FINAL REPORT Demographic Profile of Mothers with Calgary ... calgary.pdf · Demographic Profile of...

FINAL REPORT

Demographic Profile of Mothers with Postpartum Depression Attending the

Calgary Regional Home Visitation Collaborative Healthy Families Program 2005-2007, their use of Community-based

Postpartum Depression Support Programs/Resources and the Support and Interventions Provided by Home Visitors

Patricia Hull, Research Coordinator Calgary Regional Home Visitation Collaborative July 30, 2007

Table of Contents

List of Figures……………………………………………………………………………i

List of Tables.....................................................................................................................iv

Appendices………………………………………………………………………………vi

Executive Summary…………………………………………………………………….vii

Acknowledgements…………………………………………………………………….viii

1. The Calgary Regional Home Visitation Collaborative (CRHVC) ........................... 1

1.1. History of the CRHVC ......................................................................................... 1

1.2. The Present Day CRHVC ..................................................................................... 1

1.2.1. The CRHVC Leadership Team ..................................................................... 3

1.2.2. The CRHVC Administration Team .............................................................. 3

1.2.3. The CRHVC Contracted Service Provider Agencies .................................. 3

1.2.4. The CRHVC Home Visitors........................................................................... 4

1.2.5. The CRHVC Supervisors Team .................................................................... 5

2. The 2004 CRHVC Evaluation Project - Link to the CRHVC 2005-2007

Postpartum Depression Research Project ................................................................ 5

3. The ALVA Foundation - Funding Support for the CRHVC 2005-2007

Postpartum Depression Research Project ................................................................ 6

4. Literature Review - Postpartum Depression.............................................................. 7

4. 1. Overview of Postpartum Depression.................................................................. 7

4. 2. The Edinburgh Postnatal Depression Scale (EPDS) ........................................ 7

4. 3. Prevalence of Postpartum Depression ............................................................... 8

4.4. Risk Factors for Postpartum Depression........................................................... 10

4.4.1. Risk Factors for Postpartum Depression that Relate to the Mother ....... 10

4.4.2. Risk Factors for Postpartum Depression that Relate to the Baby ........... 11

4. 5. The Impact of Postpartum Depression ............................................................ 11

4. 5. 1. The Impact of Postpartum Depression on the Mother............................... 11

4. 5. 2. The Impact of Postpartum Depression on the Infant/Child ...................... 12

4. 6. Onset and Duration of Postpartum Depression .............................................. 13

4. 7. Treatment of Postpartum Depression .............................................................. 13

4.8. The Role of Community Support/Home Visitation as an Intervention for

Postpartum Depression ...................................................................................... 14

5. Detection of Postpartum Depression in the CRHVC Healthy Families Program 15

5.1. Overview of the Support and Interventions Provided for Mothers with

Postpartum Depression Attending the CRHVC Healthy Families Program 16

6. The CRHVC 2005-2007 Postpartum Depression Research Project....................... 16

6.1. Goals of the CRHVC 2005-2007 Postpartum Depression Research Project.. 18

6.2. Schedule of Activities and Timeframes for the CRHVC 2005-2007

Postpartum Depression Research Project ........................................................ 18

6. 3. Guiding Principles for the CRHVC 2005-2007 Postpartum Depression

Research Project ................................................................................................. 18

6.4. Project Planning Activities - The CRHVC 2005-2007 Postpartum Depression

Research Project ................................................................................................. 19

6.4.1. Project Planning Phase - Design of the Pilot Phase, Implementation Phase

and Close-out Phase ...................................................................................... 19

6.4.2. Project Pilot Phase - Design and Testing of the Data Collection Forms.. 20

6.4.3. Project Implementation Phase - Data Collection and Interim Analysis .. 21

6.4.4. Project Close-out Phase - Data Analysis and Final Reporting ................. 22

7. Findings and Results of the CRHVC 2005-2007 Postpartum Depression Research

Project ........................................................................................................................ 22

7.1. Data Analysis and Overview of Findings........................................................... 22

7.1.1. Mothers with Postpartum Depression who Screened Positive on the First

Edinburgh Screen and Positive on the Second Edinburgh Screen .......... 23


Edinburgh Screen and Negative on the Second Edinburgh Screen ............... 30

7.1.3. Mothers with Postpartum Depression who Screened Negative on the First

EDPS and Positive on the Second Edinburgh Screen ............................... 38


Edinburgh Screen and Closed Early........................................................... 44

8. Consolidated Findings and Conclusions ................................................................... 52

8.1 Interventions for Postpartum Depression Prior to the Mothers’ Admission to

the CRHVC Healthy Families Program ........................................................... 54

8.2. First Language of Mothers with Postpartum Depression Attending the

CRHVC Healthy Families Program.................................................................. 55

8.3. Ages of Mothers with Postpartum Depression Attending the CRHVC Healthy

Families Program................................................................................................ 55

8.4. Educational Support and Information Provided by Home Visitors to Mothers

with Postpartum Depression Attending the CRHVC Healthy Families

Program ............................................................................................................... 55

8.5. Referrals Made by Home Visitors for Mothers with Postpartum Depression

Attending the CRHVC Healthy Families Program ......................................... 56

9.0 Benefits of Home Visitation as Perceived by Mothers with Postpartum

Depression Attending CRHVC Healthy Families Program 2005-2007 and

Reported to Home Visitors....................................................................................... 56

10. Risk Factors Identified by Home Visitors for Mothers with Postpartum

Depression Attending the CRHVC Healthy Families Program 2005-2007......... 59

11. Barriers to Attendance at Community-Based Based Support Programs for

Mothers with Postpartum Depression Attending the CRHVC Healthy Families

Program 2005-2007................................................................................................... 60

12. Postpartum Depression Goal Statements for Mothers with Postpartum

Depression Attending the CRHVC Healthy Families Program 2005-2007......... 67

13. Risk Factors Identified at the Time of Postpartum Screening for Mothers with

Postpartum Depression Attending CRHVC Healthy Families Program 2005-

2007............................................................................................................................. 71

14. Discussion and Conclusions of the CRHVC 2005-2007 Postpartum Depression

Research Project ....................................................................................................... 76

14.1. Comparison of the Results of the CRHVC 2005-2007 Postpartum Depression

Research Project with the Findings in the Literature ..................................... 76

14.1.1 Benefits of Participation in Home Visitation/CRHVC Healthy Families

Programs........................................................................................................ 76

14.1.2. Barriers to Attendance at Programs that Provide Support for

Postpartum Depression ................................................................................ 78

14.1.3. Risk Factors Related to Postpartum Depression for Mothers Attending

Home Visitation Programs........................................................................... 80

14.1.4. Demographic Profile of Mothers with Postpartum Depression Attending

Home Visitation/Healthy Families Programs............................................. 83

15. Conclusions and Recommendations of the CRHVC 2005-2007 Postpartum

Depression Research Project ................................................................................... 84

Summary Statement - the CRHVC 2005-2007 Postpartum Depression Research

Project ........................................................................................................................ 97

List of Figures

Figure 1. The Structure of the Calgary Regional Home Visitation Collaborative ..... 2 Figure 2. First Language of Mothers with Postpartum Depression who Screened

Positive on the First and Second Edinburgh Screen................................... 23 Figure 3. Educational Support Provided by Home Visitors to Mothers with

Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen........................................................................................... 25

Figure 4. Referrals Made by Home Visitors for Mothers with Postpartum

Depression who Screened Positive on the First and Second Edinburgh Screen .............................................................................................................. 26

Figure 5. Benefits of Home Visitation for Mothers with Postpartum Depression who

Screened Positive on the First and Second Edinburgh Screen .................. 27 Figure 6. Frequency of Risk Factors for Mothers with Postpartum Depression who

Screened Positive on the First and Second Edinburgh Screen .................. 29 Figure 7. Risk Factors for Individual Mothers with Postpartum Depression who

Screened Positive on the First and Second Edinburgh Screen .................. 30 Figure 8. First Language of Mothers with Postpartum Depression who Screened

Positive on the First and Negative on the Second Edinburgh Screen........ 31 Figure 9. Educational Support Provided by Home Visitors to Mothers with

Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen.................................................................. 32


Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen........................................................................................... 34

Figure 11. Benefits of Home Visitation for Mothers with Postpartum Depression

who Screened Positive on the First and Negative on the Second Edinburgh Screen .............................................................................................................. 36

Figure 12. Frequency of Risk Factors Reported by Mothers with Postpartum

Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen........................................................................................... 37

Figure 13. Identified Risk Factors for Mothers who Screened Positive on the First

and Negative on the Second Edinburgh Screen........................................... 38

i

Figure 14. First Language of Mothers with Postpartum Depression who Screened

Negative on the First and Positive on the Second Edinburgh Screen........ 39 Figure 15. Referrals Made by Home Visitors for Mothers with Postpartum

Depression who Screened Negative on the First and Positive on the Second Edinburgh Screen........................................................................................... 40


who Screened Negative on the First and Positive on the Second Edinburgh Screen .............................................................................................................. 41

Figure 17. Frequency of Risk Factors Reported by Mothers with Postpartum

Depression who Screened Negative on the First and Positive on the Second Edinburgh Screen........................................................................................... 43

Figure 18. Identified Risk Factors for Mothers who Screened Negative on the First

and Positive on the Second Edinburgh Screen ............................................ 44 Figure 19. First Language of Mothers with Postpartum Depression who Screened

Positive on the First Edinburgh Screen and Closed Early ......................... 45 Figure 20. Educational Support Provided by Home Visitors to Mothers with

Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early................................................................................ 46


Depression who Screened Positive on the First Edinburgh Screen and Closed Early.................................................................................................... 47


who Screened Positive on the First Edinburgh Screen and Closed Early 48 Figure 23. Frequency of Risk Factors Reported by Mothers with Postpartum

Depression who Screened Positive on the First Edinburgh Screen and Closed Early.................................................................................................... 50

Figure 24. Identified Risk Factors for Mothers who Screened Positive on the First

Edinburgh Screen and Closed Early ............................................................ 51 Figure 25. Early Closure Factors for Mothers with Postpartum Depression

Attending the CRHVC Healthy Families Program 2005-2007 .................. 52 Figure 26. Barriers to Attendance at all Community-based Programs and Resources

Offering Support to Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007........................................... 63

ii

Figure 27. Goal Statements Related to the Management of Postpartum Depression

for Mothers Attending the CRHVC Healthy Families Program 2005-2007.......................................................................................................................... 68

Figure 28. Risk Factors for Mothers with Postpartum Depression Attending the

CRHVC Healthy Families Program Identified at the Time of 2005-2006 Postpartum Screening.................................................................................... 72

iii

List of Tables Table 1. Reported Prevalence Rates of Postpartum Depression in Different

Populations of Mothers ...................................................................................... 9 Table 2 - Summary of Support and Interventions for Mothers with Postpartum

Depression Attending the CRHVC Healthy Families Program 2005-2007. 17 Table 3. Roles and Responsibilities and Time Frames for the CRHVC 2005-2007

Postpartum Depression Research Project ...................................................... 19 Table 4. Demographic Profile of Mothers with Postpartum Depression Attending the

CRHVC Healthy Families Program 2005-2007 and Support/Referrals Offered by Home Visitors ................................................................................ 53

Table 5. Benefits of Home Visitation as Mentioned by Mothers with Postpartum

Depression Attending the CRHVC Healthy Families Program 2005-2007 and Reported to Home Visitors ....................................................................... 57

Table 6. Risk Factors Identified by Home Visitors for Mothers with Postpartum

Depression Attending the CRHVC Healthy Families Program 2005-2007. 59 Table 7. Barriers Experienced by Mothers with Postpartum Depression Attending

the CRHVC Healthy Families Program 2005-2007 Relating to Attendance at Community-based Postpartum Depression Support Programs .............. 61

Table 8. Barriers Experienced by Mothers with Postpartum Depression Attending

the CRHVC Healthy Families Program 2005-2007 Relating to Attendance at the Family Doctor......................................................................................... 61

Table 9. Barriers Experienced by Mothers with Postpartum Depression Attending

the CRHVC Healthy Families Program 2005-2007 Relating to Attendance at Community-based Mental Health Programs............................................. 62

Table 10. Opinions of Mothers with Postpartum Depression Attending the CRHVC

Healthy Families Program 2005-2007 about Barriers to Attendance at all Community-based Postpartum Depression Support Programs and Resources ........................................................................................................... 66

Table 11. Goal Statements Relating to the Support and Management of Postpartum

Depression for Mothers Attending CRHVC Healthy Families Program 2005-2007 ........................................................................................................... 69

Table 12. Risk Factors Identified during Postpartum Screening for Mothers with

Postpartum Depression Attending CRHVC Healthy Families Program 2005-2006 ........................................................................................................... 71

iv

Table 13. Risk Factors Identified During Screening (N=408) using the CRHVC

Postpartum Screening Tool for Mothers Attending the CRHVC Healthy Families Program 2006-2007 ........................................................................... 75

Table 14. Benefits of Home Visitation Programs - Comparison of the Findings of the

CRHVC 2005-2007 Postpartum Depression Research Project with Benefits Reported in the Literature............................................................................... 77

Table 15. Barriers to Attendance at Community-based Postpartum Depression

Support Programs - Comparison of the Findings of the CRHVC 2005-2007 Postpartum Depression Research Project with Barriers Reported in the Literature........................................................................................................... 79

Table 16. Risk Factors for Mothers with Postpartum Depression - Comparison of

the Findings of the CRHVC 2005-2007 Postpartum Depression Research Project with Risk Factors Reported in the Literature .................................. 81

Table 17. Demographic Profile of Mothers with Postpartum Depression -

Comparison of the Findings of the CRHVC 2005-2007 Postpartum Depression Research Project with the Demographic Profiles Reported in the Literature .................................................................................................... 84

v

Appendices Appendix 1 - Data Collection Forms for the CRHVC 2005-2007 Postpartum Depression Research Project

vi

Executive Summary

Postpartum depression affects many new mothers and is known to have a

detrimental effect on the development of the mother-child relationship. The Calgary

Regional Home Visitation Collaborative (CRHVC) Healthy Families Program has

provided support and referral services for mothers with postpartum depression since its

inception in 2002. In 2004, the CRHVC found that over 35% of the mothers attending the

CRHVC Healthy Families Program screened positive for postpartum depression. The

CRHVC, given its commitment to research and evaluation, undertook the 2005-2007

Postpartum Depression Research Project to determine the demographic profile of mothers

with postpartum depression attending the CRHVC Healthy Families Program.

The average age of the 130 mothers with postpartum depression attending the

CRHVC Healthy Families Program was 30 (20-43) years; 81 (60%) of the mothers had

English as their first language. The CRHVC Home Visitors provided emotional support

for the mothers, arranged referrals to community-based postpartum depression support

programs and resources and provided various educational materials to the mothers. The

greatest barriers to mothers’ attendance at the community-based support programs to

which they were referred included transportation and child care issues and no perceived

benefit from attending the program. The greatest risk factors for the mothers were

financial and relationship difficulties, social isolation and current or past depression.

The CRHVC, given its commitment to research that advances support for mothers

with postpartum depression should consider additional studies, notably the development

of outcome-based best practice postpartum depression support guidelines for Home

Visitors and research to better understand mothers’ perceptions of postpartum depression.

vii

Acknowledgements

In submitting this Final Report, I would like to acknowledge the exceptional support

that I have received from the following people and organizations.

Funding Agencies

The ALVA Foundation, Toronto Ontario (majority of funding) Calgary and Area Child and Family Services Authority Calgary Children’s Initiative

The Calgary Regional Home Visitation Collaborative

Marianne Symons, Program Manager Amanda Robinson, Screener Nadine McClure Smith, Research Assistant Wichita Ferro, Screener, CRHVC Leadership Team Supervisors Team The Contracted Service Provider Agencies Home Visitors Mothers

Consultants and External Support

Dr. David Cawthorpe, Research and Evaluation Expert Petrina Hough, Evaluation Facilitator Calgary Health Region Public Health Nurses Members of the community with an interest in mother/child health

The Alberta Home Visitation Collaborative Network

Members of the Board Member organizations

viii

The Calgary Regional Home Visitation Collaborative Postpartum Depression Research Project

1. The Calgary Regional Home Visitation Collaborative (CRHVC) 1.1. History of the CRHVC

It is well-recognized that children who grow up in a home environment where there

are low levels of social support, a lack of parenting skills, insufficient funds for basic

necessities, alcohol or drug abuse concerns and/or mental health issues are susceptible to

neglect and abuse (Hough, 2004). These negative living circumstances are frequently

manifested in vulnerable children as delayed cognitive development, lifelong learning

difficulties, emotional problems or poor social adjustment.

In the early 2000’s, a number of Calgary-based organizations that served children

and families completed a comprehensive review that critically evaluated the availability

of community-based support services for vulnerable mothers and their babies/children.

This study clearly showed that the level of available support for at-risk mothers and their

families was minimal. In order to address this issue, a Steering Committee comprised of

representatives from local organizations with an interest in child and family services

responded to a provincial Request for Proposal for the creation of a Home Visitation

Program in Calgary. The Steering Committee’s efforts culminated in the creation of the

CRHVC in 2002. The mandate of the CRHVC was to oversee the development of a

comprehensive Home Visitation Program for new mothers and their babies/children who

were likely to be living in at-risk situations.

1.2. The Present Day CRHVC

Organizationally, the CRHVC includes a Leadership Team, an Administration

Team, Contracted Community Agencies, Home Visitors and a Supervisors Team. The

organizational structure of the CRHVC is depicted in Figure 1.

1


Figure 1. The Structure of the Calgary Regional Home Visitation Collaborative*

CALGARY CHILD AND FAMILY SERVICES (REGION 3)

CALGARY REGIONAL HOME VISITATION COLLABORATIVE

MANAGEMENT COMMITTEE (Leadership Team)

Screening, Research and Administrative Support (3FTE) Program Manager (Marianne Symons)

SERVICE

PROVIDER Calgary

Immigrant Women’s

Association

SERVICE PROVIDER Children’s

Cottage Society of Calgary

SERVICE PROVIDER

Salvation Army Children’s Village

SERVICE PROVIDER

Closer To Home

SERVICE PROVIDER Spectrum Youth and

Family Services Association Executive Director

SERVICE

PROVIDER Families Matter

Executive Director

Fiscal Agent Hull Child and Family Services

Program Supervisor

(0.4 FTE)

Program

Supervisor (1.4 FTE)

Program Supervisor

(1 FTE)

Program Supervisor

(0.4 FTE)

Program Supervisor

(0.6 FTE)

Program Supervisor

(1 FTE)

Home Visitors

(2 FTE) Four 0.5 positions

Home Visitors (7 FTE)

Home Visitors

(5 FTE)

Home Visitors (2 FTE)

Home Visitors

(3 FTE)

Home Visitors

(5 FTE)

* May 2007

A brief description of the roles and responsibilities of the CRHVC Leadership

Team, the CRHVC Administration Team, the Contracted Service Provider Agencies,

Home Visitors and the Supervisors Team follows.

2


1.2.1. The CRHVC Leadership Team

The CRHVC Leadership Team serves as a management committee for the

CRHVC and as such, sets the strategic direction and provides overall leadership of the

CRHVC. The Leadership Team is comprised of representatives from the fiscal agent

(Hull Child and Family Services), Calgary and Area Child and Family Services

Authority, Calgary Health Region, the CRHVC Project Manager, and sector

representatives (organizations offering home visitation services but who are not providing

services for the CRHVC Healthy Families Program and other institutions as deemed

appropriate). The Calgary Children’s Initiative served on the Leadership Team from the

inception of the CRHVC in 2002 until April 2007 at which time they determined that the

CRHVC was operating effectively and no longer required their assistance.

1.2.2. The CRHVC Administration Team

The CRHVC Administration Team hold degrees/diplomas in the Human Services

and includes a Program Manager (Marianne Symons) who coordinates and administers

the programs of the CRHVC, one fulltime Administrative Research Assistant (Nadine

McClure-Smith), one full-time Screener (Amanda Robinson) and a part-time Screener

(Wichita Ferro). The Administration Team also includes a Research Coordinator (Patricia

Hull) who oversees the design and evaluation of targeted research projects.

1.2.3. The CRHVC Contracted Service Provider Agencies

The Contracted Service Provider agencies provide Home Visitation services

through the CRHVC Healthy Families Program. The Contracted Service Provider

agencies of the CRHVC include: Closer to Home Community Services, Calgary

Immigrant Women’s Association (CIWA), Families Matter, Spectrum Youth and Family

3


Services Association, Children’s Cottage Society of Calgary and the Salvation Army

Children’s Village (SACV). The staffing complement of each agency includes a Program

Supervisor and a specified number of Home Visitors; the standard ratio of Supervisor to

Home Visitor is 1:5. The Contracted Service Provider Agencies have established solid

working relationships and partnerships with the organizations in communities where they

provide services. These partner organizations provide community-based support services

that can be accessed by families participating in the Healthy Families Program. In order

to promote increased utilization of their services, the CRHVC has developed information

brochures, consent for service and assessment tools, many of which have been translated

into different languages including Chinese, Vietnamese, Punjabi, Arabic, and Spanish. In

addition, qualified Aboriginal Home Visitors are employed by the Closer to Home

agency and their involvement has increased the participation of Aboriginal families.

