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Enablers and barriers to seeking help for a postpartum mood disorder Foulkes, Michelle 2011

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TITLE: Enablers and barriers to seeking help for a postpartum mood disorder RUNNING HEAD: “Enablers and Barriers”  Michelle Foulkes, RN BA BScN MSc CPMHN(c) PhD(c) NP-PHC(student) Advanced Practice Nurse Inpatient Psychiatry and Eating Disorders Program 401 Smyth Road Ottawa, ON K1H 8L1 “Enablers and Barriers” 1  Enablers and barriers to seeking help for a postpartum mood disorder                  Key words:  postpartum mood disorders, help-seeking behaviours, barriers, enablers  ABSTRACT Objective:  To explore the barriers and enablers identified by women experiencing a postpartum mood disorder (PPMD) that both preclude and facilitate their help-seeking behaviours for this often devastating illness. Design:  A qualitative study using a grounded theory approach Setting:  Well-Baby Clinics offered through the Public Health Department, Early Years Centres, Mothercraft and a Parent Resource Centre in a large Canadian city. Participants:  Ten women who had either been formally diagnosed as having a PPMD or who self-identified as experiencing a constellation of symptoms indicative of a PPMD  Methods:  Interviews that were transcribed verbatim and analyzed using a grounded theory approach as described by Strauss and Corbin (1998). Results:  The core category of ‘Having postpartum’ captured the essence of women’s experiences in seeking help for a PPMD.  Women identified four main stressors that contributed to their development of a PPMD, two barrier categories and an enabler category which influenced their help-seeking behaviours.   Through navigation of both formal and informal help, women were able to begin the journey to reclaim the mothering soul they had lost to mental illness.   Conclusions:  Pregnancy, birth and becoming a mother collectively represent a critical period of physical and emotional upheaval in a woman’s life.  The need for a holistic care approach that supports the emotional and physical health of the dyad is imperative.     “Enablers and Barriers” 2  Callouts  1.  Postpartum mood disorders represent a complex class of illnesses that may result in serious implications for new mothers but can also consume those around her.  2. This use of the label of ‘having postpartum’ provides safety for women in a society where the stigma around mental illness remains deeply entrenched.    3. Women need their physical health monitored appropriately but also need emotionally supportive care that values and honours the needs of both women and their babies.      “Enablers and Barriers” 3    The development of maternal mood disturbances in the postpartum period is not a 1 newly emergent phenomenon but rather has been noted as early as the 5th century B.C. in 2 the works of Hippocrates (Ugarriza, 2002).  In current times, several distinct mood and 3 anxiety disorders have been identified during the postnatal period each with unique 4 presentations and symptoms including maternal “blues”, postpartum depression (PPD), 5 postpartum psychosis, postpartum anxiety disorders, bipolar disorders and post traumatic 6 stress disorder secondary to birth trauma  (Beck & Driscoll, 2006).   7 Although women may experience a broad range of psychiatric symptoms following 8 birth and while mothering, maternal “blues”, PPD and postpartum psychosis collectively 9 fall under the umbrella term of postpartum mood disorders (PPMDs)  (Beck & Driscoll, 10 2006) although it should be understood that they are distinct disorders requiring different 11 intervention and support.   The focus of this study has been on women’s experiences with 12 seeking help for a mood disturbance (PPMD) that may have developed after giving birth.  13 Where appropriate, the term PPD has been substituted for PPMD to accurately reflect the 14 terminology used in the literature reviewed.  Post traumatic stress disorder secondary to 15 birth trauma will also be considered given its relevance to the findings of this study 16 The incidence rate for PPD varies anywhere between 10-40% worldwide 17 (Holopainen, 2002).   More commonly however, it is estimated that approximately 10-18 15% of new mothers experience a mood disorder and is the most frequently occurring 19 illness experienced by women in the puerperium (Barr, J.A., 2006; Pearson, R.M., 20 Cooper, R.M., Penton-Voak, I.S., Lightman, S.L. & Evans, J., 2010). Diagnosis for a 21 PPD is currently subsumed under the Diagnostic and Statistical Manual of Mental 22 Disorders, 4th Edition (DSM-IV-TR) criteria for major depression with a modifier that 23 “Enablers and Barriers” 4  specifies symptoms must begin within four weeks of delivery (American Psychiatric 24 Association, 2000).  