Postnatal Depression
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Transcript of Postnatal Depression
Postnatal DepressionPostnatal Depression
Dr Barbara BavdaDr Barbara BavdažžInternational Conference on Women’s International Conference on Women’s HealthHealthOctober 8th/10th 2009October 8th/10th 2009Nablus, PalestineNablus, Palestine
ChildbearingChildbearing
One of the most complex events One of the most complex events in human experiencein human experience
Physical changes of childbirthPhysical changes of childbirth Psychological changes of Psychological changes of
childbirthchildbirth Increased vulnerability to general Increased vulnerability to general
psychiatric disorderspsychiatric disorders
Postnatal Depression Postnatal Depression (PND) or PPD(PND) or PPD World-wide. Affects about 13% of women within World-wide. Affects about 13% of women within
the first year of childbirththe first year of childbirth Cultural changes (stigma !). Greater awarenessCultural changes (stigma !). Greater awareness Information. Prevention. Can escape diagnosisInformation. Prevention. Can escape diagnosis Antenatal and postnatal “screening”Antenatal and postnatal “screening” Early interventionEarly intervention Multidisciplinary approachMultidisciplinary approach Mother-infant relationship and (can affect) child Mother-infant relationship and (can affect) child
growth and cognitive and emotional growth and cognitive and emotional development of the babydevelopment of the baby
Postnatal Depression in Postnatal Depression in the Developing Worldthe Developing World Attention tends to focus on seemingly Attention tends to focus on seemingly
more pressing health problemsmore pressing health problems Recent studies show 25-30 % new Recent studies show 25-30 % new
mothers (prevalence almost double)mothers (prevalence almost double) Mental health pays a central role in Mental health pays a central role in
maintaining physical health and maintaining physical health and development of the communitydevelopment of the community
Lower status relative to men, lack of Lower status relative to men, lack of autonomy, birth of a girl, poor housing, autonomy, birth of a girl, poor housing, isolation, povertyisolation, poverty
Postnatal Depression in Postnatal Depression in the Developing Worldthe Developing World
Environment more hostileEnvironment more hostile More infection, less sanitationMore infection, less sanitation Lot of pressure, unable to do all those Lot of pressure, unable to do all those
thingsthings Baby does not get all the nutrients; Baby does not get all the nutrients;
diarrhoea, losing vital nutrientsdiarrhoea, losing vital nutrients Does not respond appropriately to Does not respond appropriately to
child’s illness, not taking the baby to child’s illness, not taking the baby to be vaccinatedbe vaccinated
Postnatal Depression in Postnatal Depression in the Developing Worldthe Developing World In Ethiopia 10% die in their first year of life: In Ethiopia 10% die in their first year of life:
50-60% because they are malnourished and 50-60% because they are malnourished and don’t have the strength to fight the illnessdon’t have the strength to fight the illness
Projects asking local clinicians to use local and Projects asking local clinicians to use local and not Western standards to define mental not Western standards to define mental disorderdisorder
In Pakistan: ‘Lady Health Workers’ since 1994 In Pakistan: ‘Lady Health Workers’ since 1994 About 96,000 LHW cover more than 80% of About 96,000 LHW cover more than 80% of
Pakistan’s rural populationPakistan’s rural population Support through empathic listening and Support through empathic listening and
positive reinforcementpositive reinforcement ‘‘We are working for optimal health of the child’We are working for optimal health of the child’ ‘‘A healthy mother leads to a healthy child’A healthy mother leads to a healthy child’
Old ClassificationOld Classification