1.2.4. The CRHVC Home Visitors

The majority of the CRHVC Home Visitors have diplomas or degrees in the

human services fields and in general, their career experience exceeds two years. The

Home Visitors support the mothers attending the CRHVC Healthy Families Program by:

developing individualized service/goal plans/interventions based on family needs;

assessing progress towards those goals; teaching parenting skills to mothers; providing

emotional support for the mothers and; making referrals to community resources. Each

CRHVC Home Visitor has a caseload of between 15 and 20 families.

The CRHVC Home Visitors are committed to connecting families to needed

community-based postpartum depression support programs and specialized

services/resources. They make their first visit to the family within a week of referral and

4


depending on family needs (and the parents desire to remain in the CRHVC Healthy

Families Program) may continue to see the family until the child reaches age five.

1.2.5. The CRHVC Supervisors Team

The CRHVC Supervisors Team serves as an operations committee and facilitates

achievement of the CRHVC’s strategic directives. The Supervisors Team is comprised of

a Supervisor from each of the Contracted Service Provider agencies, the CRHVC

Program Manager and other members of the Administration Team as may be appropriate.

2. The 2004 CRHVC Evaluation Project - Link to the CRHVC 2005-2007 Postpartum Depression Research Project

In 2004, the CRHVC organized a review and evaluation of its operations. A

consultant, Petrina Hough coordinated this initiative and her findings are detailed in a

comprehensive report (Hough, 2004). One part of the evaluation focused on postpartum

depression in mothers attending the CRHVC Healthy Families Program. Hough (2004)

determined that:

Eighty-eight percent (n=129) of the mothers in the 2004 CRHVC evaluation sample completed the Edinburgh Postpartum Depression Screening Tool (EPDS)

The rate of postpartum depression at the time of the first EPDS was 35% (n= 42) The rate of postpartum depression at the time of the second EPDS was 21% (n= 17)

On the basis of her study findings, Hough (2004) concluded that:

The percentage of women in the 2004 CRHVC evaluation sample who screened positive for postpartum depression at either the first or second screen was significantly higher than that reported for the general population;

Given this, postpartum depression appeared to be an important issue for service delivery by the CRHVC;

The services to which mothers with postpartum depression are usually referred to are not ideal for many mothers due to the nature of the treatment offered (usually group work), the long waitlist for services, the logistics of getting there (transport, childcare), and because services are not available in languages other than English;

Given that the existing services are not meeting the identified need in the Healthy Families postpartum depression population, a coordinated effort to assist mothers suffering from postpartum depression needs to be defined and;

5


The profile of the mothers who are dealing with postpartum depression, notably their demographics and any relation to scores on screening tools needs to be explored in Calgary. The CRHVC fully endorsed the findings in Hough’s (2004) Report and, in 2004

sought funding to undertake a follow-up study to address her recommendations.

3. The ALVA Foundation - Funding Support for the CRHVC 2005-2007 Postpartum Depression Research Project

The CRHVC is committed to carrying out its mandate in the context of an

evaluation and research framework. Based on Hough’s (2004) recommendations, the

CRHVC made a decision to undertake a study that would describe the demographic

profile of mothers with postpartum depression attending the CRHVC Healthy Families

Program specifically, their use of community-based postpartum depression support

services and resources and the relation between their postpartum screening scores (with

the Parkyn Screen/Healthy Families America Screen) and postpartum depression. In

2004, the CRHVC requested and received majority funding from the ALVA Foundation

(Toronto, Ontario) to undertake the CRHVC 2005-2007 Postpartum Depression Research

Project, an exploratory evidence-based research initiative that would describe:

1) The demographic profile of mothers with postpartum depression attending the CRHVC Healthy Families Program

2) The relationship/frequency between risk factors identified on the postpartum screening tools (the Parkyn Screen and the Healthy Families America Screen) in mothers with postpartum depression attending the CRHVC Healthy Families Program

3) The community-based support services and resources accessed by mothers with postpartum depression and the barriers to accessing these programs

The Calgary and Area Child and Family Services Authority and the Calgary

Children’s Initiative provided additional funding support. Patricia Hull was hired as the

Research Coordinator in April 2005.

6


4. Literature Review - Postpartum Depression

4. 1. Overview of Postpartum Depression

Postpartum depression is a costly common major depressive disorder that affects

10-20% of women in their child-bearing years (Gjerdingen andYawn, 2007). According

to Beck (2006), its diagnosis is dependent on a mother having five or more of the

following symptoms for at least two weeks; insomnia or hypersomnia, psychomotor

agitation or retardation, fatigue, changes to appetite, feelings of worthlessness or guilt,

decreased concentration and suicidality and in addition; symptoms of one or both of

depressed mood or loss of pleasure. Baby blues, which manifest as anxiety, tearfulness

and mild irritability within several days after the baby’s birth (and tend to disappear

within several weeks of birth) affect 50-75% of new mothers (Beck, 2006). On the other

hand, postnatal psychosis is a rare but severe psychiatric disturbance where a mother

becomes "out of touch'' with reality after the birth of a baby (Ballard, Davis, Cullen,

Mohan and Dean, 1994; Seyfried and Marcus, 2003; Sit, Rothschild and Wisner, 2006).

Stewart, Robertson, Dennis, Grace and Wallington (2003) completed a

comprehensive literature review of postpartum depression with a particular focus on four

areas: risk factors for postpartum depression; detection, prevention and treatment of

postpartum depression; effects of the illness on the mother-infant relationship and; public

health interventions and strategies to mitigate the impact of postpartum depression. This

publication is an excellent resource and includes a comprehensive list of references.

4. 2. The Edinburgh Postnatal Depression Scale (EPDS)

The Edinburgh Postnatal Depression Scale (EPDS) is a ten-item self-reporting

measurement tool designed to identify postnatal depression in new mothers (Cox, Holden

7


and Sagovsky, 1987). The validity of the EPDS in terms of its ability to detect postnatal

depression has been widely reported (Boyce and Hickey, 2005; Dennis and Ross, 2006;

Sword, Watt and Kreuger, 2006). The EPDS questionnaire is the most frequently used

screening tool for detecting postpartum depression; a score of > 12 is indicative of

postpartum depression (Dennis 2005).

4. 3. Prevalence of Postpartum Depression

Various authors have noted that 60% of women experienced their first depression

after becoming a mother and that the presence of a pre-existing depressive disorder made

relapse more likely after the baby’s birth (Arnold, Baugh, Fisher, Brown and Stowe,

2002; Flores and Hendrick, 2002). Ramsay (1993) noted that 50% of cases of postpartum

depression were not detected, and hence not treated. At the same time, only 49% of

mothers who reported depression actually sought help and support (MacLennan, Wilson

and Taylor, 1996). Cooper and Murray (1998) noted that, over a five year period women

with postpartum depression were twice as likely to experience future episodes of

depression.

The prevalence rate of postpartum depression has been widely reported for

different populations of mothers in various countries. Overall, these studies concluded

that postpartum depression was a major public health issue/concern affecting mothers and

families from most cultures. The onset and duration of postpartum depression was

influenced by various medical/health and psychosocial factors in the mothers’ home

environment. A summary of the findings from various studies is detailed in Table 1.

8


Table 1. Reported Prevalence Rates of Postpartum Depression in Different Populations of Mothers Prevalence - Postpartum Depression

Reference Comments

13% O’Hara & Swain (1996) Diverse population-based studies; summary results of 59 studies; rate in adolescent mothers was 25%

3-25% Dennis, Janssen & Singer (2004)

Rates fluctuated in relation to sample size, timing of the assessment, choice of diagnostic criteria, and whether the studies were retrospective or prospective

3.5- 40%

Inandi, Bugdayci, Sasmaz, Dunbar & Sumer (2005)

Rates varied depending on definition of postpartum depression, evaluation criteria and geographical location; (31% in Turkish mothers - the focus of their study)

1-5.9 % Beck (2006) Study focused on the first 12 months postpartum with the highest rates noted at two and six months postpartum; reference to mothers from different cultures

11.5% Fuggle, Glover, Khan & Haydon (2002)

Study focused on Bengali women in England and Bangledash x

10% Righhetti-Veltema, Conne-Perreard, Bousquet & Manzano (1998)

General population-based study

10-20% Surkan, Peterson, Hughes & Gottlieb (2006)

Reference to various literature studies

Variable (see comments)

Bloch, Rotenberg, Koren & Klein (2005)

Rates of 43.9%, 46.8% and 31.3 % found in African-American, Hispanic and white women respectively

23 % Baker, Cross, Greaver, Wei, Lewis, and the Healthy Start CORPS (2005)

Native population studies, authors noted that this rate of postpartum depression was significantly higher than that for other populations

35% Hough (2004) Mothers of different cultures attending CRHVC Healthy Families Program - mothers pre-screened by Calgary Health Region, thus accounting for the relatively high prevalence

9


4.4. Risk Factors for Postpartum Depression

Risk factors for postpartum depression have been extensively documented (Beck,

1998, 2001, 2006; Bernazzanni, Saucier and Borgeat, 1997; Boyce and Hickey, 2005;

Dennis et al., 2004; Misri, Kostaras, Fox, and Kostaras, 2000; Righhetti-Veltema et al.,

1998; Ryan, Milis and Misri, 2005; Seyfried and Marcus, 2003; Stewart et al., 2003;

Vasquez and Pitts, 2006). A summary of the most usual and important risk factors for

postpartum depression follows.

4.4.1. Risk Factors for Postpartum Depression that Relate to the Mother

The mother-related risk factors for postpartum depression that have been reported

in the literature include:

Prenatal depression, anxiety, panic, obsessive thoughts or behavior History of childhood abuse Psychiatric illness in other family members, notably partners Relationship difficulties Inadequate social support (family, friends and partners); loneliness Low level of education Socio-economic issues including unemployment Multiparity Inability to breastfeed; unhappiness with child feeding Stressful life events, particularly financial problems Marital conflict/domestic violence Low confidence as a parent Child care stress Low self-esteem Poor coping/stress management skills Maternal non-adjustment; negative attitude to the baby New immigrant status Single parent status inclusive of recent separation or divorce situations Super woman syndrome Perfectionist ideals and attitudes Hormonal risks (thyroid imbalance) or premenstrual dysmorphic disorder or

infertility issues) Reluctance to seek support for physical/mental health related concerns

10


4.4.2. Risk Factors for Postpartum Depression that Relate to the Baby

The baby-related risk factors for postpartum depression that have been reported in

the literature include:

Obstetric complications; negative birth experience Unplanned pregnancy Inadequate prenatal care Early mother-child separation Young age of mother at the time of birth Having a baby of the non-desired sex Baby's personality, health or disability Difficult infant behavior; fussy, demanding, poor eating habits, poor sleeping

patterns

It is important to note that the literature generally indicated that these mother/child-

related risk factors did not actually cause postpartum depression; in fact many women

who had these risk factors never became depressed.

4. 5. The Impact of Postpartum Depression

The devastating effects of postpartum depression on the maternal-child/family

interactions have been reported in numerous studies. Beck (1998, 2002) and others

(Austin 2003; Benvenutti, Valooriani, Degl’Innocenti, Favinin, Hipwell and Pazzagli,

2001; Murray, Sinclair, Cooper, Ducournau and Turner, 1999; Stewart et al., 2003) have

noted that, in general mothers and children were likely to be living in at-risk

circumstances if postpartum depression was present and/or not adequately managed.

4. 5. 1. The Impact of Postpartum Depression on the Mother

In a study of 570 women, Righhetti-Veltema et al., (1998) found that the coping

abilities of depressed mother were decreased while their vulnerability to new stress

factors increased. Mothers with postpartum depression have been shown to display

flatness of affect with less affection shown to their infants (Beck, 2002). Dennis et al.,

11


(2004) noted that mothers with postpartum depression frequently exhibited symptoms of

dysphoria, emotional lability, insomnia, confusion, anxiety, guilt, and suicidal ideation;

poor ability to cope, low self-esteem, negative maternal attitudes and loneliness which

tended to exacerbate postpartum depression symptoms. According to Goldsmith (2007),

mothers with postpartum depression felt overwhelmed and were often unable to complete

basic activities such as self-care, caring for the baby and doing household chores.

Logsdon, Wisner and Pinto-Foltz (2006a) noted that mothers with postpartum depression

were less likely to comply with recommended preventative health interventions. Other

researchers have noted that mothers with postpartum depression were also more unlikely

to seek necessary treatment and help (Dennis and Chung-Lee 2006).

4. 5. 2. The Impact of Postpartum Depression on the Infant/Child

Beck (1995) noted that infants of mothers with postpartum depression were

fussier and made fewer positive facial expressions and vocalizations than infants of

mothers who were not depressed. Ryan et al., (2005) and Logsdon et al., (2006a) reported

that postpartum depression negatively affected infants with consequent deleterious effects

on the child’s cognitive and emotional development in the early years. Infants of mothers

with postpartum depression have also demonstrated an aversion to interaction and

communication, thus contributing to their mothers’ negative mood and depression (Cohn

and Tronick, 1983; Forbes, Cohn, Allen and Lewinsohn (2004); Murray et al., 1999;

Stewart et al., 2003). Other adverse effects of postpartum depression on infants/children

that have been reported include attachment insecurity, social difficulties and long-term

behavioral difficulties (Beck, 1999; Orvaschel, Walsh-Allis and Ye, 1988). Finally,

postpartum depression has also been shown to adversely affect family health (Beck,

12


2006, Stewart et al., 2003) and additionally, to compromise child safety (Rhodes and

Iwashyna, 2007).

4. 6. Onset and Duration of Postpartum Depression

The onset of postpartum depression has been reported to be greatest in the first 12

weeks postpartum (Cooper and Murray, 1998; Stewart et al., 2003). The duration of

postpartum depression generally depends on its severity and the mothers’ timeliness in

seeking and receiving appropriate treatment(s) and support.

4. 7. Treatment of Postpartum Depression

According to Dennis (2006), Highet and Drummond (2004), Holden, Sagovsky

and Cox (1989), Horowitz and Goodman (2005) and Stewart et al., (2003), a variety of

interventions have been used to treat postpartum depression; these interventions include:

Psychological interventions (interpersonal psychotherapy, cognitive behavioral therapy, psychological debriefing)

Psychosocial interventions (antenatal and postnatal classes, intrapartum support, supportive interactions)

Quality of care improvements (continuity of care, antenatal identification and notification, early postpartum follow-up by general practitioners, flexible postpartum care, education strategies, relaxation and guided imagery

Dennis (2006) and Cooper and Murray (1998) and Murray, Cooper, Wilson and

Romaniuk (2003) suggested that postpartum depression was a major health issue and as

such, there was a need for timely and effective preventive strategies. Studies completed

by Dennis and Ross (2006) noted that early screening in conjunction with an

understanding of new mothers’ biological and psychosocial risk factors for postpartum

depression could form a sound basis for its early identification and timely treatment.

Lumley (2005) concluded that psychosocial and psychological strategies or specific

interventions tested in trials have not effectively prevented postpartum depression and

13


advised that the use of mental health workers could be an important strategy for

preventing postpartum depression. Dennis (2005) proposed that intensive care and

support in the home for new mothers should be considered as a key intervention for

managing postpartum depression. According to Whitton and Appleby (1996), successful

therapy partly involved mothers addressing incorrect ideals (such as expecting too much

of themselves) and having some time to themselves a strategy that in turn, would

strengthen the mother-child relationship.

Charbrol, Teissdre, Armitage, Danel and Walburg (2004) and others (Boath,

Bradley and Henshaw, 2004; Malone, Papagni, Ramini and Keltner, 2004; Stewart et al,

2003) noted that antidepressant therapy was a successful option for treating postpartum

depression in some, though not all mothers.

4.8. The Role of Community Support/Home Visitation as an Intervention for Postpartum Depression Holden et al., (1989) determined that mothers who had regular visits (average of

nine visits over thirteen weeks) from Health Visitors (Home Visitors) showed a greater

improvement in maternal mood and the quality of mother-infant relationship compared to

women who were not visited, a finding supported by Seeley, Murray and Cooper (1996).

Matthey (2004), citing the results of various studies noted that home visiting did not

appear to have a lasting impact on mother’s mood or self-esteem; at the same time, and

depending on the study, he concluded that home visiting was associated with positive

gains in the mother-child interaction. Ray and Hodnett (2001) conducted a

comprehensive review of randomized and quasi-randomized trials wherein they assessed

the effect of additional professional caregiver and/or social support interventions on the

14


course of postpartum depression. They concluded that there is evidence to affirm the

positive effect of professional support on reducing postpartum depression.

Shaw, Levitt, Wong and Kaczorowski (2006) examined the effectiveness of

postpartum support programs in improving the mothers’ knowledge, attitudes and skills

relating to parenting, mental health status, maternal quality of life and physical health.

They concluded that home visitation or peer support could benefit high risk populations

and that scores on the Edinburgh Postnatal Depression Scale were significantly reduced

when mothers participated in home visitation programs.

Leahy-Warren and McCarthy (2007) reviewed the evidence relating to different

treatment options for postpartum depression and noted that there was: limited success

with antidepressant medications, some success with psychotherapeutic options and a

positive impact of professional home visits and social support networks for mothers with

postnatal depression. These authors, citing Dennis (2005) concluded that the only

intervention that demonstrated a clear preventative effect with vulnerable mothers was

individual intensive postpartum support in the guise of postnatal home visits provided by

professionals.

5. Detection of Postpartum Depression in the CRHVC Healthy Families Program The results of the EPDS are considered valid if the screen is administered six

weeks to twelve months postpartum. The CRHVC Home Visitors first offer the EPDS to

mothers at sixteen weeks postpartum and again at thirty-two weeks postpartum. As

deemed necessary, the CRHVC Home Visitors can offer the EDPS a third time if they

believe that the mother might have become depressed. The CRHVC Home Visitors may

15


also offer screening at eight weeks if professionals from other organizations had not

already offered the EDPS to mothers.

Mothers who score twelve on the English version of the EPDS and mothers who

score ten on the translated versions of the EPDS are considered to have screened

positively for postpartum depression. The CRHVC Home Visitors, in conjunction with

the mothers who have a positive EDPS score, develop individualized treatment plans and

goal statements to address the mothers’ postpartum depression. The goal statements and

plans for treating the mothers’ postpartum depression range from offering emotional

support and education about postpartum depression to making referrals/connections to

community-based postpartum depression support programs and resources.

5.1. Overview of the Support and Interventions Provided for Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program

The CRHVC Healthy Families Program provides support to mothers with

postpartum depression, part of which is referral to community-based postpartum

depression support programs and resources. Table 2 provides a summary of the support

that the CRHVC Home Visitors provide for mothers with postpartum depression.

6. The CRHVC 2005-2007 Postpartum Depression Research Project

The CRHVC is committed to the continual improvement of its programs and to

adding new knowledge about how Home Visitors can best serve vulnerable mothers with

postpartum depression and their families. As such, the CRHVC 2005-2007 Postpartum

Depression Research Project, with a mandate of addressing Hough’s (2004)

recommendations (p. 5 of this Report) was undertaken in 2005. The research approach

used for the CRHVC 2005-2007 Postpartum Depression Project was exploratory in

16


nature given that the overall goal of the Project was to learn about “what was going on”

with mothers who had postpartum depression and “ what issues concerned them”.

Table 2 - Summary of Support and Interventions for Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007 Intervention/Support

Provided by Home Visitors

Description of Support/Intervention

Emotional Support Listening to mothers/supporting mothers, serving as company

Postpartum Depression Education Package

Education Package that includes information about postpartum depression, phone numbers of community resources such as the Distress Centre, Children’s Cottage; support contacts, tips for moms/dads; self-care suggestions

Articles and Handouts about Postpartum Depression

Education Resource that includes articles such as “Why are you Feeling Blue”, Ideas for moms/dads, new news and ideas about postpartum depression, “Shaken Baby” information/video, social support information

Video about Postpartum Depression

Video that provides information about postpartum depression; CRHVC Home Visitors may watch it with mothers; Hope - Living through Postpartum Depression

Self-care Strategies A variety of strategies for coping with postpartum depression - time alone, baby sitting arrangements, time with friends/other mothers, rest and sleep, visualization, relaxation techniques, good nutrition/exercise - both short-term/long-term; CRHVC Home Visitors review and discuss strategies with mothers; develop goal plans to address the mothers’ postpartum depression

Community-based Postpartum Support Programs and Resources

Phone support and/or visitation through Families Matter by moms who have had postpartum depression; Referrals to Programs - Parent Link, Community Resource Centres, Home Start, Collaborative Mental Health, YWCA Drop-in, Nurturing Yourself

Counseling Referral to Families Matter and other counseling services in keeping with the mothers’ ability to access services, programs include Woods Youth and Family Services and the Calgary Counseling Centre

Family Physician Referral to family doctor if the mother has a family doctor; the family doctor may arrange medication

Specialist Physician Referral to psychiatrist/counseling support

Community Nurse Referral to Calgary Health Region Community Clinics, may include home-based or clinic-based support/child care and parenting information

Community Mental Health Services

Referral to community-based mental health programs; review of information from the Alberta Mental Health Association

17


6.1. Goals of the CRHVC 2005-2007 Postpartum Depression Research Project

The five goals of the 2005-2007 CRHVC Postpartum Depression Research

Project were to:

1) Determine and assess the demographic profile of mothers with postpartum depression attending the CRHVC Healthy Families Program;

2) Determine the community-based support services and resources that mothers with postpartum depression attending the CRHVC Healthy Families Program were referred to;

3) Determine and assess the factors that influenced the decisions of mothers with postpartum depression attending the CRHVC Healthy Families Program to participate/not participate in community-based support services and resources for postpartum depression;

4) Determine and assess the perceptions of mothers with postpartum depression attending the CRHVC Healthy Families Program about the support and services offered by their Home Visitors and;

5) Use the results of the CRHVC 2005-2007 Postpartum Depression Research Project as a source of input for recommending additional research studies and/or for strengthening the CRHVC’s postpartum depression support strategies

6.2. Schedule of Activities and Timeframes for the CRHVC 2005-2007 Postpartum Depression Research Project

The time frame for the CRHVC Postpartum Depression Research Project was

May 2005 to July 2007. The roles of the CRHVC Administration Team, Contracted

Service Agencies/Home Visitors and the Research Coordinator are detailed in Table 3.