In practice, however, it is generally accepted that PPD may develop 25 any time in the first year after giving birth  (Goodman, 2004).    26 Women may also experience posttraumatic stress disorder secondary to birth 27 trauma which presents with a unique configuration of symptoms that may include 28 extreme fear, panic, dissociation, and flashbacks (Beck & Driscoll, 2006).  Within the 29 literature, it is estimated that between 1.5 and 6% of mother’s experience a posttraumatic 30 stress disorder (PTSD) after childbirth (Beck, 2004).  PTSD after childbirth does not have 31 a distinct diagnostic category in the DSM-IV-TR but the experience can be defined as a 32 traumatic event resulting in PTSD which may manifest itself as profound anxiety, 33 depression, hopelessness, fear, and constant arousal deeply affecting a woman’s mental 34 health.  Because of the affective elements of the disorder, it does share some 35 commonalities with PPMDs.   36 For women experiencing a PPMD, symptoms may persist for months and even 37 years if left untreated with an increased incidence of self-medication for relief of the 38 debilitating symptoms that define these disorders (e.g. alcohol abuse) (Beck & Driscoll, 39 2006).  This single psychiatric event may also be the launch of continuing and recurrent 40 mental illness over the long-term and significantly reduce a woman’s functioning 41 capacity and her overall quality of life (Forman, Videbech, Hedegaard, Salvig & Secher, 42 2000).  Women who experience a PPMD also have a 50% higher risk of developing it 43 again in subsequent pregnancies (Gold, 2002; The Maternity Center Association, 2002). 44 For her infant, both short-term and long-term sequelae from exposure to maternal 45 mood disturbances may ensue with an increased risk for neglect, higher accident and 46 “Enablers and Barriers” 5  hospitalization rates, increased incidence of non-organic failure to thrive, social and 47 affective disorders and cognitive delays noted (Field, T., 2010, Gao, W., Paterson, J., 48 Abbott, M., Carter, S., Iusitini,  L., 2007; Tough, S.C., Siever, J.E., Leew, S., Johnston, 49 D.W., Benzies, K., & Clark, D., 2008).  Mothers with mood disturbances often present 50 with a flat affect and show less contingency responsiveness towards their infants (Beck & 51 Driscoll, J.W., 2006).  Overtime, infants of these mentally ill mothers develop an 52 interaction style that “mimics” that of their mothers (Cohen, L.S. & Nonacs, R.M., 2005).  53 By 12-18 months of age, cognitive delays, particularly for male children, are often 54 apparent (Tronick, E., 2007). 55 Longitudinal studies have evaluated the emotional, cognitive and behavioural 56 effects of exposure to maternal mood disturbances and have indicated that the effects are 57 enduring. By age 11, both male and female children present with lower IQ scores, 58 attention problems, conduct disorders, and difficulties in mathematical reasoning (Hay, 59 Pawlby, Sharp Asten, Mills & Kumer, 2001).  For the family as a whole, a PPMD can 60 exert significant influence on the dynamics within the unit and ultimately may result in 61 increased marital discord further disabling the functioning, development, and quality of 62 life for all family members (Beck, 1999; Meighan, Davis, Thomas & Droppleman, 1999).   63 Therefore, PPMD’s represent a complex and multi-faceted class of illnesses that may 64 result in serious implications for new mothers but can also cascade to consume and 65 threaten those around her (Gold, 2002).   66 Because the presence of a PPMD can have such a significantly negative impact on 67 health, a qualitative study was proposed that asked the central question: “What are the 68 perceived barriers and enablers identified by women that preclude and facilitate their 69 “Enablers and Barriers” 6  seeking help for a postpartum mood disorder?”  This broad and open-ended research 70 question directed the research process and served as the focus around which all data were 71 collected and analyzed to ultimately allow us a better understanding of the enablers and 72 barriers for women to seeking help for a PPMD given the deleterious consequences on 73 women, children and families.  74 Method 75 At present, our understanding of help-seeking behaviours in women experiencing a 76 PPMD remains largely undeveloped.  Grounded theory is a recommended method of 77 inquiry for areas where little previous research has been done on the phenomena of 78 interest (Strauss & Corbin, 1998).   