Under Three Headings:Under Three Headings: Maternity blues (30-75% 3-4 days Maternity blues (30-75% 3-4 days
after birth)after birth) Post-partum ( post-natal ) Post-partum ( post-natal )
depressiondepression Post-partum ( puerperal ) Post-partum ( puerperal )
psychosispsychosis
New classification New classification **
Four-part classification:Four-part classification: PsychosisPsychosis Mother-infant relationship disordersMother-infant relationship disorders DepressionDepression Anxiety and stress-related disordersAnxiety and stress-related disorders
* I. Brockington* I. Brockington
PNDPND
DepressedDepressed IrritableIrritable TiredTired SleeplessSleepless Lack of Appetite AnhedoniaAnhedonia SexualitySexuality Unable to copeUnable to cope GuiltyGuilty AnxiousAnxious
Postnatal Depression Postnatal Depression **
Non-psychotic depression with an onset Non-psychotic depression with an onset within 1 year of childbirth,within 1 year of childbirth,
But…But… A lay term ?A lay term ? Weak epidemiological association ( p/d )Weak epidemiological association ( p/d ) Common in adult women ( lower rates! )Common in adult women ( lower rates! ) HeterogeneousHeterogeneous group group Causal associations same as for depression Causal associations same as for depression
generallygenerally
** Ian Brokington, Univ. of Birmingham, UK Ian Brokington, Univ. of Birmingham, UK
Detection, Prevention, Detection, Prevention, Treatment Treatment InterventionsInterventions Reduce stigma, allow Reduce stigma, allow publicpublic recognition recognition E.I. / Prompt diagnosis and (prophylactic E.I. / Prompt diagnosis and (prophylactic
?) treatment?) treatment Antenatal clinics ( risk factors, history )Antenatal clinics ( risk factors, history ) Midwifes, (community) nurses, general Midwifes, (community) nurses, general
practitioners, health visitors practitioners, health visitors Voluntary agencies, groupsVoluntary agencies, groups Involvement of fathers, family membersInvolvement of fathers, family members Impact on infant well-being and Impact on infant well-being and
development !development !
Risk factorsRisk factors
Unwanted pregnancy (single w., Unwanted pregnancy (single w., adolescents, over forty)adolescents, over forty)
Young age (interruption of schooling and Young age (interruption of schooling and of personal growth, future poverty)of personal growth, future poverty)
Having three or more childrenHaving three or more children Single m. status or poor marital Single m. status or poor marital
relationshiprelationship Lower socioeconomic status (maternal Lower socioeconomic status (maternal
education protective factor)education protective factor) Low self esteemLow self esteem Substance abuseSubstance abuse
Risk factors Risk factors continue…continue…
Ante-natal depression or anxietyAnte-natal depression or anxiety Previous episode of postnatal depressionPrevious episode of postnatal depression History of depression or bipolar disorderHistory of depression or bipolar disorder Family history of PPDFamily history of PPD Gender of child (!)Gender of child (!) Recent stressful life eventsRecent stressful life events Inadequate social support (child care Inadequate social support (child care
stress)stress) Obstetric and pregnancy complicationsObstetric and pregnancy complications
Prevention and Prevention and detectiondetection General screening:General screening:-Use questionnaires e.g. -Use questionnaires e.g. EPDS ( “the whole EPDS ( “the whole
gamut of post-partum psychiatric disorders” ) gamut of post-partum psychiatric disorders” ) !!
-Explore wider context e.g. mother’s life -Explore wider context e.g. mother’s life history, personality circumstances !history, personality circumstances !
-Follow course of the pregnancy including -Follow course of the pregnancy including parturition, puerperium !parturition, puerperium !
-Assess quality and strength of relationships !-Assess quality and strength of relationships !-Identify vulnerability and availability of support -Identify vulnerability and availability of support
!!