6. 3. Guiding Principles for the CRHVC 2005-2007 Postpartum Depression Research Project

The CRHVC Postpartum Depression Research Project was undertaken in the

context of a research and evaluation framework. Its execution was guided by the

following principles: the use of evidence to support statements and conclusions; attention

to practical feasible recommendations to better understand and/or enhance the needs of

families served by the CRHVC Healthy Families Program; extensive involvement with

18


internal and external stakeholders and; the generation of new ideas for further study and

strengthening of the CRHVC Healthy Families Program.

Table 3. Roles and Responsibilities and Time Frames for the CRHVC 2005-2007 Postpartum Depression Research Project

Postpartum depression Project Activity

Roles and Responsibilities

Start Date Finish Date

Project Planning Phase: Design of data collection forms and procedures for the collection of postpartum depression data from the CRHVC Contracted Service agencies; development of guidelines for undertaking the pilot phase, implementation phase and close-out phase; confirmation of time frames for the different phases, design of guidelines for data analysis and final reporting

CRHVC Administration Staff, Research Coordinator

May 2005 August 2005

Pilot Phase: Review and revision of data collection forms; initial data collection from the CRHVC Home Visitors using the data collection forms

Project Coordinator, CRHVC Supervisors Team, CRHVC Healthy Families Staff

September 2005

October 2005

Implementation Phase: Continued data collection, analysis of the data collected during the implementation phase

Project Coordinator, CRHVC Administration Team, Supervisors Team

November 2005

February 2007

Close-out Phase: Data analysis, consolidation of findings and submission of the Final Report

Project Coordinator, CRHVC Administration Team, Supervisors Team; Healthy Families Staff

March 2007 July 2007

6.4. Project Planning Activities - The CRHVC 2005-2007 Postpartum Depression Research Project The following activities were completed during the project planning phase which

took place between May and October 2005.

6.4.1. Project Planning Phase - Design of the Pilot Phase, Implementation Phase and Close-out Phase The Research Coordinator and the CRHVC Administration Team developed a

framework for completing the Project in relation to specific criteria i.e. the CRHVC

2005-2007 Postpartum Depression Project had to:

Achieve the 5 stated goals Be completed by May 2007 Be literature-driven Provide recommendations for further study and research

19


Use a participative approach and involve the CRHVC Administration Team, Supervisors and Home Visitors as well as external expert Consultants

In planning the CRHVC Postpartum Depression Research Project, the Research

Coordinator and the CRHVC Administration Team identified three distinct phases; the

pilot phase, the implementation phase and the post-pilot phase. The pilot phase was

scheduled for completion between August 2005 and December, 2005; its key activities

included the development and testing of the forms for collecting data about/from the

mothers with postpartum depression. The time frame for the implementation phase was

January 2006 until March 31, 2007. The key activities of the implementation phase

included continued data collection and an interim analysis of the findings. The main

activities of the post-pilot phase, which was scheduled for completion between April and

May, 2007 included a comprehensive analysis of the data and writing of the Final Report.

6.4.2. Project Pilot Phase - Design and Testing of the Data Collection Forms The Research Coordinator and the CRHVC Administration Team developed data

collection forms between May and August 2005. The forms were designed to capture

information about the mothers’ demographics, the nature of support/interventions

provided by the CRHVC Home Visitors, the type/nature of referrals made to community-

based postpartum depression support programs and resources (family doctor, specialist

physician, community health nurse and community-based postpartum depression support

programs) and the mothers’ perceptions about barriers to accessing these services.

The Supervisors Team reviewed the data collection forms and based on their

feedback, some changes were made. At the conclusion of the pilot phase, the Supervisors

as well as the CRHVC Administration Team completed a final review of the forms and

20


recommended several additional changes, primarily the clarification of several questions.

A copy of the data collection forms is included in Appendix 1.

For the purposes of data collection, the mothers with postpartum depression were

categorized as mothers who:

Screened positive on the first EDPS screen and positive on the second EDPS screen

Screened positive on the first EDPS screen and negative on the second EDPS screen

Screened negative on the first EDPS screen and positive on the second EDPS screen

Screened positive on the first EDPS screen and had early closure from the CRHVC Healthy Families Program

Mothers were included in the CRHVC 2005-2007 Postpartum Depression Research

Project if: they had attended the CRHVC Healthy Families Program in 2005-2007 and if;

the CRHVC Home Visitors could collect the information on the data collection forms.

6.4.3. Project Implementation Phase - Data Collection and Interim Analysis

The implementation phase of the Project took place between January 2006 and March

2007. During the implementation phase, the CRHVC Home Visitors continued to

complete and return the data collection forms to the CRHVC Research Assistant. As of

December 2006, data were available for 103 mothers attending the CRHVC Healthy

Families Program who had screened positive for postpartum depression. Overall, the

quality of the data collected/reported by the CRHVC Home Visitors was excellent.

An interim analysis of the data for mothers with postpartum depression was

completed in March 2006 and again in December 2006. The findings of the interim

analysis in December 2006 were as follows:

English was the first language of approximately half of the mothers with postpartum depression attending the CRHVC Healthy Families Program

21


The most usual forms of support offered to the mothers by the CRHVC Home Visitors were emotional support/company; the provision of education information packages about postpartum depression and; referrals to community-based postpartum depression support programs and resources

The most usual risk factors for postpartum depression identified by the CRHVC Home Visitors included financial difficulties (insufficient money for basic necessities), relationship difficulties, past/current depression and social isolation

Approximately 30% of the mothers with postpartum depression had early closure from the CRHVC Healthy Families Program

6.4.4. Project Close-out Phase - Data Analysis and Final Reporting

The implementation phase of the Project finished on March 31, 2007. During May,

June and July 2007 a comprehensive analysis of the data was completed and the Final

Report was written.

7. Findings and Results of the CRHVC 2005-2007 Postpartum Depression Research Project 7.1. Data Analysis and Overview of Findings

As noted earlier, the CRHVC 2005-2007 Postpartum Depression Research Project

categorized mothers with postpartum depression attending the CRHVC Healthy Families

Program into four distinct groups. Data were available for 130 mothers inclusive of:

34 (26%) of the 130 mothers who screened positive on the first EDPS and positive on the second screen

29 (22%) of the 130 mothers screened who positive on the first EDPS and negative on the second screen

15 (12%) of the 130 mothers who screened negative on the first EDPS and positive on the second screen

52 (40%) of the 130 mothers who screened positive on the first EDPS and had early closure from the CRHVC Healthy Families Program

The following sections of this Report summarize the findings for each of these

categories of mothers.

22


7.1.1. Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Positive on the Second Edinburgh Screen In this study, thirty-four (26%) of the 130 mothers with postpartum depression

attending the CRHVC Healthy Families Program screened positive on both the first and

second EDPS. The profile of these mothers is described below.

First Language of Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen The first language of mothers with postpartum depression attending the CRHVC

Healthy Families Program who screened positive on both the first and second EDPS is

depicted in Figure 2.

Figure 2. First Language of Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen

First Language of Mothers with Postpartum Depression (Positive 1st and Positive 2nd Edinburgh Screen) Attending the CRHVC Healthy

Families Program 2005-2007 (N=34)

Arabic, 3, 9%

Farsi, 2, 6%

Other*, 7, 21%

Spanish, 3, 9%

English, 19, 56%

EnglishSpanish

ArabicFarsi

Other*

* includes 1 mother whose first language/cultural background is Albanian, Cantonese, Hindi, Punjabi, Somalian, Tagalog and Vietnamese

23


Findings and Conclusions

Nineteen (56%) of the 34 mothers with postpartum depression attending the

CRHVC Healthy Families Program who screened positive on both the first and second

EDPS had English as their first language; 15 (44%) of the mothers had a language other

than English as their first language.

Based on the results of this study, we suggest that postpartum depression occurred

in mothers from a wide variety of cultural backgrounds and that its likelihood was

relatively the same in mothers who had English as their first language and mothers

(collectively) whose first language was a language other than English.

Educational Support Provided by Home Visitors to Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen Figure 3 depicts the type/nature of educational support that Home Visitors

provided to mothers attending the CRHVC Healthy Families Program who screened

positive on both the first and second EDPS.


The Home Visitors provided various kinds of educational support to 28 of 34

(82%) of mothers with postpartum depression attending the CRHVC Healthy Families

Program who screened positive on both the first and second EDPS. The most usual form

of educational support that the CRHVC Home Visitors provided to these mothers was an

educational information package about postpartum depression. This education package

was given to 18 (64%) of the 28 mothers. The next most usual type of support that Home

Visitors gave mothers was educational handouts and articles about postpartum

depression. These materials were given to 6 (21%) of the 28 mothers. The mothers also

24


indicated that the CRHVC Home Visitors provided much-appreciated emotional support

and company while providing education and information about postpartum depression.

Figure 3. Educational Support Provided by Home Visitors to Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen

Educational Support Provided by Home Visitors to Mothers withPostpartum Depression (Positive 1st and Positive 2nd Edinburgh Screen)

Attending the CRHVC Healthy Families Program 2005-2007 (N=28)

Self-care Strategies,

1, 4%Video, 2, 7%

PPD Package, 18, 64%

Counseling Information,

1, 4%

Handouts, 6, 21%

Handouts

CounselingInformationPPD Package

Video

Self-careStrategies

Based on the results of this study, we suggest that the most usual type of

educational support that Home Visitors provided for mothers attending the CRHVC

Healthy Families Program who scored positive on both the first and second EDPS was

education and information about postpartum depression. The emotional support offered

by the CRHVC Home Visitors while providing this information was also highly valued

by the mothers.

Referrals Made by Home Visitors for Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen Figure 4 depicts the type/nature of referrals to community-based postpartum

depression support programs and resources that the Home Visitors made for mothers

25


attending the CRHVC Healthy Families Program who screened positive on both the first

and second EDPS.

Figure 4. Referrals Made by Home Visitors for Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen

Referrals Made by Home Visitors for Mothers with Postpartum Depression (Positive 1st and Positive 2nd Edinburgh Screen) Attending the CRHVC Healthy

Families Program 2005-2007 (N=53 Referrals for 34 Mothers)

Mental Health Services,

4, 8%

Community Health Nurse, 0, 0%

PPD Program, 36, 67%

Specialist Physician,

0, 0%

Family Doctor, 13, 25%

PPD Program

Family Doctor

Mental HealthServicesCommunityHealth Nurse SpecialistPhysician


The Home Visitors made 53 referrals to community-based postpartum depression

support programs and resources for the 34 mothers attending the CRHVC Healthy

Families Program who scored positive on the first and second EDPS. Thirty-six (67%) of

the 53 referrals were made to community-based postpartum depression support programs

and resources. Thirteen (25%) of the 53 referrals were made to family physicians.

Based on the results of this study, we suggest that the most usual type of referrals

that Home Visitors made for mothers attending the CRHVC Healthy Families Program

who scored positive on both the first and second EDPS were referrals to community-

based postpartum depression support programs and resources.

26


Benefits of Home Visitation for Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen Figure 5 depicts the benefits of Home Visitation from the perspective of mothers


and second EDPS.

Figure 5. Benefits of Home Visitation for Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen

Benefits of Home Visitation for Mothers with Postpartum Depression (Positive 1st and Positive 2nd Edinburgh Screen) Attending the CRHVC Healthy Families

Program as Reported by Home Visitors (84 Responses by 34 Mothers)

Parenting Skills, 3, 4%

Company, 6, 7%

Self-esteem, 4, 5%

Basic Needs, 4, 5%

Goal Setting, 3, 4%

Advice, 3, 4%

Provide Information***,

10, 12%

Community Referral, 16, 19%Listening,

12, 14%

Same Language, 2, 2%

Support**, 21, 24%

Support

CommunityReferralListening

ProvideInformationAdvice

Company

Self-esteem

Parenting Skills

Basic Needs

Goal Setting

Same Language

**Emotional support (encouragement, understanding and comfort) *** Information about postpartum depression, self-care, coping/stress management Findings and Conclusions

The 34 mothers with postpartum depression attending the CRHVC Healthy

Families Program who screened positive on both the first and second EDPS identified 84

benefits of Home Visitation. The benefit most frequently reported by the mothers was the

emotional support (encouragement, understanding and comfort) provided by the CRHVC

Home Visitors which was identified 21 times (24% of the 84 benefits mentioned).

27


Mothers also indicated that they valued listening - 12 (14%) of the 84 benefits of Home

Visitation that were mentioned; the company of the CRHVC Home Visitors - 6 (7%) of

the 84 benefits of Home Visitation that were mentioned; and improved self-esteem - 4

(5%) of the 84 benefits of Home Visitation that were mentioned. Collectively, these

“emotional” support benefits provided by the CRHVC Home Visitors accounted for 43

(51%) of the 84 benefits of Home Visitation perceived by mothers.

Community-based referrals were identified 16 times and accounted for 19% of the

84 benefits mentioned. The provision of information (about postpartum depression, self-

care and stress management) was cited as a benefit of Home Visitation by 10 (12%) of

these mothers.

Based on the results of this study, we suggest that mothers with postpartum

depression attending the CRHVC Healthy Families Program who screened positive on

the first and second EDPS believed that the emotional support provided by the CRHVC

Home Visitors and referrals to community-based postpartum depression support

programs and resources were the greatest benefits of attending the CRHVC Healthy

Families Program.

Frequency of Risk Factors Reported by Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen Figure 6 depicts the number of times/frequency of the different risk factors (as a

percentage of all risk factors) that the Home Visitors identified/assessed for mothers


and second EDPS.

28


Figure 6. Frequency of Risk Factors for Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen

Frequency of Risk Factors for Mothers with Postpartum Depression (Positive 1st and Positive 2nd Edinburgh Screen) Attending the CRHVC Healthy Families

Program 2005-2007 (60 Risks for 27 Mothers)

Relationship Diff iculties, 14, 23%

Social Isolation, 14, 23%Financial Diff iculties,

6, 10%

Having Other Children, 6, 10%

Health Concerns, 6, 10%

Other*, 5, 8%

Mental Health, Father 2, 3%

Diff icult Baby, 3, 5%

Life Stress, 4, 7%

Relationship Diff iculties

Social Isolation

Financial Diff iculties

Health Concerns

Having Other Children

Life Stress

Diff icult Baby

Mental Health - Father

Other*

* the following risk factors were mentioned 1 time each - 1st time, young mother, legal issues, homeless, past postpartum depression/depression and lack of sleep Findings and Conclusions

The Home Visitors identified/assessed risk factors for 27 (79%) of the 34 mothers

with postpartum depression attending the CRHVC Healthy Families Program who

screened positive on both the first and second EDPS. Sixty risk factors were identified.

Relationship difficulties and social isolation were the most frequently identified risk

factors; each of these risk factors was noted 14 times (23% of the 60 risks mentioned).

Figure 7 depicts the number and percent of the 27 mothers with postpartum

depression who were assessed as having each of the individual risk factors.

29


Figure 7. Risk Factors for Individual Mothers with Postpartum Depression who Screened Positive on the First and Second Edinburgh Screen

Risk Factors for Individual Mothers with Postpartum Depression (Positive 1st and Positive 2nd Edinburgh Screen) Attending the CRHVC Healthy Families

Program 2005-2007 (27 Mothers)

Life Stress, 4, 15%

Difficult Baby, 3, 11%

Mental Health, Father 2, 7%

Other*, 5, 19%



Financial Difficulties, 6, 22%

Social Isolation, 14, 52%

Relationship Difficulties, 14, 52%

Relationship Difficulties

Social Isolation

Financial Difficulties

Health Concerns

Having Other Children

Life Stress

Difficult Baby

Mental Health - Father

Other*

* the following risk factors were mentioned 1 time each - 1st time, young mother, legal issues, homeless, past postpartum depression/depression and lack of sleep

The CRHVC Home Visitors identified that 14 (52%) of the 27 mothers had risks

relating to each of relationship difficulties and social isolation. Each of financial

difficulties and family health problems were risk factors for 6 (22%) of the 27 mothers.

Based on the results of this study, we suggest that the most usual risks for mothers

with postpartum depression attending the CRHVC Healthy Families Program who scored

positive on both the first and second EDPS were relationship difficulties, social isolation,

financial difficulties and family health problems.

7.1.2. Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Negative on the Second Edinburgh Screen In this study, twenty-nine (22%) of the 130 mothers with postpartum depression

attending the CRHVC Healthy Families Program screened positive on the first and

negative on the second EDPS. The profile of these mothers is described below.

30


First Language of Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen The first languages of mothers with postpartum depression attending the CRHVC

Healthy Families Program who screened positive on the first and negative on the second

EDPS are depicted in Figure 8.

Figure 8. First Language of Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen

First Language of Mothers with Postpartum Depression (Positive 1st and Negative 2nd Edinburgh Screen) Attending the CRHVC Healthy


Amharic, 2, 7%

Other*, 4, 14%

English, 23, 79%

English

Amharic

Other*

* includes 1 mother whose first language/cultural background is Arabic, Afghan, Chinese and Spanish Findings and Conclusions

Twenty-three (79%) of the 29 mothers with postpartum depression attending the

CRHVC Healthy Families Program who screened positive on the first and negative on the

second EDPS had English as their first language; 6 (21%) of the 29 mothers had a

language other than English as their first language.


in mothers from a wide variety of cultural backgrounds and that its likelihood was greater

31


in mothers who had English as their first language than in mothers (collectively) whose

first language was a language other than English.

Educational Support Provided by Home Visitors to Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen Figure 9 depicts the type/nature of the educational support that Home Visitors

provided to mothers attending the CRHVC Healthy Families Program who screened

positive on the first and negative on the second EDPS.

Figure 9. Educational Support Provided by Home Visitors to Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen

Educational Support Provided to Mothers with Postpartum Depression (Positive 1st and Negative 2nd Edinburgh Screen) Attending the CRHVC

Healthy Families Program 2005-2007 (N=18)

Video, 4, 22%

PPD Package,8, 44%


0, 0%


0, 0% Handouts, 6, 33%

Handouts

PPD Package

Video

Self-careStrategiesCounselingInformation


The Home Visitors provided various kinds of educational support to 18 (62%) of

the 29 mothers with postpartum depression attending the CRHVC Healthy Families

Program who screened positive on the first and negative on the second EDPS.

32


The most usual form of educational support that the CRHVC Home Visitors

provided to these mothers was an information package about postpartum depression. This

package was given to 8 (44%) of the 18 mothers. The next most usual type of educational

support that Home Visitors provided was handouts and articles about postpartum

depression. These materials were given to 6 (33%) of the 18 mothers. The mothers also

indicated that the CRHVC Home Visitors provided much-appreciated emotional support

and company while providing education and information about postpartum depression.

Based on the results of this study, we suggest that the most usual type of support

that the CRHVC Home Visitors provided for mothers who scored positive on the first and

negative on the second EDPS was education and information about postpartum

depression. The emotional support offered by the CRHVC Home Visitors while

providing this information was also highly valued by the mothers.

Referrals Made by Home Visitors for Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen Figure 10 depicts the type/nature of referrals to community-based postpartum

depression support programs and resources that Home Visitors made for mothers

attending the CRHVC Healthy Families Program who screened positive on the first and

negative on the second EDPS.



support programs and resources for the 29 mothers attending the CRHVC Healthy

Families Program who scored positive on the first and negative on the second EDPS.

Twenty-six (60%) of the 43 referrals were made to community-based postpartum

33


depression support programs and resources. Eleven (26%) of the 43 referrals were made

to family physicians.