The use of a grounded theory approach is also 79 compatible with nursing’s epistemological goals of generating nursing knowledge, 80 promoting theory development, and informing practice (McCreaddie & Payne 2010; 81 Meleis, 2005).  Therefore, the use of grounded theory as a means of increasing our 82 knowledge of the perceived barriers and enablers that direct women’s help-seeking 83 behaviours is congruent with the purpose and objectives of this study.  84 Data Collection: Following ethics approval, posters and flyers were distributed to 85 several Well-Baby Clinics offered through the Public Health Department (PHD), two 86 Ontario Early Year’s Centres, Mothercraft, and a Parent Resource Centre where a 87 Postpartum Depresion Support Group (M.O.M.’s) was based. A public health nurse 88 (PHN) served as a liaison to direct and facilitate the recruitment of interested participants 89 at Well-Baby Clinics.  The inclusion criteria for participation in the study included:  a) 90 women had to be at least 18 years of age b) English speaking c) had given birth to a 91 healthy, full-term infant within the last 24 months  d) no history of a serious pre-existing 92 “Enablers and Barriers” 7  psychiatric illness prior to the development of a PPMD e)  been formally diagnosed as 93 having a PPMD by a physician or f) not have been formally diagnosed with a PPMD by a 94 physician but who were experiencing symptoms which they identified as intrusive and 95 disabling to their functioning as mothers.  All the women who self-identified as having a 96 PPMD did experience some combination of symptoms which included extreme sadness 97 and tearfulness, irritability, thoughts of harming themselves or their infants, difficulty 98 concentrating, weight loss or gain that was not explained by normal somatic changes 99 associated with the postpartum period, or sleep difficulties which were not related to 100 infant care issues. 101  Recruitment to the study began in October 2003 and continued through to 102 February 2004 when it was determined that theoretical saturation had been achieved.  In 103 the end, 10 women who met the inclusion criteria participated in the study. A purposeful 104 sampling technique was used at the beginning of the research project which was then 105 superseded by theoretical sampling (Bryant & Charmaz, 2007).  Two participants were 106 recruited through the PHD, 2 through the postpartum depression support group 107 (M.O.M.’s), 1 through referral by a doula who had seen the recruitment poster and 5 108 through snowballing.   109 A semi-structured interview guide was developed to provide some direction to the 110 researcher but during interviews women were invited to openly tell their stories to ensure 111 their voices were heard and their experiences shared without a rigid adherence to the 112 interview guide (Charmaz, 2006).  Each interview started with the broad opening 113 question of ‘tell me what you pregnancy was like” which served as a port of entry into 114 this significant experience in a woman’s life.  All interviews were completed by a single 115 “Enablers and Barriers” 8  researcher and conducted in the participant’s homes at their request. At the end of the 116 first interview, all of the women were asked and agreed to participate in a second 117 interview to provide a ‘member check’ and validate the findings following analysis of the 118 data.  All taped interviews were transcribed verbatim by the researcher to ensure further 119 immersion in the data.  Observational notes and journal reflections were maintained 120 throughout data collection and analysis to supplement the in-depth interviews (Charmaz, 121 2006).  These served as important resources during data analysis to stimulate further 122 ideas and discussion between the researcher and her supervisor as well as the thesis 123 committee. 124 Data Analysis:  Data analysis occurred through the ‘constant comparative method’ 125 with data being analyzed in a circular fashion in keeping with the methods described by 126 Strauss and Corbin (1998).  Data were collected and analyzed concurrently with labelling 127 of the data beginning immediately after each interview had taken place to allow the 128 researcher to become sensitive to the incoming conceptual ideas.  Transcripts were 129 reviewed line-by-line with each discreet idea or concept given a label. Where it was 130 possible, in vivo codes or direct quotations from the data were used to better represent the 131 emerging conceptual ideas (Strauss & Corbin, 1998).  Emerging concepts were clustered 132 together and then collapsed into more abstract categories as analysis progressed. During 133 the final level of analysis, the core category was selected and the relationships between 134 all other major categories were filled in.  