Prediction and Prediction and DetectionDetection Healthcare professionals: Healthcare professionals:
midwives, obstetricians, health midwives, obstetricians, health visitors, GPs, community nurses, visitors, GPs, community nurses, voluntary agencies, (peer) voluntary agencies, (peer) groups,groups,
Pregnancy does not protect Pregnancy does not protect against depressionagainst depression
High relapse rates in those who High relapse rates in those who discontinue medicationdiscontinue medication
TreatmentTreatment
Should integrate both Should integrate both psychosocialpsychosocial and and biologicalbiological modalities modalities
Psychological support: hospital and community Psychological support: hospital and community nurses, health visitors, counsellors ( groups nurses, health visitors, counsellors ( groups and individual sessions, anxiety and individual sessions, anxiety management…) management…)
Social support: social workers, motherhood Social support: social workers, motherhood classes, o.t. (support workers), self help classes, o.t. (support workers), self help groups groups
Involvement of fathersInvolvement of fathers
Pharmacological treatmentPharmacological treatment
Risks of Not Treating Risks of Not Treating PPDPPD Harm to the mother throughHarm to the mother through1.1. Poor self-carePoor self-care2.2. Lack of obstetric careLack of obstetric care3.3. Self-harmSelf-harm
Harm to the foetus or neonate Harm to the foetus or neonate ranging fromranging from
1.1. Neglect toNeglect to2.2. infanticideinfanticide
Mild or Moderate Mild or Moderate Depression During Depression During Pregnancy or During Pregnancy or During Postnatal PeriodPostnatal Period
Self-help strategiesSelf-help strategies Non-directive counsellingNon-directive counselling Brief cognitive-behavioural Brief cognitive-behavioural
therapy or interpersonal therapy or interpersonal psychotherapypsychotherapy
Treatment with Ad’s. The Treatment with Ad’s. The Maudsley Maudsley RecommendationsRecommendations Those who are already receiving ADThose who are already receiving AD Those who develop a moderate or severe Those who develop a moderate or severe
depressive illnessdepressive illness1.1. Psychological managementPsychological management2.2. Ad - tricyclics (amitript., imipr., nortript.)Ad - tricyclics (amitript., imipr., nortript.) - SSRIs (avoid paroxetine/first - SSRIs (avoid paroxetine/first
trimester/linked to cardiac malformations!)trimester/linked to cardiac malformations!) - fluoxetine has the lowest known risk- fluoxetine has the lowest known risk Continue breast-feeding and switch to Continue breast-feeding and switch to
mixed (breast/bottle) feedingmixed (breast/bottle) feeding All AD carry the risk of withdrawal or All AD carry the risk of withdrawal or
toxicity toxicity
Resources and Resources and ServicesServices Aims= prevention, early diagnosis, Aims= prevention, early diagnosis,
versatile intervention with minimal versatile intervention with minimal family disruption (community based…)family disruption (community based…)
The multidisciplinary specialist team:The multidisciplinary specialist team: psychiatrists, psychologists, nurses psychiatrists, psychologists, nurses
and nursery nurses, social workers (Ts)and nursery nurses, social workers (Ts) Voluntary agencies, self-help groups, Voluntary agencies, self-help groups,
leaflets and booklets (RCPsych, MIND leaflets and booklets (RCPsych, MIND in U.K.)in U.K.)
State of Art in the State of Art in the WorldWorld Domiciliary assessment and home Domiciliary assessment and home
treatmenttreatment Day hospital ( putting women with similar Day hospital ( putting women with similar
problems in touch with each other )problems in touch with each other ) Mother and baby units, linked to obstetric Mother and baby units, linked to obstetric
units and paediatric units in UK, units and paediatric units in UK, Australia, New Zealand, France, Germany, Australia, New Zealand, France, Germany, Belgium, The NetherlandsBelgium, The Netherlands
Italy: Trieste Italy: Trieste Service evaluation/research need to be Service evaluation/research need to be
implementedimplemented
Psychological Psychological Intervention in High Risk Intervention in High Risk PregnancyPregnancy IRCCS Burlo Garofolo- Department of Obstetrics and IRCCS Burlo Garofolo- Department of Obstetrics and
Gynaecology Dr Viviana Ive, psychologist, Gynaecology Dr Viviana Ive, psychologist, psychotherapistpsychotherapist
Centre for High Risk Pregnancy: pre-eclampsia, multiple Centre for High Risk Pregnancy: pre-eclampsia, multiple pregnancy, previous pregnancy with intrauterine death or pregnancy, previous pregnancy with intrauterine death or previous interruption caused by severe delay in foetal previous interruption caused by severe delay in foetal growth, elective medical abortion growth, elective medical abortion
Multidisciplinary integrated team to support women before Multidisciplinary integrated team to support women before
pregnancy and monitor during pregnancy, in order to reduce pregnancy and monitor during pregnancy, in order to reduce at most the risks (for health) of mother and baby. Centred at most the risks (for health) of mother and baby. Centred on physical health, emotional and psychological healthon physical health, emotional and psychological health
Coordinated by one Psychologist/PsychotherapistCoordinated by one Psychologist/Psychotherapist
Psychological Psychological Intervention in High Risk Intervention in High Risk Pregnancy Pregnancy 22 Referrals: Referrals: from medical staff or midwife, who offer the from medical staff or midwife, who offer the
possibility of psych. intervention), sometimes requested possibility of psych. intervention), sometimes requested directly by the women.directly by the women.