Figure 10. Referrals Made by Home Visitors for Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen

Referrals Made by Home Visitors for Mothers with Postpartum Depression (Positive 1st and Negative 2nd Edinburgh Screen) Attending the CRHVC Healthy

Families Program 2005-2007 (43 Referrals for 29 Mothers)

Mental Health Program, 5, 12%

Community Health Nurse, 1, 2%



0, 0%PDD Program,

26, 60%

Family Doctor

SpecialistPhysicianPPD Program

Mental HealthProgramCommunityHealth Nurse

Based on the results of this study, we suggest that the most usual type of referrals

that the CRHVC Home Visitors made for mothers who scored positive on the first and

negative on the second EDPS were referrals to community-based postpartum depression

support programs and resources. All mothers received at least one referral.

Benefits of Home Visitation for Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen Figure 11 depicts the benefits of Home Visitation from the perspective of mothers

attending the CRHVC Healthy Families Program who screened positive on the first and

negative on the second EDPS.

34




Families Program who screened positive on the first and negative on the second EDPS

identified 63 benefits of Home Visitation. The benefit most frequently reported by the

mothers was the emotional support (encouragement, understanding and comfort)

provided by the CRHVC Home Visitors which was identified 27 times (43% of the 63

benefits mentioned). Mothers also indicated that they valued listening - 7 (11%) of the 63

benefits of Home Visitation that were mentioned; the company of the CRHVC Home

Visitors - 6 (10%) of the 63 benefits of Home Visitation that were mentioned; and

improved self-esteem - 3 (5%) of the 63 benefits of Home Visitation that were

mentioned. Collectively, these “emotional” support benefits provided by the CRHVC

Home Visitors accounted for 43 (68%) of the 63 benefits of Home Visitation as perceived

by the mothers. Community-based referrals were identified 8 times and accounted for

13% of the 63 benefits mentioned.


depression who screened positive on the first and negative on the second EDPS believed

that the emotional support provided by the CRHVC Home Visitors and referrals to

community-based postpartum depression support programs and resources were the

greatest benefits provided by the CRHVC Healthy Families Program.

35


Figure 11. Benefits of Home Visitation for Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen

Benefits of Home Visitation for Mothers with Postpartum Depression (Positive 1st and Negative 2nd Edinburgh Screen) Attending the CRHVC Healthy Families

Program as Reported by Home Visitors (63 Responses by 29 Mothers)

Advice, 7, 11%

Other*, 2, 3%

Company, 6, 10%

Self-esteem,3, 5%

Listening, 7, 11%


3, 5%Community

Referral, 8, 13%

Support**,27, 43%

Support

Community ReferralListening


Company

Self-esteem

Other*

* Parenting skills and goal setting mentioned 1 time each **Emotional support (encouragement, understanding and comfort) *** Information about postpartum depression, self-care, coping/stress management Frequency of Risk Factors Reported by Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen Figure 12 depicts the number of times/frequency of different risk factors (as a

percent of all risk factors) identified/assessed by Home Visitors for mothers attending the

CRHVC Healthy Families Program who screened positive on the first and negative on the

second EDPS.




screened positive on the first and negative on the second EDPS. The mothers identified

44 risk factors. Relationship difficulties and life stress were the most frequently

36


mentioned risk factors; these risks were mentioned 8 times (18% of the 44 risks

mentioned) and 6 times (14% of the 44 risks mentioned) respectively.

Figure 12. Frequency of Risk Factors Reported by Mothers with Postpartum Depression who Screened Positive on the First and Negative on the Second Edinburgh Screen

Frequency of Risk Factors Reported for Mothers with Postpartum Depression (Positive 1st and Negative 2nd Edinburgh Screen) Attending the CRHVC Healthy

Families Program 2005-2007 (44 Risks for 20 Mothers)

Difficulties with Baby, 3, 7%

Mental Health -Mother, 3, 7%

Other*,4, 9%

Life Stress, 7, 16%

1st Time young Mother, 3, 7%


Financial Difficulties,

4, 9%Health Concerns, 5, 11%

RelationshipDifficulties,

8, 18%Relationship Difficulties

Social Isolation


Health Concerns

Life Stress

1st Time young Mother

Difficulties with Baby Mental Health-Mother Other*

* the following risk factors were mentioned 1 time each - young children, pregnant again and past postpartum depression/depression; involvement with Child Welfare was mentioned 2 times

Figure 13 depicts the number and percent of the 20 mothers who were assessed as

having the individual risk factors. The CRHVC Home Visitors indicated that 8 (40%) and

7 (35%) of the 20 mothers had risks relating to relationship difficulties and life stress

respectively. Social isolation was a risk factor for 6 (30%) mothers while family health

problems were a risk factor for 5 (25%) of the mothers.


with postpartum depression who scored positive on the first and negative on the second

EDPS were relationship difficulties, life stress, social isolation and financial difficulties.

37


Figure 13. Identified Risk Factors for Mothers who Screened Positive on the First and Negative on the Second Edinburgh Screen

Identified Risk Factors Reported by Mothers with Postpartum Depression (Positive 1st and Negative 2nd Edinburgh Screen) Attending the CRHVC Healthy Families

Program 2005-2007 (20 Mothers)

Relationship Difficulties,

8, 40%



4, 20%


1st Time young Mother, 3, 15%

Life Stress, 7, 35%

Other*, 4, 20%

Mental Health - Mother, 3, 15% Difficulties with

Baby, 3, 15 %

Relationship Difficulties

Social Isolation Financial Difficulties

Health Concerns

Life Stress

1st Time young Mother

Difficulties with Baby Mental Health-Mother

Other*

* the following risk factors were mentioned 1 time each - young children, pregnant again and past postpartum depression/depression; involvement with Child Welfare was mentioned 2 times 7.1.3. Mothers with Postpartum Depression who Screened Negative on the First EDPS and Positive on the Second Edinburgh Screen In this study, fifteen (12%) of the 130 mothers with postpartum depression

attending the CRHVC Healthy Families Program screened negative on the first and

positive on the second EDPS. The demographic profile of these mothers is described

below.

First Language of Mothers with Postpartum Depression who Screened Negative on the First and Positive on the Second EDPS The first language of mothers with postpartum depression attending the CRHVC

Healthy Families Program who screened negative on the first and positive on the second

EDPS is depicted in Figure 14.

38


Figure 14. First Language of Mothers with Postpartum Depression who Screened Negative on the First and Positive on the Second Edinburgh Screen

First Language of Mothers with Postpartum Depression (Negative 1st and Positive 2nd Edinburgh Screen) Attending the CRHVC Healthy


Other*, 3, 20%

Urdu, 2, 13%

Arabic, 2, 13%

Punjabi, 2, 13%

English, 6, 41%

English PunjabiArabic UrduOther*

* includes 1 mother whose first language/cultural background is Cantonese, Korean and Mandarin Findings and Conclusions Six (41%) of the 15 mothers with postpartum depression attending the CRHVC

Healthy Families Program who screened negative on the first and positive on the second

EDPS had English as their first language; 9 (60%) of the 15 mothers had a language other

than English as their first language.


in mothers from a wide variety of cultural backgrounds and that it was somewhat less

likely to occur in mothers who had English as their first language than in mothers


39


Referrals Made by Home Visitors for Mothers with Postpartum Depression who Screened Negative on the First and Positive on the Second Edinburgh Screen Figure 15 depicts the type/nature of referrals that Home Visitors made for

mothers attending the CRHVC Healthy Families Program who screened negative on the

first and positive on the second EDPS.

Figure 15. Referrals Made by Home Visitors for Mothers with Postpartum Depression who Screened Negative on the First and Positive on the Second Edinburgh Screen

Referrals Made by Home Visitors for Mothers with Postpartum Depression (Negative 1st and Positive 2nd Edinburgh Screen) Attending

the CRHVC Healthy Families Program 2005-2007 (7 Referrals for 15 Mothers)

PDD Program, 5, 71%

Community HealthNurse, 0, 0%



0, 0%Mental Health Service, 1, 14% Family Doctor

PPD Program

Mental Health Service

Community Health NurseSpecialist Physician



support programs and resources for the 15 mothers with postpartum depression attending

the CRHVC Healthy Families Program who scored negative on the first and positive on

the second EDPS. Five (71%) of the 7 referrals were made to community-based

postpartum depression support programs and resources. One referral was made to a

family doctor and one referral was made to community mental health services.

40


Based on the results of this study, we suggest that the CRHVC Home Visitors

were most likely to make referrals to community-based postpartum depression support

programs and resources for mothers who scored negative on the first and positive on the

second EDPS.

Benefits of Home Visitation for Mothers with Postpartum Depression who Screened Negative on the First and Positive on the Second Edinburgh Screen Figure 16 depicts the benefits of Home Visitation from the perspective of mothers

attending the CRHVC Healthy Families Program who screened negative on the first and

positive on the second EDPS.

Figure 16. Benefits of Home Visitation for Mothers with Postpartum Depression who Screened Negative on the First and Positive on the Second Edinburgh Screen

Benefits of Home Visititation for Mothers with Postpartum Depression (Negative 1st and Positive 2nd Edinburgh Screen) Attending the CRHVC Healthy Families

Program 2005-2007 (29 Responses by 15 Mothers)

Listening, 7, 24%

Other*, 1, 3%

Company, 4, 14%

Goal Setting, 2, 7%


2, 7%

Community Referral, 2, 7%

Support**, 11, 38%

Support


ProvideInformationCompany

Goal Setting

Other

* Program in own language **Emotional support (encouragement, understanding and comfort) *** Information about postpartum depression, self-care, coping/stress management Findings and Conclusions

The 15 mothers with postpartum depression who screened negative on the first

and positive on the second EDPS identified 29 benefits of Home Visitation. The benefit

41


most frequently reported by the mothers was the emotional support (encouragement,

understanding and comfort) provided by the CRHVC Home Visitors which was identified

11 times (38% of the 29 benefits mentioned). Mothers also indicated that they valued

listening - 7 (24%) of the 29 benefits of Home Visitation that were mentioned; and the

company of the CRHVC Home Visitors - 4 (14%) of the 29 benefits of Home Visitation

that were mentioned. Collectively, these “emotional” support benefits provided by the

CRHVC Home Visitors accounted for 22 (76%) of the 29 benefits of Home Visitation as

perceived by mothers. Community-based referrals for postpartum depression support

were identified 2 times and accounted for 7% of the 29 benefits mentioned.


depression attending the CRHVC Healthy Families Program who screened negative on

the first and positive on the second EDPS believed that the emotional support provided

by the CRHVC Home Visitors and referrals to community-based postpartum depression

support programs (as well as goal setting and the provision of educational materials) were

the greatest benefits of attending the CRHVC Healthy Families Program. Frequency of Risk Factors Reported by Mothers with Postpartum Depression who Screened Negative on the First and Positive on the Second Edinburgh Screen Figure 17 depicts the number of times/frequency of different risk factors that the

Home Visitors identified/assessed for mothers attending the CRHVC Healthy Families

Program who screened negative on the first and positive on the second EDPS.




screened negative on the first and positive on the second EDPS. Financial difficulties and

42


relationship difficulties were the most usual risks; these were mentioned 4 times (24% of

the 17 risks mentioned) and 3 times (18% of the 17 risks mentioned) respectively.

Figure 17. Frequency of Risk Factors Reported by Mothers with Postpartum Depression who Screened Negative on the First and Positive on the Second Edinburgh Screen

Frequency of Risk Factors Reported by Mothers with Postpartum Depression (Negative 1st and Positive 2nd Edinburgh Screen) Attending the CRHVC Healthy




4, 24%


Other*, 6, 34%


3, 18%

RelationshipDifficulties SocialIsolationFinancialDifficultiesHaving OtherChildrenOther*

* the following risk factors were mentioned 1 time each - health concerns for mother or baby, life stress, difficulties with infant, homeless, past postpartum depression/depression and Child Welfare involvement

Figure 18 depicts the number and percent of the 9 mothers who were assessed as

having the individual risk factors. The CRHVC Home Visitors identified that 4 (44%) of

the 9 mothers had risks relating to financial difficulties while 3 (33%) of the 9 mothers

had risk factors related to relationship difficulties.



negative on the first and positive on the second EDPS were financial difficulties and

relationship difficulties.

43


Figure 18. Identified Risk Factors for Mothers who Screened Negative on the First and Positive on the Second Edinburgh Screen

Identified Risk Factors for Mothers with Postpartum Depression (Negative 1st and Positive 2nd Edinburgh Screen) Attending the CRHVC

Healthy Families Program 2005-2007 (9 Mothers)


3, 33%

Other*, 6, 66%



4, 44%

Social Isolation, 2, 22% Relationship

Difficulties SocialIsolationFinancialDifficultiesHaving OtherChildrenOther*

* the following risk factors were mentioned 1 time each - health concerns for mother or baby, life stress, difficulties with infant, homeless, past postpartum depression/depression and Child Welfare involvement 7.1.4. Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early Fifty-two (40%) of the 130 mothers with postpartum depression attending the

CRHVC Healthy Families Program screened positive on the first EDPS and closed early.

The profile of these mothers is described below.

First Language of Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early The first language of mothers with postpartum depression attending the CRHVC

Healthy Families Program who screened positive on the first EDPS and closed early is

depicted in Figure 19.

44


Figure 19. First Language of Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early

First Language of Mothers with Postpartum Depression (Positive 1st Screen and Early Closure) Attending the CRHVC Healthy Families

Program 2005-2007 (N=52)

Arabic, 8, 15%

Spanish, 3, 6%

Other*, 8, 15%

English, 33, 63%

English

Arabic

Spanish

Other*

* includes 1 mother whose first language/cultural background is Amharic, Hindi, Japanese, Korean, Nuer, Urdu, Other and Vietnamese Findings and Conclusions

Thirty-three (63%) of the 52 mothers attending the CRHVC Healthy Families

Program with postpartum depression who screened positive on the first EDPS and closed

early had English as their first language.


in mothers from a wide variety of cultural backgrounds and that its likelihood was

somewhat greater in mothers who had English as their first language than in mothers


Educational Support Provided by Home Visitors to Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early Figure 20 depicts the type/nature of the educational support that the Home

Visitors provided to mothers attending the CRHVC Healthy Families Program who

screened positive on the first EDPS and closed early.

45


Figure 20. Educational Support Provided by Home Visitors to Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early

Educational Support Provided by Home Visitors to Mothers withPostpartum Depression (Positive 1st Screen and Early Closure)

Attending the CRHVC Healthy Families Program 2005-2007 (N=34)

Video, 6, 18%


0, 0%


0, 0%

Handouts, 6, 18% PPD Package,

22, 65%

PPD Package

Handouts

Video

Self-careStrategiesCounselingInformation


The Home Visitors provided various kinds of educational support to 34 (65%) of

the 52 mothers with postpartum depression attending the CRHVC Healthy Families

Program who screened positive on the first EDPS and closed early. The most usual form

of educational support was an information package about postpartum depression which

was given to 22 (65%) of the 34 mothers. Handouts about postpartum depression were

given to 6 (18%) of the mothers. In addition to these education materials, the mothers

also indicated that the CRHVC Home Visitors provided much-appreciated emotional

support and company at the time of visiting.

Based on the results of this study, we suggest that the provision of an information

package about postpartum depression was the most usual type of educational support that

the Home Visitors provided for mothers attending the CRHVC Healthy Families Program

46


who scored positive on the first EDPS and closed early. The emotional support offered by

the CRHVC Home Visitors while providing this information was also highly valued by

the mothers.

Referrals Made by Home Visitors for Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early Figure 21 depicts the type/nature of referrals to community-based postpartum

depression support programs and resources that the Home Visitors made for mothers

attending the CRHVC Healthy Families Program who screened positive on the first

EDPS and closed early.

Figure 21. Referrals Made by Home Visitors for Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early

Referrals Made by Home Visits for Mothers with Postpartum Depression (Positive 1st Screen and Early Closure) Attending the CRHVC Healthy

Families Programs 2005-2007 (N=73 Referrals for 52 Mothers)


1, 1% Community

Health Nurse, 1, 1%

Mental Health Services,12, 16%

Family Doctor, 17, 23% PPD Program,

42, 58%

PPD Program

Family Doctor

Mental Health ServicesSpecialist Physician

Community HealthNurse



support programs and resources for the 52 mothers with postpartum depression attending

the CRHVC Healthy Families Program who screened positive on the first EDPS and

47


closed early. Forty-two (58%) of the 73 referrals were made to community-based

postpartum depression support programs. Seventeen (23%) of the 73 referrals were made

to family doctors.

Based on the results of this study, we suggest that referrals to community-based

postpartum depression support programs and resources were the most likely type of

referral that the Home Visitors made for mothers attending the CRHVC Healthy Families

Program who screened positive on the first EDPS and closed early.

Benefits of Home Visitation for Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early Figure 22 depicts the benefits of Home Visitation programs from the perspective

of mothers attending the CRHVC Healthy Families Program who screened positive on

the first EDPS and closed early.

Figure 22. Benefits of Home Visitation for Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early

Benefits of Home Visitation for Mothers with Postpartum Depression (Positive 1st Screen and Early Closure) Attending the CRHVC Healthy Families Program

2005-2007 as Reported by Home Visitors (83 Responses by 34 Mothers)

Support**, 21, 26%

Community Referral, 15, 18%Listening,

10, 12%Provide Information***,

9, 11%

Advice, 7, 8%

Self-esteem, 4, 5%

Other*, 2, 2%

Basic Needs, 7, 8%

Company, 4, 5%

Parenting Skills, 4, 5%

Support



Basic Needs

Self-esteem

Parenting Skills

Company

Other*

…

* Planning/goal setting and service in same cultural background mentioned 1 time each **Emotional support (encouragement, understanding and comfort) *** Information about postpartum depression, self-care, coping/stress management

48




Families Program who screened positive on the first EDPS and closed early identified 83

benefits of Home Visitation. The benefit most frequently reported by the mothers was the

emotional support (encouragement, understanding and comfort) provided by the CRHVC

Home Visitors which was identified 21 times (26% of the 83 benefits mentioned)

Mothers also indicated that they valued listening - 10 (12%) of the 83 benefits of Home

Visitation that were mentioned; the company of the CRHVC Home Visitors - 4 (5%) of

the 83 benefits of Home Visitation that were mentioned; and improved self-esteem - 4

(5%) of the 83 benefits of Home Visitation that were mentioned. Collectively, these

“emotional” support benefits provided by the CRHVC Home Visitors accounted for 39

(47%) of the 83 benefits of Home Visitation as perceived by mothers. Community-based

referrals were identified 15 times and accounted for 18% of the 83 benefits mentioned.


depression attending the CRHVC Healthy Families who screened positive on the first

EDPS and closed early believed that the emotional support provided by the CRHVC

Home Visitors and referrals to community-based support programs and resources were

the greatest benefits of attending the CRHVC Healthy Families Program.

Frequency of Risk Factors Reported by Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early Figure 23 depicts the number of times/frequency of different risk factors that

Home Visitors identified/assessed for mothers attending the CRHVC Healthy Families

Program who screened positive on the first EDPS and closed early.

49


Figure 23. Frequency of Risk Factors Reported by Mothers with Postpartum Depression who Screened Positive on the First Edinburgh Screen and Closed Early

Frequency of Risk Factors Reported by Mothers with Postpartum Depression (Positive 1st Edinburgh Screen and Early Closure) Attending the CRHVC Healthy


Other*, 3, 5%

Life Stress, 5, 9%

Past PPD Depression,

4, 7%


9, 16%



13, 24%

Social Isolation, 15, 27%Mental Health -

Mother, 3, 5%

Social Isolation

RelationshipDifficultiesFinancialDifficultiesLife Stress

Past PPDDepression Health Concerns

Mental Health -MotherOther*

* the following risk factors mentioned 1 time each – young mother/pregnant again, homeless and Child Welfare involvement Findings and Conclusions The Home Visitors identified/assessed risk factors for 32 (62%) of the 52 mothers


screened positive on the first EDPS and closed early. A total of 55 risk factors were

identified. Social isolation and relationship difficulties were the most frequently

mentioned risk factors; these risks were mentioned 15 times (27% of the 55 risks

mentioned) and 13 times (24% of the 55 risks mentioned) respectively. Financial

difficulties accounted for 9 (16%) of the mothers’ risk factors.

Figure 24 depicts the number and per cent of the 32 mothers who were assessed

as having the individual risk factors. Home Visitors identified that 15 (47%) of the 32

50


mothers had risks relating to social isolation. Relationship difficulties and financial

difficulties were risk factors for 13 (41%) and 9 (28%) of the 32 mothers respectively.

Figure 24. Identified Risk Factors for Mothers who Screened Positive on the First Edinburgh Screen and Closed Early

Identified Risk Factors Reported by Mothers with Postpartum Depression(Positive 1st Edinburgh Screen and Early Closure) Attending the CRHVC Healthy


Mental Health -Mother,3, 9%

Social Isolation,15, 47%


13, 41%

Health Concerns,3, 9%


9, 28%

Past PPD Depression,

4, 13%

Life Stress, 5, 16%

Other*, 3, 9%

Social Isolation

RelationshipDifficulties FinancialDifficultiesLife Stress

Past PPDDepression Health Concerns

Mental Health -MotherOther*



positive on the first EDPS and closed early were social isolation, relationship difficulties

and financial difficulties.

Early Closure Factors Figure 25 depicts the reasons for mothers’ early closure from the CRHVC

Healthy Families Program.