All of the initial interviews were coded by the 135 researcher and her thesis supervisor together.  After the first set of interviews were 136 completed and analyzed, the findings were then reviewed with the researcher’s thesis 137 supervisor and committee members together to check for logical flow of the findings.   138 “Enablers and Barriers” 9  In order to ensure the quality of a grounded theory study, four criteria must be 139 present (Glaser & Strauss, 1967, p. 237).  These properties include:  fitness, 140 understanding, generality, and control.  The criteria of fit and understanding were met by 141 doing ‘member checks’ to ensure participants could provide comments on the emerging 142 theory.  All of the participants were contacted within 6 months of their first interview to 143 allow for feedback and validation of emerging themes.  Peer debriefing with nursing 144 colleagues also provided an avenue for reflection and evaluation.  Both participants and 145 colleagues provided feedback that indicated that the theory was easy to understand and 146 ‘resonated’ with both their personal and professional experiences.  147    The property of generality was met by gathering both sufficient amounts of data 148 from a diversity of sources which included not only information from participants but 149 also through ongoing consultation with several public health and mental health nurses.  150 The final criterion of control was attained by developing both general and specific 151 interventions to direct care around pregnancy and the postnatal period for potential users 152 of the substantive theory to help in the management of a woman with a developing or 153 present PPMD.         154 Ethical Considerations and Approval:  After receiving approval from the 155 affiliated University Human Ethics Board, ethical approval was then sought from the 156 Public Health Department (PHD) Human Ethics Board of a large Canadian city. Given 157 the sensitive nature of examining PPMD’s, an action plan was developed to assess 158 whether women were experiencing either no distress, mild distress, moderate distress, or 159 severe emotional distress.  Women were assessed using a basic mental health status exam 160 to evaluate such factors as thought content and safety in relation to themselves and their 161 “Enablers and Barriers” 10  children to determine whether inclusion within the study was appropriate.  Within this 162 sample, the only intervention that was necessary for the participants was to provide 163 psycho-educational support.  Informed consent was obtained from all study participants 164 and each participant was given an identification number for purposes of anonymity.  The 165 tapes and transcripts have been locked in a safe location and will be destroyed 7 years 166 after completion of this research project.  167 Findings 168 Participants:  The 10 women who participated in this study were a relatively 169 homogenous sample.  They were mature (mean age=32.6 years with a standard deviation 170 of 2.011), well educated, Caucasian and economically middle-class.  All of the 171 participants were married and English speaking with the exception of one woman whose 172 first language was French although she was fluently bilingual.  173 At the time of the first interview, 6 of the participants had 2 children, 2 of the 174 participants had 1 child but both were in their 3rd trimester of a second pregnancy, and 2 175 of the women had a single child. The ages of the children at the time of the first interview 176 ranged from 7 months to 3 years.  Two of the 6 participants who had 2 children at the 177 time of the first interview had experienced a PPMD after each baby.  Two of the 178 participants with 2 children experienced a PPMD after the first baby only.  One of the 179 participants with 2 children experienced a PPMD after the second child only.  One 180 participant with 2 children experienced a PPMD that began after the first child and did 181 not resolve through the second pregnancy and continues to be treated.  At the time of the 182 second interview, both mothers who were pregnant at the first interview had given birth 183 to their second children and both were experiencing significant symptoms of a PPMD 184 “Enablers and Barriers” 11  again.  Of the two remaining participants who had single children, one woman had 185 consciously decided not to get pregnant again as a direct result of her experience with a 186 PPMD.  