Assessments: Assessments: on ward if urgent, alternatively opa’s on ward if urgent, alternatively opa’s Crisis intervention Crisis intervention (on ward): intra-uterine death or peri-(on ward): intra-uterine death or peri-
natal deathnatal death communication of dubious or communication of dubious or
poor prognosis (after echography)poor prognosis (after echography) emotional distress during emotional distress during
pregnancy (panic attacks, phobias, pregnancy (panic attacks, phobias, mood disordersmood disorders)) traumatised by parturitiontraumatised by parturition post-natal emotional distress post-natal emotional distress
(difficulties in relating with newborn baby)(difficulties in relating with newborn baby) Intensive psychological intervention during hospital admission. Intensive psychological intervention during hospital admission.
Some women need further care and follow up in OPC.Some women need further care and follow up in OPC. Network intervention: Network intervention: the hospital social service and the the hospital social service and the
community based servicescommunity based services
Psychological Psychological Intervention in High Risk Intervention in High Risk Pregnancy Pregnancy 33 OPAOPA CounsellingCounselling and and psychotherapy,psychotherapy, focussed focussed on on
bereavement (with disfunctional features), emotional bereavement (with disfunctional features), emotional disturbance in pregnancy (anxiety, mood disorders) disturbance in pregnancy (anxiety, mood disorders) oror post- natal depression post- natal depression, difficulties in , difficulties in relationship with baby or marital problems, PTSDrelationship with baby or marital problems, PTSD
Network intervention:Network intervention: hospital social service, hospital social service, community based services (CMHTs, PCTs, Social community based services (CMHTs, PCTs, Social Services, GPs, Alcohol and Substance Misuse Services, GPs, Alcohol and Substance Misuse Services)Services)
AimsAims of intervention: of intervention: to provide care, support, to provide care, support, containment and elaboration of pain caused by any containment and elaboration of pain caused by any pathological condition, foetal death, emotional pathological condition, foetal death, emotional distress; to allow sufficient or good care to new born distress; to allow sufficient or good care to new born baby in any circumstancesbaby in any circumstances
‘‘Synergic Effects of Oxytocin andSynergic Effects of Oxytocin andPsychotherapy in Postpartum Psychotherapy in Postpartum Depression’ Depression’ 11
A 3 year randomized controlled trialA 3 year randomized controlled trialon 150 women; area of intervention is the province of on 150 women; area of intervention is the province of TriesteTrieste
Financed by the Department of Reproductional and Financed by the Department of Reproductional and Developmental ScienceDevelopmental Science
-Dr. Andrea Clarici - MD - Senior Lecturer at the -Dr. Andrea Clarici - MD - Senior Lecturer at the University of Trieste Faculty of MedicineUniversity of Trieste Faculty of Medicine(IRCCS Paediatric Hospital Burlo Garofolo, Trieste).(IRCCS Paediatric Hospital Burlo Garofolo, Trieste).-Dr. Sandra Pellizzoni - Psychologist - Postgraduate -Dr. Sandra Pellizzoni - Psychologist - Postgraduate student at thestudent at theIRCCS Paediatric Hospital Burlo Garofolo TriesteIRCCS Paediatric Hospital Burlo Garofolo Trieste
‘‘Synergic Effects of Oxytocin andSynergic Effects of Oxytocin andPsychotherapy in Postpartum Depression’ Psychotherapy in Postpartum Depression’ 22
Hypothalamic neuropeptide implicated in Hypothalamic neuropeptide implicated in regulation of social, reproductive and stress-regulation of social, reproductive and stress-related functionsrelated functions
A key role in intimate attachment such as A key role in intimate attachment such as marital relationship and early interaction with marital relationship and early interaction with offspringoffspring
Twofold effect: to strengthen attachment and Twofold effect: to strengthen attachment and reduce stressreduce stress