The Home Visitors assessed early closure factors for 9 (17%) of the 52 mothers


screened positive on the first EDPS and closed early. Financial difficulties accounted for

51


3 (27%) of the early closure factors. Information was generally not available for the other

mothers primarily because of their early closure.

Figure 25. Early Closure Factors for Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007

Early Closure Factors - Mothers with Postpartum Depression (Positive 1st Screen and Early Closure) Attending the CRHVC Healthy Families

Program 2005-2007 (N=9) Other*, 4, 37%

Moved, 2, 18%

No Support from Baby's Father,

2, 18%


3, 27%


No Support fromBaby's Father

Moved

Other*

* Relationship difficulties, hospitalization, lost contact and lost custody were each mentioned 1 time

Based on the results of this study, we suggest that financial difficulties were the

most likely factors that caused mothers with postpartum depression to have early closure

from the CRHVC Healthy Families Program. Further targeted studies are suggested.

8. Consolidated Findings and Conclusions

The CRHVC Home Visitors took an active role in the CRHVC 2005-2007

Postpartum Research Project and returned the completed data sheets to the CRHVC

Research Assistant in a timely manner. In general, the quality and quantity of the

information that they were able to collect was excellent. Clearly, this finding is a

reflection of the trusting relationship that the CRHVC Home Visitors had established

with the mothers.

52


The findings of the CRHVC 2005-2007 Postpartum Depression Project as

depicted in Figures 2-24 are summarized in Tables 4, 5 and 6.

Table 4. Demographic Profile of Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007 and Support/Referrals Offered by Home Visitors Categories

of Mothers

No. Mothers

Postpartum Support Prior to Home

Visitor*

First Language

of Mothers

Age of Mother

(Average/ Range)

Educational Support and Information Provided by

Home Visitors

Referrals Made by Home Visitors

Mothers with Positive 1st and Positive 2nd EDPS

34 Meds - 2 Counseling - 1 Both - 6

English -19 Arabic - 3 Spanish - 3 Farsi - 2 Other - 7 **

Average - 29 Range - 20-43

PPD Pack -18 Handouts - 6 Video - 2 Counseling Info -1 Self-care Info - 1

Family Doctor - 13 Specialist Physician - 0 Postpartum Support - 36 Mental Health Service - 4 Community Nurse - 0

Mothers with Positive 1st and Negative 2nd EDPS

29 Meds - 3 Counseling - 0 Both - 1

English - 23 Amharic - 2 Other - 4 ***


PPD Pack - 8 Handouts - 6 Video - 4 Counseling Info -0 Self-care Info - 0


Mothers with Negative 1st and Positive 2nd EDPS

15 Information not available

English - 6 Arabic - 2 Punjabi - 2 Urdu - 2 Other - 3****


Information not available


Mothers with Positive 1st Screen and Early Closure

52 Meds - 3 Counseling - 0Both - 1

English -33 Arabic - 8 Spanish - 3 Other - 8 *****


PPD Pack -22 Handouts - 6 Video - 6 Counseling Info - 0 Self-care Info - 0


All Mothers with Postpartum Depression

130 Meds - 8 Counseling - 1 Both - 8*

English - 81 Arabic - 14 Spanish - 7 Amharic - 3 Urdu - 3 Punjabi -3 Other -19******

Average - 30 Range- 19-43

PPD Pack - 48 Handouts - 18 Video - 12 Counseling Info -1 Self-care Info - 1


*Based on admission information for 67 mothers **Other - 1 mother with first language Albanian, Cantonese, Hindi, Punjabi, Somalian, Tagaloog, and Vietnamese *** Other – 1 mother with first language Arabic, Afhgan, Chinese and Spanish **** Other - 1 mother with first language Cantonese, Korean and Mandarin ***** Other - 1 mother with first language Amharic, Hindi, Japanese, Korean, Nuer, Urdu, Vietnamese and unknown ****** Other 19 mothers (2 mothers with first language Cantonese, Farsi, Vietnamese, Korean, Hindi, and 1 mother with first language Albanian, Somalian, Mandarin, Japanese, Nuer, Afhghan, Tagaloog and unknown)

53


Table 4 summarizes the interventions used by other health professionals to treat

the mothers’ postpartum depression prior to their referral to the CRHVC Healthy

Families Program. The mothers provided this information to the CRHVC Home Visitors.

It was beyond the scope of the CRHVC 2005-2007 Postpartum Depression Research

Project to ascertain the duration of these treatments and/or their relative effectiveness in

decreasing the mothers’ postpartum depression.

Table 4 also summarizes: the demographic profile of mothers with postpartum

depression attending the CRHVC Healthy Families Program; the educational support

offered to the mothers by the CRHVC Home Visitors and; referrals made to community-

based postpartum depression support programs and resources for the mothers.

8.1 Interventions for Postpartum Depression Prior to the Mothers’ Admission to the CRHVC Healthy Families Program

Information regarding interventions used to treat mothers with postpartum

depression prior to their referral to the CRHVC Healthy Families Program was available

for 67 mothers (this information was not requested during the earlier part of the study

thus accounting for the lesser amount of information for this question). Seventeen (25%)

of the 67 mothers who screened positive for postpartum depression had received prior

treatment(s), most notably medication or a combination of medication and counseling.

Based on the results of this study, we suggest that approximately 25% of mothers

received treatment for postpartum depression prior to their admission to the CRHVC

Healthy Families Program and that the intervention was most likely to be medication

and/or counseling.

54


8.2. First Language of Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program As detailed in Table 4, 81 (62%) of the 130 mothers with postpartum depression

attending the CRHVC Healthy Families Program had English as their first language. The

next two most common first languages were Arabic, 14 (11%) and Spanish, 7 (5%) of the

130 mothers respectively.

Based on the results of this study, we suggest that postpartum depression affected

mothers from a wide variety of cultures and that approximately 60% of the mothers with

postpartum depression attending the CRHVC Healthy Families Program had English as

their first language with the remaining 40% of mothers having a variety of languages as

their first language.

8.3. Ages of Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program As detailed in Table 4, the average age of mothers with postpartum depression

attending the CRHVC Healthy Families Program was 30 years (range 19-43 years).

Based on the results of this study, we suggest that mothers of all ages attending

the CRHVC Healthy Families Program and notably women in their twenties and thirties

were susceptible to having postpartum depression. It is important to note that young

mothers (< 19 years of age) received support from other Calgary organizations that have

a mandate to help young mothers.

8.4. Educational Support and Information Provided by Home Visitors to Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program As detailed in Table 4, the CRHVC Home Visitors provided educational support

in the form of an information package or articles/handouts/video about postpartum

55


depression to 78 (60%) of the 130 mothers with postpartum depression. The level of

support with respect to counseling and self-care strategies was minimal.

Based on the results of this study, we suggest that 60% of the mothers attending

the CRHVC Healthy Families Program received some form of educational material about

postpartum depression. The most usual form of educational support that the CRHVC

Home Visitors provided to mothers was an information package about postpartum

depression.

8.5. Referrals Made by Home Visitors for Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program As detailed in Table 4, the CRHVC Home Visitors made 176 referrals for the 130

mothers attending the CRHVC Healthy Families Program. The CRHVC Home Visitors

were most likely to make referrals to community-based postpartum depression support

programs and resources; 109 (62%) of the 176 referrals were made to these programs.

Forty-two (24%) of the 176 referrals were made to family physicians; twenty-two (13%)

of the referrals were made to community-based mental health programs. The number of

referrals to specialist physicians and community nurses was minimal.

Based on the results of this study, we suggest that the CRHVC Home Visitors

were most likely to refer mothers attending the CRHVC Healthy Families Program to


9.0 Benefits of Home Visitation as Perceived by Mothers with Postpartum Depression Attending CRHVC Healthy Families Program 2005-2007 and Reported to Home Visitors The Home Visitors asked mothers with postpartum depression about the benefits

that they experienced from participating in the CRHVC Healthy Families Program. Table

56


5 summarizes the mothers’ perceptions about the benefits of attending the CRHVC

Healthy Families Program.

Table 5. Benefits of Home Visitation as Mentioned by Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007 and Reported to Home Visitors Benefits of Home Visitation as Reported by Mothers to Home Visitors

Mothers with Positive 1st and

Positive 2nd EDPS (N=34 Mothers)


Negative 2nd EDPS

(N=29 Mothers)

Mothers with Negative 1st and Positive

2nd EDPS (N=15

Mothers)

Mothers with Positive 1st Screen and

Early Closure (N=52

Mothers)

All Mothers with

Postpartum Depression

(N=130 Mothers)

Emotional Support and Encouragement*

21 (25%) 27 (42%) 11 (38%) 21 (25%) 80 (31%)

Referrals to Community Resources

16 (19%) 8 (13%) 2 (7%) 15 (18%) 41 (16%)

Opportunity to Speak with Home Visitor/Listening

12 (14%) 7 (11%) 7 (24%) 10 (12%) 36 (14%)

Provision of Information about Postpartum Depression

10 (12%) 3 (5%) 2 (7%) 9 (11%) 24 (9%)

Company of the CRHVC Home Visitor

6 (7%) 6 (10%) 4 (14%) 4 (5%) 20 (8%)

Increased Self-esteem/Confidence

4 (5%) 3 (5%) 0 (0%) 4 (5%) 11 (4%)

Basic Needs Support

4 (5%) 0 (0%) 0 (0%) 7 (8%) 11 (4%)

Support and Advice

3 (4%) 7 (11%) 0 (0%) 7 (8%) 17 (7%)

Learned Parenting Skills

3 (4%) 2 (3%) 0 (0%) 4 (5%) 8 (3%)

Support with Goal Setting

3 (4%) 0 (0%) 2 (7%) 1 (1%) 6 (2%)

Service in Mother’s First Language

2 (2%) 0 (0%) 1 (3%) 1 (1%) 4 (2%)

Total Number of Benefits Mentioned

84 63 29 83 258

**Emotional support (encouragement, understanding and comfort)

57


Emotional Support Benefits of Participation in the CRHVC Healthy Families Program

The 130 mothers in this study attending the CRHVC Healthy Families Program

reported a variety of benefits that related to their interaction with the Home Visitors; the

support benefits relating to emotional support for the mothers included:

Emotional support (encouragement, understanding and comfort) accounted for 80 (31%) of the 258 benefits mentioned by the mothers

Listening accounted for 36 (14%) of the 258 benefits mentioned by the mothers Providing company accounted for 20 (8%) of the 258 benefits mentioned by the

mothers Improvement in self-esteem accounted for 11 (4%) of the 258 benefits

mentioned by the mothers

Collectively, these benefits, which, overall reflected the emotional support provided

by the CRHVC Home Visitors accounted for 147 (57%) of the 258 benefits identified by

mothers attending the CRHVC Healthy Families Program.

Other Benefits of Participation in the CRHVC Healthy Families Program

The 130 mothers in this study reported a variety of ways in which they benefited from

participating in the CRHVC Healthy Families Program; the benefits relating to

educational/information support, community-based referrals and other support included:

Referrals to community-based postpartum depression support programs and resources accounted for 41 (16%) of the 258 benefits mentioned by the mothers

Information relating to postpartum depression accounted for 24 (9%) of the 258 benefits mentioned by the mothers

Advice, parenting skills information, assistance with basic needs, help with goal setting and service in the same language accounted for 46 (18%) of the 258 benefits mentioned by the mothers

Based on the results of this study, we suggest that the greatest benefits

experienced by mothers attending the CRHVC Healthy Families Program were the

emotional support provided by the CRHVC Home Visitors and referrals to community-

based postpartum depression support programs and resources.

58


10. Risk Factors Identified by Home Visitors for Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007

Home Visitors identified 175 risk factors for 88 of the mothers with postpartum

depression attending the CRHVC Healthy Families Program. Table 6 summarizes the

number and percent of the mothers’ risk factors

Table 6. Risk Factors Identified by Home Visitors for Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007

Postpartum Depression Risk Factor as

Identified by Mother to Home Visitor


Positive 2nd EDPS (N=27

Mothers)


Negative 2nd EDPS

(N=20 Mothers)

Mothers with Negative 1st

and Positive 2nd EDPS

(N=9 Mothers)


EDPS and Early Closure

(N=32 Mothers)

All Mothers with

Postpartum Depression

(N=88 Mothers)

Relationship Difficulties 14 (23 %) 8 (19 %) 3 (18 %) 13 (25%) 38 (22 %) Social Isolation/Lack of Support

14 (23 %) 6 (14 %) 2 (12 %) 15 (28%) 37 (21 %)

Financial Difficulties 6 (10 %) 4 (9 %) 4 (24 %) 9 (16%) 23 (13 %) Health Concerns - Mother/ Baby

6 (10 %) 5 (12 %) 1 (6 %) 3 (5%) 15 (9 %)

Life Stress 4 (7 %) 7 (16 %) 1 (6 %) 5 (9%) 17 (10 %) Young Mother/Pregnant Again

6 (10 %) 1 (2 %) 2 (12 %) 1 (negligible) 10 (6 %)

Difficulties with Baby 3 (5 %) 3 (7 %) 1 (6 %) - 7 (4 %) 1st Time mother/Young Mother

1 (2 %) 3 (7 %) 0 (0 %) - 4 (2 %)

Past Postpartum Depression/Depression

1 (2 %) 1 (2 %) 1 (6 %) 4 (7%) 7 (4 %)

Mental Health Issues – Mother

0 (0 %) 3 (7 %) 0 (0 %) 3 (5%) 6 (3%)

Child Welfare Involvement

0 (0 %) 2 (5 %) 1 (6 %) 1 (negligible) 4 (2%)

Homeless 1 (2 %) 0 (0 %) 1 (6 %) 1 (negligible) 3 (2 %) Mental Health Issues – Father

2 (3 %) 0 (0 %) 0 (0 %) - 2 (0.5 %)

Lack of Sleep 1 (2 %) 0 (0 %) 0 (0 %) - 1 (0.5 %) Legal Issues 1 (2 %) 0 (0 %) 0 (0 %) - 1 (0.5 %) Total Risk Factors Mentioned

60 43 17 55 175

The most significant risk factor for mothers with postpartum depression attending

the CRHVC Healthy Families Program was relationship difficulties which accounted for

38 (22%) of the 175 risk factors. Social isolation and financial difficulties were the next

59


most frequently mentioned risk factors; these risks accounted for 37 (21%) and 23 (13%)

of the 175 risk factors respectively. The least mentioned risks for the mothers in this

study were the fathers’ mental health issues, homelessness, lack of sleep and legal issues.

Based on the results of this study, we suggest that the most usual risk factors for

mothers with postpartum depression attending the CRHVC Healthy Families Program

were relationship difficulties, financial difficulties and social isolation.

11. Barriers to Attendance at Community-Based Based Support Programs for Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007 The Home Visitors asked mothers attending the CRHVC Healthy Families

Program about various factors that influenced them to attend /not attend community-

based postpartum depression support programs and resources. The factors included

distance from the referral location, lack of transportation, program costs, language

concerns, lack of childcare, waitlist issues, type/nature of support provided by the

program or no perceived benefit of attending the program. The mothers were also asked

to identify additional factors which influenced their decision to attend/ not attend


Tables 7 to 9 summarize the factors that were/were not barriers to the mothers’

attendance at community-based support services and resources. Table 7 deals with

mothers’ perceptions about barriers to their attendance at postpartum depression support

programs and resources. Tables 8 and 9 summarize mothers’ perceptions about barriers to

their attendance at the family doctor and community-based mental health programs

respectively.

60


Table 7. Barriers Experienced by Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007 Relating to Attendance at Community-based Postpartum Depression Support Programs

Barriers that Could Affect Mothers

Attendance

Positive 1st and Positive 2nd

EDPS*

Positive 1st and Negative 2nd EDPS **

Positive 1st EDPS and

Early Closure***

All Mothers (N=61 Mothers)

Barrier Barrier Barrier Barrier Yes No Yes No Yes No Yes No

Distance from Referral

7 6 3 2 10 5 20 13

Limited Transportation

5 6 6 1 11 5 22 12

Costs of Attending 2 8 - 2 4 9 6 19 Language Concerns 3 8 2 3 10 9 15 20 Lack of Childcare 8 6 3 2 7 4 18 12 Waitlist Issues 1 5 - 2 4 4 5 11 Type of Support 4 5 3 - 4 4 11 9 No Perceived Benefit 11 4 5 1 4 4 20 9 Other 7 - 4 - 8 - 19 0 Totals 48 48 26 13 62 44 136 105

* 21 Mothers ** 12 Mothers *** 28 Mothers Table 8. Barriers Experienced by Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007 Relating to Attendance at the Family Doctor


Attendance

Positive 1st and Positive 2nd EDPS*

Positive 1st and Negative 2nd EDPS**


Early Closure***


Barrier Barrier Barrier Barrier Yes No Yes No Yes No Yes No Distance from Referral 1 4 - 1 1 3 2 8 Limited Transportation 1 3 - 1 1 4 2 8 Costs of Attending - 4 - 1 - 4 0 9 Language Concerns 1 3 - 1 2 3 3 7 Lack of Childcare 3 2 2 - 2 3 7 5 Waitlist Issues 3 1 - - 1 3 4 4 Type of Support 1 2 - - 1 2 2 4 No Perceived Benefit 2 4 - 2 3 2 5 8 Other 1 - - - 1 1 2 1 Totals 13 23 2 6 12 25 27 54

* 8 Mothers ** 3 Mothers *** 9 Mothers

61


Table 9. Barriers Experienced by Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007 Relating to Attendance at Community-based Mental Health Programs

Barriers that Could

Affect Mothers Attendance

Positive 1st and Positive 2nd EDPS*

Positive 1st and Negative 2nd EDPS**


Early Closure***


Barrier Barrier Barrier Barrier Yes No Yes No Yes No Yes No Distance from Referral

2 - - - 1 1 3 1


1 - 1 - 1 2 3 2

Costs of Attending 1 1 - - 1 1 2 2 Language Concerns - 2 - - 1 1 1 3 Lack of Childcare 2 - 1 - 1 - 4 0 Waitlist Issues 1 - - - 2 1 3 1 Type of Support 2 - - - 1 1 3 1 No Perceived Benefit 1 1 - - - 2 1 3 Other - - - - 1 - 1 0 Totals 10 4 2 0 9 9 21 13

* 2 Mothers ** 1 Mother *** 6 Mothers Findings and Conclusions

Based on the information in Tables 7 to 9, we suggest that the most usual barriers

to mothers’ attendance at community-based postpartum depression programs and

resources for mothers with postpartum depression were lack of childcare, limited

transportation and no perceived benefit from attending the program. The factors least

likely to be barriers for the mothers with postpartum depression were program costs and

the language of the program.

Figure 26 provides a summary of the information detailed in Tables 7 to 9 with

respect to whether various factors were/were not barriers to attendance at community-

based postpartum support programs and resources, family doctors and mental health

services for mothers with postpartum depression attending the CRHVC Healthy Families

Program.

62


Figure 26. Barriers to Attendance at all Community-based Programs and Resources Offering Support to Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007

Barriers to Attendance at Community-Based Support Programs for Mothers with Postpartum Depression Attending the CRHVC

Healthy Families Program 2005-2007

2527

8

19

29

1216

26

2122 22

30 30

1614

20

1

17

0

5

10

15

20

25

30

35

Distance from Resource


Program Cost

Language of Program

Lack of Childcare

WaitlistedType of Support

No Perceived Benefit

Other

Barriers to Mothers' Attendance

Num

ber o

f Mot

hers

* Community-based postpartum depression support programs, family doctors and mental health services Consolidated Findings and Conclusions - Individual Barriers to Attendance at Community-based Postpartum Depression Support Programs and Resources The CRHVC Home Visitors asked the mothers if certain factors were/were not

barriers to their attendance at community-based postpartum depression support programs

and resources. The findings for these factors - distance from the resource, limited

transportation, program cost, language of program, lack of childcare, waitlist issues,

type/nature of support provided by the program, no perceived benefit of attending the

program or other factors are summarized in the following sections.

Distance from the Resource as a Barrier to Attendance at Community-based Postpartum Depression Support Programs and Resources Forty-seven mothers provided information about whether distance from the

resource was/was not a barrier to attendance at support programs. Twenty-five (53%) of

63


the 47 mothers considered distance from the resource to be a barrier to attendance while

22 (47%) of the 47 mothers did not consider distance from the resource to be a barrier.

Limited Transportation as a Barrier to Attendance at Community-based Postpartum Depression Support Programs and Resources Forty-nine mothers provided information about whether limited transportation

was/was not a barrier to attendance at support programs. Twenty-seven (55%) of the 49

mothers considered distance from the resource to be a barrier to attendance while 22

(45%) of the 49 mothers did not consider limited transportation to be a barrier.

Program Cost as a Barrier to Attendance at Community-based Postpartum Depression Support Programs and Resources Thirty-eight mothers provided information about whether program cost was /was

not a barrier to attendance at support programs. Eight (21%) of the 38 mothers considered

program cost to be a barrier to attendance while 30 (79%) of the 38 mothers did not

consider program cost to be a barrier.