The remaining mother was in the process of planning her second pregnancy but 187 was methodically reviewing her experience to arrange and organize for the appropriate 188 resources to be in place before she would actively attempt a pregnancy again.  The ages 189 of the children at the time of the second interview ranged from 3 weeks to 3 ½ years.   190 In terms of use of obstetrical service providers, 5 of the participants had shared care 191 with their family physicians and obstetricians, 2 received care from their family 192 physicians and obstetricians while employing the additional services of a doula, and the 193 remaining 3 participants used midwife services exclusively.  Eight women gave birth 194 vaginally and 2 delivered by caesarean delivery.  All of the participants initiated breast-195 feeding while in hospital.  Of the 10 women in the study, 8 sought out professional help 196 while 2 relied exclusively on the support of lay others for resolution of their PPMD.  All 197 8 who received professional attention were diagnosed as having a mood disorder and 198 were prescribed pharmacological therapy for their illness.  Of the eight women prescribed 199 medication, 3 were referred on for individual counselling, 1 returned to a counsellor that 200 she had previously accessed for a separate depressive episode, and 3 participants attended 201 a weekly postpartum depression support group for auxiliary assistance in dealing with 202 their illness.  At the time of the second interview, 4 of the 10 participants were continuing 203 to experience some moderately debilitating symptoms, 3 women were experiencing 204 mildly distressing symptoms and 3 participants were virtually symptom-free.   205 The Core Category 206 “Enablers and Barriers” 12  Following a protracted involvement with the data, the core category of ‘Having 207 postpartum’ emerged to capture the experience of seeking help for a PPMD and refers to 208 a process across time from the inception of the mood disorder through to varying levels 209 of recovery.  This is the terminology used by mothers to identify their illness.  It provides 210 a label for the disease process while at the same time removing it from the mental illness 211 spectrum.  There is no qualifier attached to the title.  For in fact, all women who give 212 birth have ‘postpartum’.  This use of the label of ‘having postpartum’ provides safety for 213 women in a society where the stigma around mental illness remains deeply entrenched.            214 Samantha: Saying ‘postpartum’ just sounds better.  Kind of less serious.  Like it 215 still sounds bad but I don’t know…. If it just wasn’t so tied to the word ‘depression’ 216 because that is just so stigmatized.  217 Four main stressors were also identified by the women as significantly influencing 218 their mental health and contributed to their downward spiral into a PPMD. These factors 219 included: 1) An unplanned or unsupported pregnancy 2) Lack of identification of risk for 220 developing symptoms of a PPMD and/or delayed diagnosis 3) A traumatic birth 221 experience and 4) Breast feeding difficulties.  Two barrier categories and a single enabler 222 category were further identified by the women as influencing their help-seeking 223 behaviours.  The barrier categories include: 1) stigma and 2) health care provider issues.  224 The enablers identified by women were collapsed into a single category that was all 225 encompassing titled ‘comprehensive maternal-child care’ which fundamentally 226 represented a philosophy that fully embraces holistic care from health care providers.  227  Significant stressors that contributed to the development of a PPMD 228 “Enablers and Barriers” 13  Pregnancy is in and of itself a significant emotional and physical event in a 229 woman’s life.  The stressors that women who participated in this study identified as 230 contributing to the development of a PPMD are consistent with those found in the 231 literature (Beck, 2004; Cohen & Nonacs, 2005; Forman, Videbeck, Hedegaard, Salvig & 232 Secher, 2000; The Maternity Centre Association, 2002).  Some participants talked about 233 the experience of an unplanned or unsupported pregnancy resulting in considerable 234 emotional turmoil and ambivalence leaving the mother with a wash of negative emotions 235 while laying the foundation for the beginning symptoms of a mood disorder (Rich-236 Edwards, et al., 2006). For some women in the present study, a previous history of a 237 PPMD or symptoms of a mental illness were clearly developing or were exacerbated 238 during the pregnancy and were not identified or treated in a timely fashion.  