Referrals from paediatricians, obstetricians Referrals from paediatricians, obstetricians and midwifesand midwifes
Two random groups: psychotherapy and Two random groups: psychotherapy and Oxytocin vs. psychotherapy and placeboOxytocin vs. psychotherapy and placebo
Depression, post-partum, Depression, post-partum, violenceviolence 11
Trieste, IRCCS-Burlo G. – Psychology Dept. Trieste, IRCCS-Burlo G. – Psychology Dept. University of Trieste and University of University of Trieste and University of California in San FranciscoCalifornia in San Francisco
Study on 352 women, mean age 32, Study on 352 women, mean age 32, September 2004 to March 2005September 2004 to March 2005
Part 1: two questionnairesPart 1: two questionnaires (Common) violence acted by partner or family (Common) violence acted by partner or family
membermember Leads to depression, anxiety, low self esteem, Leads to depression, anxiety, low self esteem,
has negative impact on physical and mental has negative impact on physical and mental health (well being) of both, mother and childhealth (well being) of both, mother and child
Depression, post-partum, Depression, post-partum, violenceviolence 22
8 months after giving birth 10% of 8 months after giving birth 10% of women experience domestic violence women experience domestic violence (psychological, sexual, physical)(psychological, sexual, physical)
5% high levels of psychophysical 5% high levels of psychophysical distress with depressiondistress with depression
Incidence of depression x13 higher in Incidence of depression x13 higher in those who experience intrafamilial those who experience intrafamilial violence (27,6% vs. 2,7%)violence (27,6% vs. 2,7%)
PPD and employmentPPD and employment 33
8 months later 32% not satisfied with 8 months later 32% not satisfied with current occupational situation GHQ-current occupational situation GHQ-12*12*
No difference between those at home No difference between those at home and those at workand those at work
Significant the congruence between Significant the congruence between reality and desired situationreality and desired situation
Employment dissatisfaction negatively Employment dissatisfaction negatively associated with woman’s health after associated with woman’s health after childbirthchildbirth
*General Health *General Health Questionnaire (GHQ-12)Questionnaire (GHQ-12) General Health Questionnaire (GHQ-12)General Health Questionnaire (GHQ-12) We would like to know how your health has been in general, We would like to know how your health has been in general,
over the past few weeks.over the past few weeks.
Please answer the following questions by circling the Please answer the following questions by circling the number that best applies to you.number that best applies to you.
Have you recently….Have you recently….
……much less than usual-same as usual-more than usual-much much less than usual-same as usual-more than usual-much more than usual…more than usual…
Been able to concentrate on whatever you are doing? Lost much Been able to concentrate on whatever you are doing? Lost much sleep over worry? Felt that you were playing a useful part in things? sleep over worry? Felt that you were playing a useful part in things? Felt capable of making decisions about things? Felt constantly under Felt capable of making decisions about things? Felt constantly under strain? Felt that you couldn't overcome your difficulties? Been able strain? Felt that you couldn't overcome your difficulties? Been able to enjoy your normal day-to-day activities? Been able to face up to to enjoy your normal day-to-day activities? Been able to face up to your problems? Been feeling unhappy and depressed? Been losing your problems? Been feeling unhappy and depressed? Been losing self-confidence in yourself? Been thinking of yourself as a worthless self-confidence in yourself? Been thinking of yourself as a worthless person? Been feeling reasonably happy, all things considered? person? Been feeling reasonably happy, all things considered?