Language as a Barrier to Attendance at Community-based Postpartum Depression Support Programs and Resources Forty-nine mothers provided information about whether language was /was not a

barrier to attendance at support programs. Nineteen (39%) of the 49 mothers considered

language to be a barrier to attendance while 30 (61%) of the 49 mothers did not consider

language to be a barrier.

Lack of Childcare as a Barrier to Attendance at Community-based Postpartum Depression Support Programs and Resources Forty-four mothers provided information about whether lack of childcare was/was

not a barrier to attendance at support programs. Twenty-nine (63%) of the 46 mothers

64


considered lack of child care to be a barrier to attendance while 17 (37%) of the 46

mothers did not consider lack of child care to be a barrier.

Waitlist as a Barrier to Attendance at Community-based Postpartum Depression Support Programs and Resources Twenty-eight mothers provided information about whether waitlist was /was not a

barrier to attendance at support programs. Twelve (43%) of the 28 mothers considered

waitlist to be a barrier to attendance while 16 (57%) of the 28 mothers did not consider

waitlist to be a barrier.

Type/Nature of Support as a Barrier to Attendance at Community-based Postpartum Depression Support Programs and Resources Thirty mothers provided information about whether the type/nature of support

was/was not a barrier to attendance at support programs. Sixteen (53%) of the 30 mothers

considered the type/nature of support offered by the program to be a barrier to attendance

while 14 (47%) of the 30 mothers did not consider the type/nature of support to be a

barrier.

No Perceived Benefit of the Attending the Program as a Barrier to Attendance at Community-based Postpartum Depression Support Programs and Resources Forty-six mothers provided information about whether lack of a perceived benefit

of attending the program was/was not a barrier to attendance at support programs.

Twenty-six (57%) of the 46 mothers considered no perceived benefit of attending the

program to be a barrier to attendance while 20 (43%) of the 46 mothers did not consider

no perceived benefit of attending the program to be a barrier.

65


Other Barriers to Attendance at Community-based Postpartum Depression Support Programs and Resources Twenty-three mothers provided information about other factors that were /were

not barriers to attendance at community-based postpartum depression support programs

and resources. Twenty-two (96%) of the 23 mothers identified an additional barrier to

attendance at community-based programs while 1 (4%) of the mothers did not identify

any other barriers. The mothers reported a wide variety of barriers and none of the

barriers was mentioned more than two times.

Table 10 ranks the individual factors in terms of whether they were/were not a

barrier to attendance at community-based postpartum depression support programs and

resources.

Table 10. Opinions of Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007 about Barriers to Attendance at all Community-based Postpartum Depression Support Programs and Resources


Attendance

Number of Mothers who Responded

Number and Percent of Mothers who Perceived the

Factor to be a Barrier*

Number and Percent of Mothers who Perceived the Factor Not to be a

Barrier Lack of Childcare 46 29(63%) 17(37%) No Perceived Benefit from Attending

46 26(57%) 20(43%)


49 27(55%) 22(45%)

Type of Support 30 16(53%) 14(49%) Distance from Referral 47 25(53%) 22(47%) Waitlist Issues 28 12(43%) 16(57%) Language Concerns 49 19(39%) 30(61%) Costs of Attending 38 8(21%) 30(79%) Other 23 22(96%) * 1(4%)

*19 different barriers mentioned 1-2 times each Based on the results of this study, we suggest that mothers with postpartum

depression attending the CRHVC Healthy Families Program experienced various barriers

to attendance at community-based postpartum depression support programs and

66


resources. Lack of a perceived benefit to attending the program and child care or

transportation issues were the most notable barriers for the mothers.

It was beyond the scope of the CRHVC 2005-2007 Postpartum Depression

Research Project to study: the benefits experienced by mothers from attending the

community-based postpartum depression support programs and resources; the duration of

their attendance at these programs and reasons for attrition and; the impact of attendance

on the course of the mothers’ postpartum depression.

It was also beyond the scope of the CRHVC 2005-2007 Postpartum Depression

Research Project to study the number of mothers in different groups (i.e. mothers who

had a positive first and second EDPS; mothers with a positive first and negative second

EDPS, mothers with a negative first and positive second EDPS and mothers with a

positive first EDPS and early closure) who actually attended the community-based

postpartum depression support programs and resources. Likewise, the CRHVC 2005-

2007 Postpartum Depression Research Project did not examine the relationship between

the mothers’ attendance at these programs and the mothers’ perceptions about the factors

that were/were not perceived to be barriers. These issues could be explored in future

targeted studies, particularly the attendance of mothers who perceived no barriers to

attending the programs.

12. Postpartum Depression Goal Statements for Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007

The Home Visitors, in consultation with mothers developed goal statements for

mothers attending the CRHVC Healthy Families Program who screened positive for

postpartum depression. The CRHVC Home Visitors used the goal statements to develop

plans and strategies to address the mothers’ postpartum depression.

67


Figure 27 summarizes/categorizes the mothers’ goal statements relating to the

management of the mothers’ postpartum depression as; goal statements related to plans

and strategies for self-care, stress management and coping, support/education for

postpartum depression, improved self-confidence and decreased social isolation.

Figure 27. Goal Statements Related to the Management of Postpartum Depression for Mothers Attending the CRHVC Healthy Families Program 2005-2007

Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program 2005-2007 - Goals Related to Postpartum Depression

(67 Goals for 39 Mothers)*

Stress Management and Coping Goals,

20, 30%

Self-care Goals, 22, 33%

Social Isolation Goals, 3, 4%

PPD Referral and Support Goals,

16, 24%

Self-esteem Goals, 6, 9%

Self-care Goals

Stress Managementand Coping GoalsPPD Referral andSupport GoalsSelf-esteem Goals

Social IsolationGoals

*39 (30%) of 130 mothers with postpartum depression had goal statements relating to postpartum depression

Table 11 categorizes the individual goal statements relating to postpartum

depression for mothers attending the CRHVC Healthy Families Program. It is important

to note that it was beyond the scope of the CRHVC 2005-2007 Postpartum Depression

Research Project to assess the extent to which mothers achieved/did not achieve their

goals and the impact of the postpartum depression strategies on decreasing the mothers’

postpartum depression.

68


Table 11. Goal Statements Relating to the Support and Management of Postpartum Depression for Mothers Attending CRHVC Healthy Families Program 2005-2007 Mothers (N=130) 67 Goal Statements Referring to Postpartum Depression (PPD) Number/% of Goals

A. PPD Goals Relating to Mothers’ Self-care Multiple self care skills 16 Mother will address her PPD issues through self care strategies 1 Maintains own health/mother recognize importance of taking care of her health 2 Mother will focus some energy on herself so that she stays healthy 1 Home Visitor will encourage mother to follow through with counseling 1 Mother will follow through with doctor's appointments 1 Mother will ask for help/take time for herself to reduce feelings of depression Summary - total goals relating to self-care interventions for the mother 22 (33%) B. PPD Goals Relating to Mothers’ Stress Management and Coping Coping skills/Stress management 12 Home Visitor will assist mother to identify and implement support for PPD and stress 1 Financial management to reduce anxiety 1 mother will be open to discussing her anxiety 1 During home visits mother will talk about how she is feeling 1 mother will report that she has more energy and can do things during the day 1 Mother able to manage daily routines with family 1 Follow safety plan to keep herself and family safe 1 Mother will report she is no longer a threat to the family’s safety/ well-being 1 Summary – total goals relating to stress and coping interventions for the mother 20(30%) C. PPD Goals Relating to PPD Support (Education, Community Referrals) Home Visitor will offer support/encouragement as mother learns to cope with depression 1 Maintains own health/mother will be referred to Families Matter to address PPD 1 Mother will follow through with supports for PPD 1 Mother will watch a video about depression and how to cope with it 1 Mother will report a decreased level of depression 1 Home Visitor will give information & referrals about PPD & ways of coping 1 Mother will be connected to Families Matter 1 mother will contact services that can help her out with PPD 1 Mother will advise Home Visitor when she is feeling her 'waves' of depression 1 Home Visitor will give Healthy Families PPD package/ Families Matters referrals 1 Increase knowledge about mental health services 1 Home Visitor will connect mother with postpartum support group 1 Mother will access resources/ build a support system to help with the PPD 1 Professional referral for PPD 1 Home Visitor will connect mother with postpartum support group 1 Self monitoring skills - mother will monitor her PPD 1 Summary - total goals relating to PPD support for the mother 16 (24%) D. PPD Goals Relating to Self-Confidence Demonstrating good self-confidence 3 Mother suffers from depression/history of abuse - she will work on developing self-esteem 1 Mother will feel better about herself and feel that she is a 'person' again 1 Home Visitor will regularly check with mother regarding her emotional status 1 Summary - total goals relating to self-confidence for the mother 6 (9%) E. PPD Goals Relating to Social Isolation Mother will enjoy spending time away from the home/feel less isolated 1 Mother will report that she feels less isolated 1 Mother will call Home Visitor when she needs to talk with somebody 1 Summary - total goals relating to social isolation for the mother 3 (4%)

69



Thirty-nine (30%) of the 130 mothers had 67 goal statements that were related to

the management of their postpartum depression. The goals relating to postpartum

depression fell into five distinct categories. Twenty-two (33%) of the 67 goal statements

were related to self-care strategies for the mothers; 20 (30%) of the goal statements

related to stress management and coping for the mothers; 16 (24%) of the goal statements

related to support and encouragement for the mothers’ postpartum depression; 6 (9%) of

the goal statements related to improving mothers’ self-confidence; and 3 (4%) of the goal

statements related to decreasing the mothers’ social isolation.

Based on the results of this study, we suggest that the most usual goal statements

that the CRHVC Home Visitors developed to strategically address the mothers’

postpartum depression were related to self-care, stress and coping and support and

encouragement. It was beyond the scope of the CRHVC 2005-2007 Postpartum

Depression Project to assess actual goal achievement/non-achievement for the individual

mothers and any related impact on decreasing the mothers’ postpartum depression.

The foregoing results suggest that goal statements relating to postpartum

depression were developed for only 30% of the mothers. It is important to note that the

CRHVC Home Visitors developed strategies to address postpartum depression for all

mothers; these strategies were detailed in the mothers’ files and had not yet recorded as

goal statements when the analysis for the CRHVC 2005-2007 Postpartum Depression

Research Project was completed. In essence, the goal statements detailed in Table 11

represent only part of the plans and strategies that were developed for mothers with

postpartum depression. This finding is further discussed in the conclusions of this Report.

70


13. Risk Factors Identified at the Time of Postpartum Screening for Mothers with Postpartum Depression Attending CRHVC Healthy Families Program 2005-2007

Table 12 depicts the risk factors identified at the time of postpartum screening for

125 mothers who screened positive on the EDPS during the CRHVC 2005-2007

Postpartum Depression Research Project. These mothers had been screened in 2005-2006

with one of two postpartum screens – either the Parkyn Screen or the Healthy Families

America Screen. No mother was screened with both screens.

Table 12. Risk Factors Identified during Postpartum Screening for Mothers with Postpartum Depression Attending CRHVC Healthy Families Program 2005-2006

Risk Factor Identified for the Mother at the Time of Postpartum Screening (with the Parkyn Screen or the Healthy Families America Postpartum Screen)

Number of Mothers Screening Positive for the Risk - Parkyn Screen (N=84)*

Number of Mothers Screening Positive for the Risk - Healthy Families America Screen (N=41)*

Total Number of Mothers Screening Positive for the Risk - Both Screens (N=125)*

Financial Difficulties 63 (75%) 35 (85%) 98 (78%) No Emergency Contacts/No Support (1 or 2 Parents)

49 (58%) 14 (34%) 63 (50%)

Mental Illness - History of Depression /Postpartum Depression

17 (20%) 36 (89%) 53 (42%)

Low Education - Grade School to Some High School

20 (24%) 17 (41%) 37 (30%)

Inadequate Prenatal Care 10 (12%) 5 (12%) 17 (14%) Marital Difficulties 5 (6%) 5 (12%) 10 (8%) Complications Pregnancy/Delivery 35 (42%) NA** - Abortion or Adoption Considered NA** 17 (42%) - History Substance Abuse NA** 13 (32%) - Unstable Housing NA** 11 (27%) - Partner Unemployed NA** 9 (22%) - Parenting Difficulties 16 (19%) NA** - Single (Level of Support not Stated) NA** 7 (17%) - Low Birth Weight 12 (14%) NA** - Family History of Genetic Challenges 12 (14%) NA** - Prolonged Maternal Separation With Infant Contact

9 (11%) NA** -

Single - with support 9 (11%) NA** - Age of Mother (15-19) 7 (8%) NA** - Mental Illness Mother/Father 7 (8%) NA** - Marital Difficulties 7 (8%) NA** - Congenital Health Challenges (Baby) 5 (6%) NA** - Assessed Lack of Bonding 2 (2%) NA** - Prolonged Maternal/Infant Separation 1 (1%) NA** - Other ***

*The percentages represent the percent of mothers from the total groups of mothers who screened positive for the risk factor; ** Screening factor not on the Screen; ***There were 63 “other reasons” of which 17 were low education, 16 were parenting difficulties and 7 were marital difficulties. Note: The Parkyn Screen was used in 2005 and 2006. The Healthy Families America Screen was used in 2006 when the Parkyn Screen was discontinued.

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Five mothers were screened with the CRHVC Postpartum Screening Tool in late

2006 and early 2007 and, because of its minimal use these screening results were not

included in the analysis.

Figure 28 summarizes the risk factors for mothers with postpartum depression

that were identified that during 2005-2006 postpartum screening with the Parkyn Screen

or the Healthy Families America Screen. These two screens were used by the CRHVC

Healthy Families Program prior to the development and use of the CRHVC Postpartum

Screening Tool which was developed and implemented in 2005-2006.

Figure 28. Risk Factors for Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program Identified at the Time of 2005-2006 Postpartum Screening

Number of Mothers with Postpartum Depression Attending the CRHVC Healthy Families Program - Top Risk Factors Identified During

2005-2006 Postpartum Screening (N=125)*

History of Depression,

Mental Illness 53, 42%

Lack of Support, 63, 50%


98, 78%

Inadequate Prenatal Care,

17, 14%Marital Difficulties,

10, 8%Low Education, 37, 30%


Lack of Support

History ofDepression/MentalIllnessLow Education

Inadequate PrenatalCare

Marital Difficulties

* common risk factors that could be identified on both the Parkyn Screen and the Healthy Families America Screen; low education is less than 12 years of school/no high school Findings and Conclusions

Eighty-four (67%) of the 125 mothers with postpartum depression were screened

with the Parkyn Screen while 41(33%) of the mothers were screened with the Healthy

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Families America Screen in 2005-2006. As noted in Table 12, these two postpartum

screens also included other risk factors that were unique to the individual screens. The

common risk factors identified on the Parkyn Screen and the Healthy Families America

Postpartum Screen included financial difficulties, lack of support, depression/mental

illness, low education level, inadequate prenatal care and marital difficulties. Financial

difficulties, the most usual risk factor was identified as a risk factor for 98 (78%) of the

125 mothers; lack of available social support was a risk factor for 63 (50%) of the 125

mothers. Depression/mental illness were risk factors for 53 (19%) of the 125 mothers.

Thirty-seven (30%) of the 125 mothers had risks relating to a low level of education

(essentially no high school) and 10 (8%) of the mothers with postpartum depression had

risks associated with marital difficulties.

The Parkyn Postpartum Screen also identified complications of

pregnancy/delivery as a risk factor for 35 (42%) of the 84 mothers; parenting difficulties

as a risk factor for 16 (19%) of the 84 mothers; and low birth weight of the baby as a risk

factor for 12 (14%) of the 84 mothers. These findings likely reflected the medical/health

nature of the questions on the Parkyn Screen.

The Healthy Families America Postpartum Screen identified mothers’

consideration of adoption/abortion as a risk factor for 17 (42%) of the 41 the mothers;

unstable housing as a risk factor for 11 (27%) of the 41mothers and; history of substance

abuse as a risk factor for 13 (32%) of the 41mothers. These findings likely reflected the

psychosocial nature of the questions on the Healthy Families America Screen.

Based on the results of this study, we suggest that the most usual risk factors

identified at the time of postpartum screening that characterized mothers who later

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screened positive for postpartum depression were financial difficulties, lack of

support/social isolation, depression/mental illness and low education (less than 12 years

of school.

The CRHVC 2005-2007 Screening Tool Project (completed concurrently with the

CRHVC Postpartum Depression Research Project) culminated in the development of a

standardized postpartum screening tool with demonstrated high validity and reliability.

Table 13 summarizes risk factors identified with the CRHVC Postpartum Screening Tool

during its early implementation in 2006-2007.

The most usual risk factors that were identified at the time of screening with the

CRHVC Postpartum Screening Tool included lack of sufficient money (i.e. correlates

with financial difficulties identified on the Parkyn and Healthy Families America

Screen); lack of confidence in caring for the baby (i.e. correlates with parenting

difficulties identified on the Parkyn and Healthy Families America Screen); mother

depressed/past depression (i.e. correlates with depression/mental difficulties identified on

the Parkyn and Healthy Families America Screen); social isolation (i.e. correlates with no

support/social isolation identified on the Parkyn and Healthy Families America Screen).

The three screens used during the time frame of the CRHVC 2005-2007

Postpartum Depression Research Project - the Parkyn Postpartum Screen, the Healthy

Families America Postpartum Screen and the CRHVC Postpartum Screening Tool -

consistently identified specific risk factors - financial difficulties, lack of confidence in

caring for the baby, social isolation and present/past depression/mental illness as common

risk factors at the time of postpartum screening. These risk factors have also been shown

to be risk factors for postpartum depression.

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Table 13. Risk Factors Identified During Screening (N=408) using the CRHVC Postpartum Screening Tool for Mothers Attending the CRHVC Healthy Families Program 2006-2007 Category of Risk for

Mothers with Positive Postpartum Screens

No. Mothers

Number of Mothers who had the Risk

Number of Mothers who did not have the Risk

Comments

Insufficient money for basic necessities/financial difficulties

408 222 (54%) 177 (43%) 9 (2%) of mothers didn’t know

Lack of confidence in caring for the baby

408 202 (49%) 206 (51%)

Social Isolation/lack of social support

408 202 (49%) 206 (51%) 2 mothers chose not to answer

Mother depressed since the baby’s birth (postpartum depression)

356 136 (38%) 220 (62%)

History of depression (mother) 290 57 (20%) 232 (80%) Presence of a medical health problem in the family that could interfere with caring for baby

408 36 (9%) 369 (90%) 3 (0.7%) of mothers didn’t know

Family involvement with Welfare Services during past 2 years

408 31 (8%) 376 (92%) 1 mother chose not to answer; 6 (1%) of mothers involved with Welfare more than 2 years earlier

Low level of education (no or some grade school)

408 27 (7%) 381 (93%)

Unsafe Home for baby/children 408 28 (7%) 372 (91%) 8 (2%) of mothers didn’t know

Mental health problem in the family that could interfere with caring for baby

408 25 (6%) 378 (93%) 5 (1%) of mothers didn’t know

Alcohol use in the home likely to make parenting difficult for mother

408 6 (1%) 92 (91%) 101 (25%) of homes had alcohol use

Emotional abuse in the home 408 11 (3 %) 396 (97%) 1 mother chose not to answer

Verbal abuse in the home 408 7 (2%) 400 (98%) 1 mother chose not to answer

Baby not wanted 408 8 (2%) 356 (87%) 42 (10%) of mothers would have preferred to have the baby earlier or later in life

No or minimal prenatal medical care

408 6 (1%) 402 (99%)

Drug use likely to make it difficult to care for baby

408 1 (0.02%) 407 (99.8%) 5 (1%) of homes had drug use

Physical abuse in the home 408 1 (0.02%) 407 (99.8%)

Further studies that could explore the extent to which any or all of these four risk

factors - financial difficulties, lack of confidence in caring for the baby, social isolation

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and current/past depression/mental illness that were consistently identified at the time of

postpartum screening could be early predictors of postpartum depression in new mothers

- are suggested.

14. Discussion and Conclusions of the CRHVC 2005-2007 Postpartum Depression Research Project 14.1. Comparison of the Results of the CRHVC 2005-2007 Postpartum Depression Research Project with the Findings in the Literature The results of the CRHVC 2005-2007 Postpartum Depression Research Project

were compared with the findings in the literature. These comparisons are detailed in the

following sections.

14.1.1 Benefits of Participation in Home Visitation/CRHVC Healthy Families Programs

The 130 mothers participating in the CRHVC 2005-2007 Postpartum Depression

Research Project identified 258 benefits of Home Visitation Programs (Table 5). Eighty

(31%) of the 130 mothers stated that the most important benefit of attending the CRHVC

Healthy Families Program was the emotional support and encouragement offered by the

Home Visitors. Table 14 compares the benefits of attendance at the CRHVC Healthy

Families Program with benefits of Home Visitation that have been reported in the

literature.