This has also 239 been shown to be a strong predictor of the development of a PPMD in the literature 240 (Dennis & Chung-Lee, 2006; Watt, Sword, Krueger, & Sheehan, 2002). Many women 241 identified what they would describe as a traumatic birth experience as the single greatest 242 event that triggered the beginning of the spiral into the darkness that defines the illness 243 (Beck, 2004; Benoit, Westfall, Treloar, Phillips, & Jansson, 2007).  Finally, a number of 244 participants also identified breast-feeding as a tremendous stressor that contributed 245 significantly to the development or worsening of symptoms.  All of the participants 246 attempted to breast-feed and stated that the “extreme societal pressure” to breast-feed at 247 any cost because all ‘good’ mothers should very much impacted their decision to start 248 and provided tremendous guilt in the event that they felt unable to continue (Wall, 2001). 249 Being aware of and attentive to these stressors for women which may contribute to the 250 development of a PPMD is critical and has significant implications for nursing practice. 251 “Enablers and Barriers” 14  Barrier categories to seeking help for a PPMD 252 The category of stigma represents an in vivo code with women speaking often of 253 the shame associated with having a mental illness. As a result of the stigma and shame 254 that continues to plague those with mental illness, the mothers identified it as a significant 255 barrier to reaching out to both professional and lay help which often begins only when 256 symptoms are no longer manageable. When rebuffed by others for expressing their 257 concerns, women were left shaken and forced to manage symptoms on their own.  258 Invalidated feelings by a close significant other were particularly painful.   259 Maggie:  I think the biggest one was with my husband.  I was worried that he would 260 look at me as “Oh, she’s not doing a very good job” and my in-laws too “Oh, she can’t 261 cope and she’s not doing a very good job as a mother” and I always had in the back of my 262 mind that if something ever happened between my husband and I that he would get the 263 kids cause I’m just not doing a good job. 264   The category of health care provider issues developed as a result of no single 265 discipline being responsible for women’s mental health concerns during the perinatal 266 period.  Despite frequent contacts with various health care providers (e.g. physicians, 267 nurses, midwives) symptoms go largely unnoticed without one discipline specifically 268 addressing and monitoring these issues. It also leads to confusion for women as to who 269 they should reach out to for professional help.  Without professional ownership for 270 assessing and managing mental health of women throughout the perinatal period, 271 symptoms went largely unnoticed.    272 Lynn:  My six-week visit?  It was a waste of time.  An absolute waste of time.  She 273 went in, I got weighed, she saw the baby and said “Oh, how cute!” and then that was it.  274 “Enablers and Barriers” 15  Absolutely no questions about how I was feeling at all, at all.  It was a social tea.  It was a 275 social tea with somebody who is really afraid to ask you if you are feeling “blue” because 276 then you will take up too much of their time. 277 As an extension of health care provider issues, a lack of knowledge/ awareness was 278 demonstrated by many health care providers and laypersons about PPMD’s.  PPMD’s can 279 configure and present themselves in many different ways and often begin prenatally.   A 280 lack of knowledge about when these illnesses may begin and the extreme variability of 281 symptom patterns may leave practitioners and significant others unprepared to identify 282 problems as they appear.  Lack of knowledge/awareness about PPMD’s was also 283 apparent once a PPMD was identified as pharmacological intervention was offered as the 284 only solution to most of the women who sought professional help.  Few were given the 285 option of supportive conjunctive therapy.  This was a significant barrier for women as 286 they described a strong distaste for pharmacological intervention and often delayed the 287 women from seeking treatment because they felt that they would be offered medications 288 for symptom management and that this would solidify the depth of their illness, prevent 289 them from continuing breastfeeding or be the only option available to them.  290 Darcy:  So, I went for my six-week postpartum check-up at eight weeks.  I was a 291 couple of weeks late but I saw the guy, you know, the OB who did the c-section and he 292 just basically looked at me and like I was bawling in his office and crying and telling 293 about my experience and my fears and he gave me a prescription for antidepressants then 294 he just wrote me a bunch of repeats for the Zoloft and offered no-follow-up. 295 Mothers strongly felt that pharmacological intervention alone was unsuitable and 296 served as a ‘quick fix’ or ‘band-aid’ to the reality of their illness.  