NHS- Mother & Baby Unit NHS- Mother & Baby Unit (Thumbswood)(Thumbswood) 11
Hertfordshire, Welwyn G.C., QE II Hertfordshire, Welwyn G.C., QE II HospitalHospital
Purpose-built, self-contained unitPurpose-built, self-contained unit Provide specialist assessmnet, Provide specialist assessmnet,
care and treatment for mothers care and treatment for mothers suffering from mental illnesses suffering from mental illnesses associated with childbirth (as early associated with childbirth (as early as possible)as possible)
Support to families and carersSupport to families and carers
NHS- Mother & Baby Unit NHS- Mother & Baby Unit (Thumbswood)(Thumbswood) 22
Provide a joint service between health Provide a joint service between health and social care professionalsand social care professionals
Ensure comprehensive follow-up careEnsure comprehensive follow-up care Sensitive to cultural differences in Sensitive to cultural differences in
parenting practicesparenting practices Sustain and facilitate the developing Sustain and facilitate the developing
relationship between mother and baby relationship between mother and baby and other family membersand other family members
MDT, liaison with Health Visitors, GPs, MDT, liaison with Health Visitors, GPs, and Community Servicesand Community Services
NHS- Mother & Baby Unit NHS- Mother & Baby Unit (Thumbswood)(Thumbswood) 33
ReferralsReferrals from any area but exclusively from any area but exclusively from GP, consultant psychiatrist, from GP, consultant psychiatrist, maternity within QE II Hospitalmaternity within QE II Hospital
TreatmentTreatment: education, O.T., : education, O.T., psychotherapy, postnatal groups, baby psychotherapy, postnatal groups, baby massage sessions, cooking, practical massage sessions, cooking, practical guidance, empowerment and ventilation guidance, empowerment and ventilation of feelings, fathers’ group, weekly of feelings, fathers’ group, weekly review; on-site support from midwives, review; on-site support from midwives, obstetricians, gynaecologists, obstetricians, gynaecologists, paediatricianspaediatricians
NHS- Mother & Baby NHS- Mother & Baby UnitsUnits November 27th 2008 1st annual forum November 27th 2008 1st annual forum
for the Quality Network for Perinatal for the Quality Network for Perinatal Mental Health ServicesMental Health Services
13 mother and baby units from across 13 mother and baby units from across the countrythe country
Emergency admissions, admissions in Emergency admissions, admissions in late pregnancy, involvement of late pregnancy, involvement of specialised community teams, safety specialised community teams, safety and formal physical assessment of and formal physical assessment of infantsinfants
Mind.org.uk; Perinatal.nhs.uk; Mind.org.uk; Perinatal.nhs.uk; Cemach.org.ukCemach.org.uk
Community Based Community Based ServiceServiceASS1 Trieste and ASS1 Trieste and ‘Percorso Nascita’ since ‘Percorso Nascita’ since 1997-20021997-2002 Based in Consultorio Familiare (Family Based in Consultorio Familiare (Family
Planning Clinics) in each Health DistrictPlanning Clinics) in each Health District Support in non problematic (physiologic) Support in non problematic (physiologic)
pregnancypregnancy Antenatal classes, postnatal classes, advice Antenatal classes, postnatal classes, advice
through breastfeeding; vaccinationsthrough breastfeeding; vaccinations Cervical screening; menopause clinics; breast Cervical screening; menopause clinics; breast
cancer prevention-self examinationcancer prevention-self examination Direct access; privacy and confidentiality for Direct access; privacy and confidentiality for
under 18under 18; teen pregnancy; teen pregnancy (Illegal) immigrant women and the most (Illegal) immigrant women and the most
vulnerable situationsvulnerable situations
Percorso NascitaPercorso Nascita
Midwife has a central and independent role (max. Midwife has a central and independent role (max. autonomy!), collaborating (when necessary) with autonomy!), collaborating (when necessary) with gynaecologistgynaecologist
3 groups monthly, each with 20 participants. Increasing 3 groups monthly, each with 20 participants. Increasing number.number.
Assessments, referrals, home visits when needed, visits Assessments, referrals, home visits when needed, visits to mother and baby after discharge from hospitalto mother and baby after discharge from hospital
Network with other community based servicesNetwork with other community based services High users’ satisfaction : continuity, accessibility; High users’ satisfaction : continuity, accessibility;
multidisciplinary, positive, constructive, optimistic multidisciplinary, positive, constructive, optimistic approach, users’ centred, shaped on needsapproach, users’ centred, shaped on needs
Connected with other health and social services Connected with other health and social services (e.g.DSM)(e.g.DSM)
Baby blues, no PND recalled by the staff; is that Baby blues, no PND recalled by the staff; is that prevention?prevention?
Services network? Accessibility?Services network? Accessibility?