Discussion and Conclusions

The benefits of participation in the CRHVC Healthy Families Program that were

identified in the CRHVC 2005-2007 Postpartum Depression Research Project reflected

the benefits that have been reported in peer-reviewed publications. In particular, the key

role of the emotional support that the CRHVC Home Visitors provided to mothers with

postpartum depression was noteworthy and it is likely that there is significant opportunity

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to further develop the important role of the Home Visitor in treating postpartum

depression. The education support offered by the CRHVC Home Visitors consisted of

information packages/articles/videos about postpartum depression. The mothers also

considered referrals to community-based postpartum depression support programs and

resources as a key benefit of attending the CRHVC Healthy Families Program.

Table 14. Benefits of Home Visitation Programs - Comparison of the Findings of the CRHVC 2005-2007 Postpartum Depression Research Project with Benefits Reported in the Literature

Study/ Reference

Greatest Benefits of Home Visitation Programs

Comments

CRHVC 2005-2007 Postpartum Depression Research Project

>Support and encouragement of CRHVC Home Visitors (emotional support) >Referrals to community-based support resources > Provision of educational materials

130 mothers with postpartum depression

Sweet & Applebaum (2004)

>Parenting education >Parent social support > Parent counseling >Information on child development >Improved child-parent relationships >Improved child development screening >Provision of material goods >Referrals to social and health services

Overview of the effectiveness of home visiting

Shaw et al; (2006) >Home Visitation or peer support produced a statistically significant reduction in EDPS scores for mothers at high risk for postpartum depression >Home visitation may improve parent-infant interaction, maternal mental health

Literature search - 22 studies 1999/2003/2005

Ueda, Yamashita & Yoshida, (2006)

>Infant-related health problems requiring hospital care related to postnatal depression; Home Visitors provided emotional support

70 Japanese mothers, 19 of whom had postpartum depression

Logsdon et al., (2006a)

>Health care workers have responsibility to educate mothers about community support resources

Focus of article – impact of postpartum depression on mothering/need for mental health services

Dennis & Chung-Lee (2006)

>Opportunity for the mother to talk (develop a close working relationship with) with an empathetic non-judgmental health professional who listens - most desired treatment for postpartum depression

Consolidated findings of 40 articles (note - the opportunity to speak with a Home Visitor was listed as an important benefit in the CRHVC 2005-2007 postpartum depression study

Ray & Hodnett (2001)

>Professional and/or social support which may help in the treatment of postpartum depression

Review of 2 studies in the Cochrane database involving 137 mothers

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Discussions and Conclusions

The literature provides general and specific descriptions of the support that Home

Visitors provide for mothers with postpartum depression. The support offered by the

CRHVC Home Visitors mirrors the type of support reported in the literature.

14.1.2. Barriers to Attendance at Programs that Provide Support for Postpartum Depression

Sixty-one (47%) of the 130 mothers who participated in the CRHVC 2005-2007

Postpartum Depression Research Project provided feedback about whether certain factors

were/were not barriers to attendance at community-based postpartum depression support

programs and resources. As noted in Table 10, 29 (63%) of 46 mothers identified lack of

childcare as a barrier to attendance at community-based postpartum depression support

programs and resources. The next two most frequently mentioned barriers were no

perceived benefit of attending the program and limited transportation which were

identified by 26 (57%) of 46 mothers and 27 (55%) of 49 mothers respectively. Other

barriers to attendance were the type/nature of support offered by the program, distance

from the referral location, waitlist issues, language concerns and costs of attendance. At

the same time, many of the mothers confirmed that these factors were not barriers to

attendance.

Table 15 compares the barriers to attendance at community-based postpartum

depression support programs identified in the CRHVC 2005-2007 Postpartum Depression

Research Project with barriers reported in the literature.


The barriers to participation in community-based postpartum depression support

programs and resources that were identified in the CRHVC 2005-2007 Postpartum

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Depression Research Project reflected the barriers that have been reported in peer-

reviewed publications, notably with respect to child care issues and transportation

concerns.

Table 15. Barriers to Attendance at Community-based Postpartum Depression Support Programs - Comparison of the Findings of the CRHVC 2005-2007 Postpartum Depression Research Project with Barriers Reported in the Literature

Study/ Reference

Greatest Barriers to Attendance at Community-based postpartum depression support programs

Comments


>Lack of childcare >No perceived benefit of attendance at the support program >Limited transportation >Distance from referral >Type of support offered by the program

61 (of 130) mothers with postpartum depression

Teng, Blackmore & Stewart (2006)

>Practical barriers - not knowing how to and where to access services and language difficulties >Cultural barriers - fear of stigma and lack of validation of depressive symptoms by family and society

Study focused on immigrant women in Canada

Ross et al., (2006) >Transportation issues >Childcare issues

Literature review

Sword et al; (2006) >Reluctance to identify or acknowledge health concerns because of beliefs that depression is normal consequence of childbirth >Reluctance to get necessary help; therefore many unmet learning needs > Belief that postpartum depression is unacceptable, therefore not acknowledged >Language - unable to understand health information

Study focused on immigrant women in Canada

Gjerdingen & Yawn (2007)

> Cost-related issues >Time constraints >Lack of access >Lack of follow-through >Lack of childcare >Fear of referral to Child Protection Services > Fear of judgment

Comprehensive literature review

Dennis & Chung-Lee (2006)

>Mothers reluctant to seek support and to disclose their depressive state >Lack of awareness about support services >Lack of awareness of being depressed >Denial > Mothers’ concerns about postpartum depression not taken seriously by professionals (doctors); insufficient length of appointment; not referred to other services

Focus on mothers from different cultures; in-depth literature review

Murray, Woolgar, Murray & Cooper (2003)

>Self-exclusion from programs Case-control study; data from computerized health systems

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The CRHVC Postpartum Depression Project identified two barriers - no perceived

benefit of attending the program and the type/nature of support offered by the support

program that to the best of this researcher’s (P. Hull) knowledge have not been previously

reported. We suggest that these two factors could be predictors of poor attendance and

early attrition from community-based support programs for postpartum depression, an

issue that has been well-documented in the literature. It is therefore important that Home

Visitation Programs ensure that mothers fully understand the type of/nature of support

offered by programs prior to recommending attendance; this will allow mothers to make

well-informed decisions about attendance. Home Visitors are in an ideal position to

provide this information and proactively support the mothers’ decision-making about

attendance at community-based postpartum depression support programs and resources.

It was beyond the scope of the CRHVC 2005-2007 Postpartum Depression

Research Project to study how these barriers actually impacted mothers’ attendance at

community-based postpartum depression support programs and resources and the

mothers’ perceptions about the benefits/lack of benefits of attendance.

14.1.3. Risk Factors Related to Postpartum Depression for Mothers Attending Home Visitation Programs

One hundred and twenty-five (96%) of the 130 mothers who participated in the

CRHVC 2005-2007 Postpartum Depression Research Project provided feedback to the

Home Visitors about personal and environmental risk factors identified at the time of

screening and/or that had become important after admission to the CRHVC Healthy

Families Program. As noted in Table 13, insufficient money for basic necessities was a

risk factor for 222 (54%) of the 408 mothers and lack of confidence in caring for the baby

was a risk factor for 202 (50%) of the 408 mothers. The next two most frequently

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mentioned risk factors were social isolation and depression. Table 16 compares the risk

factors identified in the CRHVC 2005-2007 Postpartum Depression Research Project

with risk factors reported in the literature.

Table 16. Risk Factors for Mothers with Postpartum Depression - Comparison of the Findings of the CRHVC 2005-2007 Postpartum Depression Research Project with Risk Factors Reported in the Literature

Study/ Reference

Greatest Risks for Mothers with Postpartum Depression Comments


>Insufficient money >Lack of confidence to care for baby >Mothers’ depression >Social isolation/lack of social support

408 mothers attending the Healthy Families Program

Webster, Pritchard, Creedy & East (2003)

>Previous postnatal depression (most significant risk); severe baby blues >Low social support >Dissatisfaction with the birth experience >Difficult infant temperament >Obstetric complications/satisfaction with labour/delivery >Infant feeding method (bottle-feeding)

Comparative study - antenatal and post natal risks

Horowitz & Goodman ( 2005)

> Prenatal depression or anxiety, history of depression > Inadequate social support > Poor relationship with partner >Life and child care stress

American study - focus timely intervention

Beck (2006) >Inadequate clinician support, caring, communication issues >Long painful labour; mother feels powerless > Unmet emotional needs >Prenatal depression > Anxiety >Low self-esteem >High stress level >Child care difficulties/ difficult infant temperament >Poor marital relationship >Maternity blues >Single marital status >Low socioeconomic status >Unplanned/unwanted pregnancy > Lack of social support

Review and summary article

Josefsson & Sydsjo (2007)

>Use of antidepressant medication and other medications >Presence of affective disorders

675 mothers; 221 with postpartum depression

Small, Lumley & Yelland (2006)

>Mothers under age 25 >Newcomers to the country, little or no English >No social support >Physical health problems >Baby with feeding problems >Homesickness (immigrants)

Australian study - 318 Vietnamese, Turkish and Filipino mothers

Sword et al., (2006)

>Low family income, need for financial assistance > New immigrants

Canadian study - 1,250 mothers,

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> Low social support > Unmet learning needs (hospital)

31% new Canadians

Dennis et al., (2004)

>Immigration within the last 5 years >History of depression independent of childbirth >Diagnosis of pregnancy-induced hypertension >Vulnerable personality style >Stressful life events >Low social support/partner support >Lack of readiness for hospital discharge >Dissatisfaction - infant feeding method >Low maternal confidence in caring for infant

Canadian study - 594 mothers

Boyce & Hickey (2005)

>16 years of age or less >Having baby of non-desired sex >Past history of psychiatric illness >Experiencing stressful life events since conception >Marital dissatisfaction >Low social support >Vulnerable personality (vulnerability scale used) >Colicky baby > Early discharge from hospital

Australian study - convenience sample of 425 new mothers

Bloch et al., (2005)

>Past history of depression or the blues >Mood disorders during oral contraceptive use

Retrospective review 1800 mothers

Harvey & Pun (2007)

>Prenatal depression and related disorders Psychiatric patient clinical findings

Surkan et al., (2006)

>Number of children >Perceived discrimination >Lack of social support

Multiethnic urban population

Austin, Tulley & Park (2007)

>Prenatal anxiety Screening tool development study

Howell, Mora, Horowitz & Leventhal (2005)

>Lack of social support >Lack of self-efficacy >Skills in managing household and infants >Access and trust in support services

Telephone survey of 655 white, African-American and Hispanic women


The risk factors identified for mothers who participated in the CRHVC 2005-2007

Postpartum Depression Research Project reflected the risks that have been reported in

peer-reviewed publications. In general, the most common risk factors identified in

studies (across cultures) for postpartum depression were insufficient income for basic

necessities, lack of confidence in caring for the baby, social isolation, new to the country

(thus language issues for many mothers), stressful life events and current/past depression.

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One study (Boyce and Hickey, 2005) reported that 20 (25%) of the 80 mothers who had

infants of the non-desired sex developed postnatal depression while other investigators

(Webster et al., 2003) asserted that “postnatal highs” was a risk factor. Similarly,

mothers’ unmet learning needs (Sword et al., 2006) have been recently reported as a risk

factor. The impact/importance of risk factors could be further studied by the CRHVC.

14.1.4. Demographic Profile of Mothers with Postpartum Depression Attending Home Visitation/Healthy Families Programs

The CRHVC 2005-2007 Postpartum Depression Research Project assessed the

demographic profile of the 130 mothers with postpartum depression. Table 4 summarizes

these results. Table 17 compares the risk factors identified in the CRHVC 2005-2007

Postpartum Depression Research Project with the demographic profiles of mothers

reported in the literature.


The demographic profile for the 130 mothers who participated in the CRHVC

2005-2007 Postpartum Depression Research Project reflected the mothers’ demographic

profiles that have been reported in peer-reviewed publications. In general, mothers with

postpartum depression tended to be 25-35 years old, predominantly white (English),

married and of middle to higher socioeconomic status. Much of the literature regarding

the demographic profile of mothers with postpartum depression is sketchy or inconsistent

(Ross et al., 2006). These authors completed an in-depth literature review and concluded

that only four variables - age, ethnicity, relationship status and socioeconomic status

could be assessed. Clearly, there is a need to further undertake studies of the demographic

profile of mothers with postpartum depression, particularly mothers from different

cultures.

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Table 17. Demographic Profile of Mothers with Postpartum Depression - Comparison of the Findings of the CRHVC 2005-2007 Postpartum Depression Research Project with the Demographic Profiles Reported in the Literature

Study/Reference Demographic Profile of Mothers Comments CRHVC 2005-2007 Postpartum Depression Research Project

> Average age 30 (19-43) > First language (English) - 81 (62%) >First language other than English - 49 (38%) > First language Arabic - 14 (11%) of mothers (7% of referred Arabic mothers)

130 mothers with postpartum depression - identified risks included insufficient income, minimal social support, past/current depression and life stress

Boyce & Hickey (2003)

>Average age - 26.9 years (no difference from study sample of 425 mothers) > Majority married

42 mothers with postpartum depression

Surkin et al., (2006) >Average age 29 > Mix of Black, Latina and English backgrounds; English - 40% range

Multiethnic study - comparative study

Josefsson & Sydsjo (2007)

>Average age - 33.5 (range of 5 years)

Comparative study - 675 mothers; 221 with postpartum depression

Ross et al., (2006) >Age predominantly 25-35 years > Predominantly white >Middle or higher socioeconomic status > Married or equivalent status

In-depth literature review; mothers a homogeneous group - not representative of general population

*660 mothers referred who had English as their first language; 406 mothers referred who had a language other than English as their first language; it was beyond the scope of this study to determine the percent of mothers from different cultures who had postpartum depression. The percent of mothers with postpartum depression in relation to all referred mothers is 25% (Marianne Symons, Program Manager). This higher percent of mothers with postpartum depression in the CRHVC (in comparison with the literature) is a reflection of the fact that the Calgary Health Region assesses mothers’ risks prior to referral to the CRHVC. 15. Conclusions and Recommendations of the CRHVC 2005-2007 Postpartum Depression Research Project On the basis of the findings of the CRHVC 2005-2007 Postpartum Depression

Research Project, a number of conclusions and recommendations can be made. These are

detailed in the following section.

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Conclusion and Recommendation 1 - Community-based Home Visitation Programs, notably the CRHVC Healthy Families Program Have the Capacity to Make Valuable Contributions to the Home Visitation Profession by adding new Knowledge and Ideas for Additional Studies Relating to the Management of Postpartum Depression

The CRHVC 2005-2007 Postpartum Depression Research Project made the

following contributions to the study of postpartum depression and Home Visitation.

Confirmation of Earlier Findings in the Literature

The findings of the CRHVC 2005-2007 Postpartum Depression Research Project

confirmed the findings of earlier studies; for example, the nature of the

psychosocial, environmental and medical/health-related risk factors that

characterized mothers with postpartum depression, the benefits afforded to

mothers who attended the CRHVC Healthy Families Program and the mothers’

demographic profile reflected the findings in the literature. This finding is

important for three reasons:

It suggests that the CRHVC focuses the service delivery of its Healthy Families Program appropriately.

It further suggests that other community-based Home Visitation Programs could use a research and evaluation framework to structure their Programs that would foster a greater use of evidence to plan and structure their programs

The CRHVC is well-positioned to take a leadership role in community-based Home Visitation research and ultimately influence the evolution of Home Visitation in Canada

Use of Different Study Methods/Approaches and the Addition of New Knowledge

The CRHVC 2005-2007 Postpartum Depression Research Project used an

approach that (to the best of this researcher’s knowledge) has not been reported in

the literature; for example; the Project categorized mothers who had been

screened using the EDPS for postpartum depression as mothers who:

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Screened positive on the first EDPS screen and positive on the second EDPS screen

Screened positive on the first EDPS screen and negative on the second EDPS screen

Screened negative on the first EDPS screen and positive on the second EDPS screen

Screened positive on the first EDPS screen and had early closure from the Program

The approach used in the CRHVC 2005-2007 Postpartum Depression Research

Project is important as it confirmed the changing status of mothers’ postpartum

depression and established/confirmed the importance of multiple screenings with the

EDPS. Future large-scale university-based studies (and/or community-based programs)

could undertake targeted studies to better know the course of postpartum depression and

the factors that cause changes in screening status for individual mothers. This is

important given that most studies appear to focus on screening (often one-time screening)

in the immediate postpartum period; it is clear that if additional screening is not

completed, at-risk mothers (those who screen positive and then negative on the EDPS)

could be missed.

The CRHVC 2005-2007 Postpartum Depression Research Project added new

knowledge that (to the best of this researcher’s knowledge) had not been reported

in the literature; for example; the Project identified two different barriers to

mothers’ attendance at community-based postpartum depression support programs

and resources. These barriers were - no perceived benefit from attending the

program and mothers’ concerns about the type/nature of the program not being

appropriate (for example, group vs. individual support programs).

Such barriers (and all other barriers) are important to study and understand. These

barriers could be contributing factors to the mothers’ poor attendance/early attrition or

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self-exclusion from postpartum depression support programs, issues that are well-

documented in the literature.

The CRHVC 2005-2007 Postpartum Depression Research Project also explored

and quantified mothers’ perceptions with regard to the factors not being barriers

to attendance at community-based postpartum depression support programs and

resources. The results of this analysis indicated that almost half of the mothers did

not perceive these factors to be barriers to attendance.

It is important to further study mothers’ attendance at postpartum depression

support programs and resources. Targeted postpartum depression studies could address:

the benefits experienced by mothers who attended community-based postpartum

depression support programs and resources; attrition from these programs; duration of

attendance; the impact of attendance on the course of the mothers’ postpartum depression

and; attendance for those mothers who perceived no barriers to attendance.

Future studies could also explore the outcomes of Home Visitor support, notably from

the mothers’ perspectives, decreases in postpartum depression that are directly

attributable to Home Visitor support and the role of Home Visitors in the overall

continuum of care for mothers with postpartum depression.

Conclusion and Recommendation 2 - The CRHVC has Significant Opportunities to Partner with other Organizations to Study Postpartum Depression and Should Seek Funding to Undertake Future Research Projects Partnership/ Joint Studies with Other Organizations

The CRHVC has developed (and continues to enhance) solid databases of information

relating to its Healthy Families Program and to postpartum depression. There are likely

opportunities to partner with:

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the Calgary Health Region (which has a well-documented interest in postpartum depression and an active Network framework)

the University of Calgary (or other universities) other Home Visitation Programs in Alberta (through AHVNA) other Home Visitation Programs in Canada (through proactive consultation with

other leaders/program managers

Such partnerships could require involvement in Ethics approval processes.

Ultimately, however, the benefits derived from such partnerships could increase the scope

of studies and highlight the role of Home Visitation in the continuum of care for

postpartum depression. The CRHVC has an opportunity to take a lead (or partnering) role

in establishing these research-based relationships. Such partnerships can lead to a more

strategic approach at the local level, a fact noted to be an important mechanism for

managing this major public health problem (Deave, 2002).

The CRHVC should also continue the data collection processes that were initiated

and used during the CRHVC 2005-2007 Postpartum Depression Research Project. It

would be important to evaluate whether additional information should be collected and as

necessary, to revise the data collection forms. Ultimately, this information could be used

for longitudinal studies about mothers with postpartum depression attending Healthy

Families Programs.

Role of Home Visitors in Research Studies

The CRHVC Supervisors and Home Visitors were actively involved throughout the

CRHVC 2005-2007 Postpartum Depression Research Project. They provided excellent

feedback with regard to the content and use of the data forms and collected and reported

the mothers’ information. The CRHVC Supervisors and Home Visitors were also active

participants in the CRHVC 2005-2007 Postpartum Screening Tool Project which was

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completed concurrently. It is reasonable to assume that the CRHVC Healthy Families

staff would be willing and committed participants in future studies.

Potential Sources of Funding for Future Studies

The Alberta Centre for Child, Family and Community Research

www.research4children.com, which supports and encourages research in specific areas

(Early Childhood Development, Family Capacity Building, Community Capacity

Building, Successful Transitions to Youth and Tracking Long-term Outcomes) could be

approached to fund targeted studies.

Other potential sources of funding include the Burns Foundation, The United Way

and the Calgary Foundation. In addition, it may be feasible to approach ALVA, the

majority funder of the CRHVC 2005-2007 Postpartum Depression Project (and the

CRHVC Postpartum Screening Tool Project) to support a follow- up study. Such a study

could have national scope.

Conclusion and Recommendation 3 - The CRHVC has an Opportunity to Strengthen/Enhance its Service Delivery to Support Mothers with Postpartum Depression through Better Use of the Edinburgh Screening Tool Results and the Use of Goal Statements for Postpartum Depression The Development and Use of Goal Statements for Mothers with Postpartum Depression

The CRHVC Postpartum Depression Research Project confirmed the important

role that Home Visitors play in effectively supporting mothers with postpartum

depression: it quantified and categorized goal statements for mothers with postpartum

depression (Table 11) and as well, described the scope of services provided by Home

Visitors (Table 2), areas that have been generally reported in the literature.