For these mothers, the 297 “Enablers and Barriers” 16  fear of treatment served as a significant barrier and impacted their decisions when 298 determining if and when to seek professional help.   299 Eventually, for many women, the symptoms worsened and the length of time 300 between episodes became shorter making the need to get help more apparent.  This is a 301 significant barrier for women in seeking help and is linked to the category of health care 302 provider issues in that the periods of waxing and waning would be less deleterious if a 303 professional group was monitoring a mother’s mental health over a period of time to 304 capture the big picture.  305 Enabler categories to seeking help for a PPMD 306 The enabler category of comprehensive maternal-child care reflects a system of 307 care that fully meets the physical, psychological, and emotional needs of the mother-child 308 dyad.  By shifting care beyond the physical parameters of obstetrical care, women felt it 309 would create a safe place for them to seek help for their symptoms through open 310 dialoguing and ultimately reduce the stigma and hidden nature of mental illness during 311 the perinatal period.  By working to shift society’s views around mental illness and 312 mothering, receiving help would not be seen as a failing but as ‘normal’.  This was 313 described as a significant enabler to the help seeking process and is reciprocal in nature to 314 the barrier category of stigma. 315  Samantha: I don’t even remember it coming up [prenatally].  Maybe just briefly.  316 But ya, certainly if they made moms and their partners more aware of the possibility and 317 where to go if it does happen and stuff.  I guess just really make it open and there.  Make 318 it okay to talk about.  This whole mental illness thing is really just so stigmatized and it’s 319 really sad. 320 “Enablers and Barriers” 17   As part of comprehensive maternal-child care and the transition to making mental 321 health care an equal priority to the physical care that is given was a strong desire to 322 integrate screening for PPMD’s.    Just as screening for diabetes prenatally is a standard 323 part of care, women want screening for mental health to be integrated as the standard of 324 care. 325  Zola:  I think it needs to be a standardized thing.  Just like a gestational diabetes 326 screen.  You know, they don’t just do it on the fat women; they do it on the skinny 327 women, right?  If it was a standard thing that they gave every woman between 36 and 40 328 weeks and that they continued to do it during the follow-up that would be good. 329          For all of the women who participated in this study, none were screened with a 330 screening tool for a mood disorder at any time during the perinatal period.  This would 331 have served as a significant enabler to identifying the presence of symptoms earlier in the 332 course of the illness as women felt that the implementation of a standardized system of 333 screening for depression or mental illness in general should be a regular part of their care.  334 The integration of screening as part of a system of comprehensive maternal-child care 335 responds to many of the elements found within the barrier category of health care 336 provider issues. 337 The final significant element of truly comprehensive maternal-child care system, 338 requires that health care providers embrace mothers and babies as a single unit of care 339 such that women feel equally valued to their children.  In creating this environment, 340 mothers would feel that their concerns would be validated and seen as a similar priority.  341 Through adhering to this philosophy, women would have their concerns validated early 342 “Enablers and Barriers” 18  and often.  This would greatly enable the process of feeling safe to disclose the illness 343 experience.   344 Zola: It’s not about you.  It’s not about me.  It’s not about the woman that is having 345 the baby.  They are just there to make sure that the baby is okay, the baby is growing, and 346 it’s all about the baby.  The baby, the baby, the baby. 347 Discussion 348 The clinical implication of these findings for nursing requires that we alter our 349 practice to more adequately meet the needs of women during pregnancy and in the 350 postnatal period.  It is important that we acknowledge stressors that women have 351 identified as contributing to the development of their PPMD.  