Primary Health Care - Primary Health Care - Now More than Ever Now More than Ever (WHO)(WHO) 44 year discrepancy between 44 year discrepancy between
industrialized and developing industrialized and developing countriescountries
58 million on 136 mothers of new 58 million on 136 mothers of new born babies without sanitary born babies without sanitary assistanceassistance
Public health costs p.p./ per year vary Public health costs p.p./ per year vary between 20 and more than 6 between 20 and more than 6 thousandthousand
U.S.dollars U.S.dollars
Primary Health Care - Primary Health Care - Now More than Ever Now More than Ever (WHO)(WHO) Infant mortality rate (IMR) under Infant mortality rate (IMR) under
5y. varies even within same city 5y. varies even within same city (Nairobi) from 1,5 to 25,4 per cent(Nairobi) from 1,5 to 25,4 per cent
Lack of drinkable water, Lack of drinkable water, vaccination, nutritionvaccination, nutrition
Primary health carePrimary health care Integrated community servicesIntegrated community services Holistic approachHolistic approach
Primary Health Care - Primary Health Care - Now More than Ever Now More than Ever (WHO)(WHO) Prevention as important as curePrevention as important as cure GPs at the coreGPs at the core Equity, accessibility, efficiencyEquity, accessibility, efficiency Guidelines to develop health systems:Guidelines to develop health systems:
-available to everyone-available to everyone
-person centred-person centred
-integrated approach-integrated approach
-political leadership -political leadership
Immigrants and PNDImmigrants and PND
In Italy, 50% are womenIn Italy, 50% are women Isolation, lack of social support, poor Isolation, lack of social support, poor
knowledge of language and culture, knowledge of language and culture, stress, housing problems, young age, stress, housing problems, young age, victims of genital mutilationvictims of genital mutilation
Specific approach and service Specific approach and service provisionprovision
‘‘Dakar-Fann School’ meet under the Dakar-Fann School’ meet under the village tree (patient, carers, friends, village tree (patient, carers, friends, professionals...)professionals...)
Illegal Immigrant Illegal Immigrant Pregnant WomenPregnant Women The most vulnerable group of The most vulnerable group of
immigrantsimmigrants Often mother of other children (one Often mother of other children (one
or more)or more) In Italy has the right to health care In Italy has the right to health care
in pregnancyin pregnancy STP (foreigner, temporarily in Italy)STP (foreigner, temporarily in Italy) Interpreter for small groupsInterpreter for small groups
Traditional Traditional Communities in AfricaCommunities in Africa During pregnancy and after birth During pregnancy and after birth
care and support to mothercare and support to mother Whole village involvedWhole village involved Minimum rates of PPDMinimum rates of PPD Urbanization brings consequences Urbanization brings consequences
as reduced solidarity and isolationas reduced solidarity and isolation Increased rates of PPDIncreased rates of PPD
‘‘A Very Positive Impact’A Very Positive Impact’
Successful athletes, politicians, Successful athletes, politicians, writers, intellectuals after giving writers, intellectuals after giving birth or breastfeedingbirth or breastfeeding
Cultural and social circumstancesCultural and social circumstances Postpartum wellness, joy, positive Postpartum wellness, joy, positive
feelings, physical energiesfeelings, physical energies When pregnancy is a planned When pregnancy is a planned
choice and based on a strong choice and based on a strong relationshiprelationship
‘‘A world that is unequal as regards health A world that is unequal as regards health provisions, is unstable and unsafe.’provisions, is unstable and unsafe.’
BAN KI-MOONBAN KI-MOON WHO Secretary GeneralWHO Secretary General
Thank youThank you
Thanks to dr Daniela Gerin, gynaecologist Thanks to dr Daniela Gerin, gynaecologist and coordinator of the project Salute Donna and coordinator of the project Salute Donna ASS1 TriesteASS1 Trieste
Claudia Massopust, senior midwife, District 4, Claudia Massopust, senior midwife, District 4, ASS1 Trieste and her very kind colleague ASS1 Trieste and her very kind colleague Chiara MenegolliChiara Menegolli
Special thanks to Ms Martina Kalc mother of Special thanks to Ms Martina Kalc mother of Filip born on September 4th 2009 and who Filip born on September 4th 2009 and who lost her first baby during pregnancy in 2007 lost her first baby during pregnancy in 2007