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http://www.research4children.com/


An analysis of the number of goal statements and the format/way in which they

were written revealed the following:

Goals relating to postpartum depression were developed for only 39 (30%) of the 130 mothers with postpartum depression. It was beyond the scope of this Project to assess which mothers of the four categories had goal statements related to postpartum depression. Clearly, however, there is a need to develop relevant goal statements for all mothers with postpartum depression, specifically at the time of a positive screen

Many of the goal statements were not written in the context/terms of acceptable standards for goal statements (specific, measurable, actionable, relevant and time-bound)

Outcome measures were not reported (although this was beyond the scope of the Project) but is necessary to ascertain the effectiveness of Home Visitor interventions in impacting the course of postpartum depression, both in research studies and as an essential component of service delivery Discussion with Marianne Symons, CRHVC Program Manager revealed the

following practices of the CRHVC Healthy Families Program:

1) The Home Visitors write the first goal statement for mothers at 45-60 days after referral

2) The Home Visitors write the second goal statement for mothers (sometimes a review/modification of the first goal statement at 90 days

3) The Home Visitors administer the first EDPS at 16 weeks (112 days) 4) The Home Visitors write additional goal statements for mothers at 90 day

intervals 5) Home Visitors administer the second EDPS at 32 weeks (228 days)

When the mothers screen positive for postpartum depression (screening

completed at 112 days and/or 228 days), the Home Visitors immediately develop

strategies to address postpartum depression. These strategies are detailed in the mothers’

file notes at the time of the positive EDPS and subsequently added to the goal

statements/plans at the time of the next review (90 day intervals after the 112 day goal

plan is written). The CRHVC 2005-2007 Postpartum Depression Research Project was

limited in that it did not include a review of all goal statements and thus the Home

Visitors’ goals to address postpartum depression were not identified. In essence, goal

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statements relating to postpartum depression had been developed (and were being

implemented) at the time of the CRHVC Postpartum Depression Research Project but

had not yet been added to the goal statements. This accounts for the relatively low level

of goal statements relating to postpartum depression that were identified in the CRHVC

2005-2007 Postpartum Depression Research Project. Marianne Symons, in consultation

with the CRHVC Supervisors Team, confirmed that all of the mothers with postpartum

depression had goal statements relating to postpartum depression.

At the same time, it recommended that the CRHVC reconsider the timing of

writing goal statements for mothers having positive EDPS screens. Ideally, the mothers’

goal statements should be modified in a timely manner if the EDPS is positive.

Targeted Training in Relation to the Use of EDPS Screening Results

Elliot, Ashton, Gerrard and Cox (2003) suggested that the screening for postnatal

depression should be grounded in the research process to ensure that Health Visitors

(Home Visitors) best use the results of screening to help mothers. These authors reported

the potential benefit of targeted screening tool training to assist Health Visitors.

Goldsmith (2007) reported the necessity for health professionals to have an excellent

understanding of postpartum depression in order for them to provide quality care.

Logsdon, Wisner and Shanahan (2006b) also noted the need to increase awareness about

postpartum depression for all primary care providers. Carter (2005) suggested that

postnatal visits by healthcare professionals showed promise in terms of preventing

postnatal depression. The CRHVC should seek an opportunity to undertake a three-part

postpartum depression training initiative that would:

1) Fully examine the current practices of the CRHVC Home Visitors with respect to their use of the results of the EDPS, their knowledge of best practices for

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postpartum depression and its management by Health Professionals, notably Home Visitors

2) Fully examine their existing goal statements for mothers with postpartum depression from the perspective of format, time of development and achievement of intended outcomes and explore Carter’s (2005) belief that postnatal visits can prevent postnatal depression and how this could be a component of the training program

3) Develop an evidence-based training program to address the findings in 1 and 2 and complete a follow-up study to evaluate the effectiveness (outcomes) of the training in terms of decreasing the mothers postpartum depression (and the impact on job satisfaction for the CRHVC Home Visitors)

Conclusion and Recommendation 4 - The CRHVC has an Opportunity to Take a Lead Role in Developing Best Practice Guidelines for Home Visitors who Support Mothers with Postpartum Depression Best Practice Home Visitation Guidelines for Home Visitors

McQueen and Dennis (2007) described a systematic process for developing

evidence-based best practice (clinical) postpartum depression guidelines for nurses. This

process incorporated the following steps:

Establishment of a multidisciplinary development team Identification of the scope of the guidelines and definition of outcomes Question formulation and search for evidence Appraisal of evidence Formulation of guideline recommendations and synthesis of the evidence Consultation and peer review, concensus conference and pilot testing Presentation of the Guidelines

The CRHVC has an opportunity to lead a similar initiative that would culminate in

the development of evidence-based practice guidelines for Home Visitors who support

mothers with postpartum depression. Such guidelines, which would encompass Home

Visitor interventions for screening, assessment and outcome evaluation, are not available

and if developed could foster more consistent outcomes-based management of

postpartum depression by Home Visitors. Downie, Wynaden, McGowan, Juliff, Axten,

Fitzpatrick, Ogilvie and Painter (2003) also reported guidelines for developing best

92


practices for postpartum depression; these could also serve as an important source of

information. Ingram and Taylor (2007) have suggested that Health Visitors (Home

Visitors) could play an important role in antenatal care, an opportunity that could also be

explored by the CRHVC, possibly in collaboration with the Calgary Health Region.

The CRHVC could collaborate with other Home Visitation Programs in Canada and

as such, take a lead (or partner) role in a study with national scope and relevance.

Conclusion and Recommendation 5 - The CRHVC has an Opportunity to Establish a Predictive Inventory of Risk Factors (as Part of the Postpartum Screening Process) that Could Foster Early Identification and Interventions for Mothers who are at Particular Risk for Developing Postpartum Depression The Development of a Predictive Inventory for Postpartum Depression

The CRHVC Postpartum Depression Research Project compared the risk factors

identified in postpartum screening (Table 13) with the risk factors identified following a

positive screen for postpartum depression (Table 12). Four risk factors - financial

difficulties, low maternal confidence in taking care of the baby, lack of social support and

depression/past depression - were identified as the most usual risk factors for postpartum

depression.

The CRHVC could undertake a targeted study that could be used to determine if

mothers who screen positively for these four risks at the time of postpartum screening

(with the CRHVC Postpartum Screening Tool) subsequently develop postpartum

depression and whether early intervention by the CRHVC Home Visitors could mitigate

the likelihood of postpartum depression. In essence, the CRHVC has an opportunity to

develop a succinct predictive postpartum depression screening tool within the context of

an existing postpartum screening tool. Such a predictive tool could effectively and

efficiently address the need for an easy-to-administer screening instrument for

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postpartum depression. A number of investigators such as Austin et al. (2007) and Beck

(2002) have undertaken research in this area and have tested in-depth postpartum

depression screening tools. Larger-scale randomized trials could be undertaken by other

investigators.

Conclusion and Recommendation 6 - The CRHVC has an Opportunity to Initiate Comprehensive Community-based Postpartum Depression Support Programs (Emphasis - Strengthened Social Networks) for Mothers with Postpartum Depression The Importance of Social Networks for Mothers with Postpartum Depression

The importance of social networks as an important component of effective treatment

for postpartum depression is well-documented (Boyce and Hickey, 2005; Sword et al.

2006; Teng et al., 2007). Surkan et al., (2006) reported that mothers with two or more

people who provided consistent social support had less depressive symptoms.

The CRHVC could undertake focused studies that would engage mothers

(particularly those of the same culture and/or who are not able to readily make in-person

visits) in formal (or informal) social support networks. One possible initiative could

involve the development of telephone-based or internet-based support groups with the

involvement of a CRHVC Home Visitor and two or more mothers. Wroblewski and

Tallon (2004) described a comprehensive support program for mothers with postpartum

depression and their suggestions could be used as one source of input for structuring a

CRHVC Program.

Other Opportunities for Targeted CRHVC Studies

The CRHVC (within the context of available resources) could also lead/participate in

a wide variety of other studies related to:

94


The mothers (such as the perceptions about postpartum depression from the perspective of mothers from different cultures and translation of support information and reasons for early closure bearing in mind that the mothers’ participation in the Healthy Families Program is voluntary

Home Visitors, particularly from the perspective of strengthening their important professional role in addressing postpartum depression and understanding the challenges they face in their work; Sweet and Applebaum (2004) noted that Home Visitors often influence program success but that their contribution may go unmentioned. The CRHVC has an opportunity to address this finding and in essence, increase awareness of the professional role of Home Visitors

Program development and evaluation to address gaps in services particularly for immigrant women and to enhance a person-centred approach to support with special attention to the optimal amount of support needed by mothers; the CRHVC could continue to refine its postpartum depression database and link the information with the data in the postpartum screening database

Reasons for early closure from the CRHVC Healthy Families Program (bearing in mind that the mothers’ participation is voluntary) and self-exclusion from available support, an issue noted to be of importance in many studies (Murray, Woolgar, Murray and Cooper, (2003).

Outcomes studies (for children of mothers with postpartum depression); the CRHVC routinely assesses infant development and this data could be studied

Conclusion and Recommendation 7 - The CRHVC 2005-2007 Postpartum Depression Research Project has Limitations Limitations of the CRHVC 2005-2007 Postpartum Depression Research Project

The CRHVC 2005-2007 Postpartum Depression Research Project provided a

“snapshot” of the mothers with postpartum depression attending a community-based

Healthy Families Program and as such, has a number of limitations including:

The number of mothers (130) who were involved in the study is relatively small and it is therefore not possible to make definitive statements about the results and findings; as such the study must be considered exploratory in nature. It is important to note however that the results paralleled those in the literature thus demonstrating that the data collection methods and analysis were essentially sound

The study relied on self-reporting and there were no control participants

The 130 mothers in the Project may not represent the actual population of at-risk

mothers in Calgary (though there is little reason to support this suggestion)

95


At the same time, the study identified new ideas (such as the importance of no

perceived benefit from attendance at postpartum support programs and different ways of

assessing the course of postpartum depression) that could be further studied. Thus, it is

important for the CRHVC to continue its involvement in evaluation and research studies.

Conclusion and Recommendation 8 - The CRHVC has an Opportunity to Engage in Knowledge Mobilization and Share the findings of the CRHVC 2005-2007 Postpartum Depression

It is important that the CRHVC proactively disseminate the knowledge gained

from the CRHC Postpartum Depression Research Project through presentations and

publication of the findings. Some of the opportunities are detailed below.

Presentation of the Results of the CRHVC 2005-2007 Postpartum Depression Research Project

Opportunities include:

Contacting local and provincial practice-based (and academic) organizations which are involved with Home Visitation (through AHVNA) and requesting opportunities to make presentations that would highlight the relevance of this study

Seeking media coverage - newspaper and magazines that target mothers and children’s services

Making presentations to key stakeholders of the Government of Alberta Publication of the Results of the CRHVC 2005-2007 Postpartum Depression Research Project

Opportunities include:

Adding the study results to the CRHVC and AHVNA web sites and creating links with other organizations to ensure that the study results can be readily accessed

Submitting articles to journals and magazines for publication Sending the Final Report to other investigators who have/are undertaking studies

about postpartum depression in Canada (Teng et al.,2007; Dennis et al., 2004) and seeking their input and suggestions

96


Summary Statement - the CRHVC 2005-2007 Postpartum Depression Research Project

Postpartum depression is a major public health concern in Canada that impacts at

least 10-20% of new mothers. Recent immigrants appear to be particularly vulnerable.

The sequelae of postpartum depression are devastating and negatively impact mothers,

children and their families. Leahy-Warren and McCarthy (2006, p 97) citing Dennis

(2005) who undertook a systematic review of postpartum depression in mothers noted

“the only intervention that had a clear preventative effect with vulnerable mothers was

individual intensive postpartum support in the guise of home visits provided by

professionals”. The CRHVC has a unique opportunity to confirm this finding and to

further strengthen the professional reputation of Home Visitors. This will require

initiation of targeted studies or involvement in collaborative studies.

The CRHVC 2005-2007 Postpartum Depression Research Project achieved its goals

and is well-positioned to participate in future studies given its strength-based philosophy,

the rigour of its Healthy Families and postpartum depression databases, commitment to

ongoing evaluation, cost-effective methods, use of evidence-based practices and its

dedicated professionals - the Leadership Team, Administration Team Supervisors Team

and, in particular the Home Visitors. The CRHVC should proactively seek funding to

continue its work and disseminate results.

Patricia Hull

M.Sc., M.Sc., EdD (candidate), PMP, CHE, CHRP, RD

July 30, 2007

97


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Appendices

Appendix 1 - Data Collection Forms used in the CRHVC 2005-2007 Postpartum Depression Research Project

#138, 1830 – 52nd Street SE Calgary, Alberta T2B 1N1

Ph: (403) 204-0800 Fax: (403) 204-0829

HOME VISITOR-CLIENT POSTPARTUM DEPRESSION

SUPPORT SURVEY INTENT: The purpose of this survey is to collect data about the supports and services

accessed by mothers who have screened positive for postpartum depression. Information obtained from this questionnaire will be used to better understand the services and supports accessed by these mothers.

TO COMPLETE: Supervisors are to distribute the packages to the Home Visitor (as indicated below),

who are to complete the forms in keeping with the time frames as specified below.

Mother’s Name:_____________________________ CID #:_______________________ Baby’s Name:____________________________________ Baby’s DOB:_____________ Home Visitor that Completed Screen: ________________________________

1st Screen Date:

Closure Date:

This package is to reflect postpartum care and service that were provided to the mother between ________________ (date) and ________________ (date).

Time frame covered for the Client Postpartum Depression Screen:

After the first positive screen and before client closure x

Prior Diagnosis / Treatment for Postpartum Depression To the best of your knowledge, has your client been diagnosed with Postpartum Depression by a Physician, Psychiatrist or Psychologist prior to the completion of the first positive Edinburgh Screen? □ Yes □ No □ Unknown If yes, did the professional make a referral to treat her postpartum depression? □ Yes □ No □ Unknown If yes, was the referral / treatment in the form of:

□ Medication □ Counseling and/or Personal Support □ Both At the time of the first positive Edinburgh Screen, was the mother accessing services for her postpartum depression? □ Yes □ No □ Unknown Referrals / Support Offered by the Home Visitor □ No referral was made to a Support Service because the mother was already accessing treatment or support. □ Additional supports or referrals for postpartum depression were offered in conjunction with those already being accessed (detail below if applicable). □ Home Visitor offered initial supports and/or services for postpartum depression (detail below).

Postpartum Depression Information Offered to the Mother This survey is to be completed by the Home Visitor who completed the Postpartum Depression Screens with the client.

Please indicate information offered for postpartum depression. Visit Date:

(DD/MM/YY) Describe PPD Information Given to Client (Handout, Article, Video, Etc): Additional Comments:

Postpartum Depression Supports / Services Offered to the Mother This survey is to be completed by the Home Visitor who completed the Postpartum Depression Screens with the client.

Please indicate supports/services that were/are beyond the general emotional supports offered for postpartum depression.

Visit Date: (DD/MM/YY)

Specify Referrals Made to Community Resources: (F) Family Dr; (S) Specialist Physician; (P) Postpartum Program;

(M) Mental Health Services; (C) Community Health Nurse

Did MOB Access Community Resource? (Check if applicable)

Additional Comments:

YES NO DON’T KNOW

CID #:_______________________ 2

Home Visitor Referrals for Postpartum Depression Please complete the following chart(s) IF a community resource referral for postpartum depression was made by the Home Visitor. Please complete one chart for each referral made. If no referrals were made by Home Visitor, proceed to Additional Questions on page #4.

Client Access or Non-Access of Postpartum Depression Community Resources Please Check Applicable Columns Below

Referral #1: Specify Community Resource Referral:__________________________ Factors that Influenced Client Attendance: Positively Influenced Decision to

Attend Negatively Influenced Decision to

Attend Unknown

Distance from Client’s Home Availability of Transportation Cost of Attending Resource Ability to Understand Language at Resource Ability to Make Childcare Arrangements Resource had Waitlist Family Support to Attend Resource Client’s Perceived Benefit of Resource Attendance Other Reasons (Please Specify)




Attend Unknown


CID #:_______________________ 3

Additional Questions 1) In your opinion, was the mom’s post partum depression a contributing factor to closure?

□ Yes □ No □ Unknown If yes, please comment: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2) In your opinion, were there any other factors or issues that contributed to the mother’s postpartum depression?

□ Yes □ No □ Unknown If yes, please comment: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3) In your opinion, what was the greatest benefit that the Healthy Families Program had for your client? __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ 4) In your opinion, were there any other interventions that could have been undertaken to help your client address her postpartum depression?

□ Yes □ No □ Unknown If yes, please comment: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 5) If you have any other comments that you feel are important, please indicate them here: _________________________________________________________________________________________________ _________________________________________________________________________________________________ Completed By: _______________________ Date Completed: _________________

CID #:_______________________ 4


Ph: (403) 204-0800 Fax: (403) 204-0829

HOME VISITOR-CLIENT POSTPARTUM DEPRESSION SUPPORT SURVEY

INTENT: The purpose of this survey is to collect data about the supports and services




Mother’s Name:_____________________________ CID #:_______________________ Baby’s Name:____________________________________ Baby’s DOB:_____________ Home Visitor that Completed Screens: ________________________________

Screen Dates (as applicable) 1st Screen:_________ 2nd Screen:_________ 3rd Screen:_________



1. 2. 3. 4. 5. 6.

After the first positive screen and before the second screen where the second screen was positive □ After the first positive screen and before the second screen where the second screen was negative x After the first negative screen and before the second screen where the second screen was positive □ After the second positive screen and before the third screen where the third screen was positive □ After the second positive screen and before the third screen where the third screen was negative □ After the third positive screen to present □













YES NO DON’T KNOW

CID #:_______________________ 2





Attend Unknown





Attend Unknown


CID #:_______________________ 3

Additional Questions 1) In your opinion, were there any other factors or issues that contributed to the mother’s postpartum depression?

□ Yes □ No □ Unknown If yes, please comment: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2) In your opinion, if there was a change in the results of the first and second Edinburgh Screen, were there any specific events or circumstances that influenced this change?

□ Yes □ No □ Unknown If yes, please comment: __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ 3) In your opinion, what was the greatest benefit that the Healthy Families Program had for your client? __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ 4) In your opinion, were there any other interventions that could have been undertaken to help your client address her postpartum depression?

□ Yes □ No □ Unknown If yes, please comment: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 5) If you have any other comments that you feel are important, please indicate them here: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Completed By: _______________________ Date Completed: _________________

CID #:_______________________ 4


Ph: (403) 204-0800 Fax: (403) 204-0829


INTENT: The purpose of this survey is to collect data about the supports and services








1. 2. 3. 4. 5. 6.

After the first positive screen and before the second screen where the second screen was positive x After the first positive screen and before the second screen where the second screen was negative □ After the first negative screen and before the second screen where the second screen was positive □ After the second positive screen and before the third screen where the third screen was positive □ After the second positive screen and before the third screen where the third screen was negative □ After the third positive screen to present □













YES NO DON’T KNOW

CID #:_______________________ 2





Attend Unknown





Attend Unknown


CID #:_______________________ 3

Additional Questions 1) In your opinion, were there any other factors or issues that contributed to the mother’s postpartum depression?

□ Yes □ No □ Unknown If yes, please comment: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2) In your opinion, if there was a change in the results of the first and second Edinburgh Screen, were there any specific events or circumstances that influenced this change?

□ Yes □ No □ Unknown If yes, please comment: __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ 3) In your opinion, what was the greatest benefit that the Healthy Families Program had for your client? __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ 4) In your opinion, were there any other interventions that could have been undertaken to help your client address her postpartum depression?

□ Yes □ No □ Unknown If yes, please comment: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 5) If you have any other comments that you feel are important, please indicate them here: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Completed By: _______________________ Date Completed: _________________

CID #:_______________________ 4


Ph: (403) 204-0800 Fax: (403) 204-0829


INTENT: The purpose of this survey is to collect data about the supports

and services accessed by mothers who have screened positive for postpartum depression. Information obtained from this questionnaire will be used to better understand the services and supports accessed by these mothers.

TO COMPLETE: Supervisors are to distribute the packages to the Home Visitor (as

indicated below), who are to complete the forms in keeping with the time frames as specified below.





1. 2. 3. 4. 5. 6.

After the first positive screen and before the second screen where the second screen was positive □ After the first positive screen and before the second screen where the second screen was negative □ After the first negative screen and before the second screen where the second screen was positive x After the second positive screen and before the third screen where the third screen was positive □ After the second positive screen and before the third screen where the third screen was negative □ After the third positive screen to present □

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Questions for Home Visitor 1) In your opinion, were there any other factors or issues that contributed to the mother’s postpartum depression?

□ Yes □ No □ Unknown If yes, please comment: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2) In your opinion, were there any specific events or circumstances that influenced the mother’s change in scoring negative on the first screen to scoring positive on the second screen?

□ Yes □ No □ Unknown If yes, please comment: __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 3) In your opinion, what was the greatest benefit that the Healthy Families Program had for your client? __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ 4) If you have any other comments that you feel are important, please indicate them here: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Completed By: _______________________ CID #:_______________________ Date Completed: _________________

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