Postnatal Depression

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Postnatal Depression Postnatal Depression Dr Barbara Bavda Dr Barbara Bavda ž ž International Conference on International Conference on Women’s Health Women’s Health October 8th/10th 2009 October 8th/10th 2009 Nablus, Palestine Nablus, Palestine

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Postnatal Depression. Dr Barbara Bavda ž International Conference on Women’s Health October 8th/10th 2009 Nablus, Palestine. Childbearing. One of the most complex events in human experience Physical changes of childbirth Psychological changes of childbirth - PowerPoint PPT Presentation

Transcript of Postnatal Depression

Page 1: 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

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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

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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

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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

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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

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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’

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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

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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

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PNDPND

DepressedDepressed IrritableIrritable TiredTired   SleeplessSleepless   Lack of Appetite   AnhedoniaAnhedonia SexualitySexuality Unable to copeUnable to cope   GuiltyGuilty   AnxiousAnxious

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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

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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 !

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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

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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

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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

!!

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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

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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

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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

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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

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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

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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.)

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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

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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

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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

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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

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‘‘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

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‘‘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

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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

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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%)

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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

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*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?

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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

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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

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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

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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

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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

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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?

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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

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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

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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

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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...)

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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

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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

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‘‘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

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‘‘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

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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