, the majority of review findings were categorised being ‘low’ in certainty.
One additional limitation of the review is the fact that studies of fathers’ experiences of preventive interventions were excluded. Although statistics suggest that fathers are less often affected by PND than mothers (around 1/25 fathers compared to 1/10 mothers), this may in part be due to the fact that the stigma surrounding PND makes it particularly difficult for fathers to express their struggles with PND. I can understand that it might have been important to summarise data on maternal and paternal prevention interventions separately, but excluding studies of paternal PND prevention programs altogether seems like a strange choice, especially when the authors were relatively broad on other inclusion criteria. If you’re interested in paternal PND I can recommend a recent blog by André Tomlin. Furthermore, the outcomes of this recent study protocol for a systematic review of preventive interventions for partners of pregnant women on paternal outcomes are likely to be of interest (Suto, Takehara, Yamane, & Ota, 2016).
It’s also important to note some strengths of the study. Firstly, the topic is hugely important. Prevention of depression is a major public health priority but far too little is known about how to prevent PND specifically. Secondly, the focus on qualitative research is valuable and novel. To my knowledge, no other systematic review of qualitative research on the prevention of PND exists. I hope this review inspires other researchers planning on conducting a quantitative evaluation of a prevention intervention to consider adding a qualitative arm to fully understand the effects of the intervention on the population its designed to support.
Future studies of preventive interventions should consider the value of qualitative methods.
Implications for practice
I do have reservations about the extent to which the findings from small samples of relatively poor quality studies should directly inform clinical practice. Nevertheless, we shouldn’t forget that the state of mental health care provision and uptake for expectant parents lags behind what research tells us could support them. As such it is worth considering what the outcomes of this study could have for practice.
Firstly, and I speak here from both professional and personal experience, the presence (or lack) of support can have a profound effect on the outcomes of preventive interventions. As one parent in our preventive intervention for families with a depressed parent recently told us in a qualitative interview study: “It’s one thing knowing that there are X number of people out there who have been through the same thing as you, but sitting face-to-face with them in a room and hearing them speak about their experiences is quite different”. Personally, I remember how lonely I felt when my health visitor constantly asked after my daughter’s weight and my milk production, without showing much concern for my deteriorating mental health. It gave me the impression I should pull myself together and suppress my feelings until they went away.
Secondly, the effect of stigmatisation as a barrier to accessing interventions should not be underestimated. It’s true that the lack of government investment in PND prevention is a major barrier to people accessing interventions. Nevertheless, my experience of living in Germany, where preventive interventions are subsidised by the government, and one can self-refer to specialist PND services, is that very few parents access these services. I personally knew very little about the services available (because no one tells you what’s available until it is too late) and was reluctant to use them for fear of being given a diagnosis, needing inpatient treatment and at worst, not being allowed to take care of my daughter. As long as new parents wait until they physically can’t cope with parenthood, we won’t be able to prevent PND effectively.
The stigmatisation of postnatal depression can hamper expectant parents from accessing interventions.
Conflicts of interest
I have to confess that I am primarily a quantitative researcher, so I hope the authors can forgive me for perhaps not understanding all of their decisions in the conduct of the study. On the other hand, I am currently conducting a qualitative study of a preventive intervention for the children of depressed parents and as such am openly biased in believing this to be an important avenue of research.
Links
Primary paper
Scope A, Booth A, Morrell CJ, Sutcliffe P, Cantrell A. (2017) Perceptions and experiences of interventions to prevent postnatal depression. A systematic review and qualitative evidence synthesis. Journal of Affective Disorders, 210, 100–110. Journal Article, Review. https://doi.org/10.1016/j.jad.2016.12.017 [PubMed abstract]
Other references
Dennis, C.-L., & Dowswell, T. (2013). Psychosocial and psychological interventions for preventing postpartum depression. The Cochrane Database of Systematic Reviews, (2), CD001134. Journal Article, Meta-Analysis, Research Support, Non-U.S. Gov’t, Review. https://doi.org/10.1002/14651858.CD001134.pub3
Midgley, N., Ansaldo, F., & Target, M. (2014). The meaningful assessment of therapy outcomes: Incorporating a qualitative study into a randomized controlled trial evaluating the treatment of adolescent depression. Psychotherapy (Chicago, Ill.), 51(1), 128–137. https://doi.org/10.1037/a0034179 [PubMed abstract]
Suto, M., Takehara, K., Yamane, Y., & Ota, E. (2016). Effects of prenatal childbirth education for partners of pregnant women on paternal postnatal mental health: a systematic review and meta-analysis protocol. Systematic Reviews, 5, 21. https://doi.org/10.1186/s13643-016-0199-3
Thank you for an interesting blog post on our study Belinda. Our paper was part of a larger commissioned review including a quantitative systematic review and a cost effectiveness model. Our aim for the qualitative review was to identify (across all interventions) the mechanisms of preventive interventions which were perceived by women and by HCPs as important to the success of the intervention and could therefore contribute towards an understanding of what might make a more successful intervention.
We agree with the strengths of our review that you outline. This is a very important area of research and no other review exists in this area. We also agree more primary research studies should be undertaken to strengthen the evidence base.
We would also like to address the concerns about methodology you raise. We think that of the four points you raise, only two of them relate to our decisions about methodology. Firstly, regarding combining data from different interventions, our intention was to be inclusive with regard to women’s views about preventative interventions. We were interested in identifying the mechanisms across all interventions that would contribute to an understanding of what might make a future successful intervention. We were therefore interested in the common features across different interventions that emerged as helpful, unhelpful or barriers. As such, some strong themes across all interventions emerged, such as the importance of support.
With regard to the point about father’s experiences, we agree these data are very important and a future review should address this. However, as this review was part of a larger commissioned review this was not part of the remit. Furthermore, we did note during the undertaking of the review that such evidence was very sparse, and even if it had been part of our inclusion criteria there may not have been sufficient evidence to make any meaningful conclusions.
As a review team we share your frustrations regarding the paucity of the evidence for addressing the research questions, and regarding the quality of included studies. For practical reasons systematic reviews seek evidence that addresses tightly focused questions and so are always constrained by the quantity and quality of available data. We have sought to address as diverse a range of questions as was feasible through several complementary review methods, have privileged mechanisms over specific interventions and have also sought to optimise rigour and relevance. Your critique therefore attests to our team role as an honest broker rather than seeking to advance favoured interventions.