This should direct our 352 practice by giving us important opportunities to ask women without judgment about the 353 emotional impact of their pregnancy, previous mental health issues, birth experiences, 354 and breast-feeding issues. This may provide helpful insight into the mental well-being of 355 a woman and allow for open and safe discussions in various clinical contexts. The 356 continuing stigma and shame associated with having a psychiatric illness serves as a 357 significant barrier for women to seek out help from both lay and professional others when 358 experiencing a PPMD (Pinto-Foltz & Logsdon, 2008).    In this study, the mothers spoke 359 often of the stigma around mental illness that forced them to hide and mask their 360 symptoms and negative feelings around mothering ultimately diminishing their quality of 361 life.  At the same time, in delaying their treatment to avoid judgement from others, they 362 identified that their interactions with their children were often markedly compromised.  363 Maternal mood disorders greatly diminish the quality of the interaction between the dyad 364 ultimately resulting in emotional, social, and cognitive delays for their children (Luoma, 365 “Enablers and Barriers” 19  Tamminen, Kaukonen, Laippala, & Puura et al., 2001).  The outcomes for children are 366 particularly compromised and correlated with the chronicity of their mother’s illness 367 indicating that delayed treatment has significant long-term implications for the dyad and 368 family unit as a whole (Hay, Pawlby, Sharp, Asten & Mills et al., 2001).  These findings 369 highlight the urgency in detecting and treating mental illness within this population while 370 also giving strong evidence that women want to be asked open and direct questions 371 around their mental health. 372 The finding that maternity care should be delivered within the context of the 373 mother-child dyad as the unit of care is an important one. Our current system often places 374 primary focus on the health and wellness of infants to the exclusion of their mothers.  375 Women need their physical health monitored appropriately but also need emotionally 376 supportive care that values and honours the needs of both women and their babies.  This 377 philosophy of care highlights the necessity for a holistic approach with the dyad together 378 as a focus throughout this life event (Health Canada, 2002).   379 Women very clearly identified that they wanted universal screening for mood 380 disorders to be implemented as part of the standard of practice for maternity care. 381 Screening for mood disorders is a simple and economical process that is well within the 382 scope of our nursing practice allowing us to take ownership for not only its 383 implementation but also to be leaders in advocating for this best practice standard to be 384 available to all women.   The design and delivery of mass screening programs for 385 perinatal mood disorders will require the concerted effort of maternal-child nurses, public 386 and community health nurses and other nurses who work directly with this population. 387 “Enablers and Barriers” 20  The most significant limitation of the study findings is that they are not 388 generalizeable beyond the present participant sample.  The mothers who participated 389 within this study were all well educated, white, mature (mean age = 32.6), professional 390 women with few financial or social limitations.  Further, all of the participants had 391 partners who were able to provide at least minimal instrumental and emotional support.  392 For new mothers without these financial, emotional, and social benefits, the experience of 393 a PPMD would undoubtedly be more profound and complex (Beck, 1996).  As a result, 394 the study findings must be transferred to other populations with considerable caution.  395 Conclusion 396 In listening to women’s voices, we now have a greater understanding of the barriers 397 that prevent them from seeking help for a PPMD.  Further, by directly asking mothers 398 how the process can be enabled, the women have provided solutions towards improving 399 care around their mental health needs during this important development life stage.  This 400 may be best achieved through providing screening for all women across the perinatal 401 period.  This should also facilitate making women’s mental health a priority within the 402 context of a safe and open environment for disclosure of symptoms while enabling 403 women to reclaim their mothering souls. 404   405 “Enablers and Barriers” 21   References  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4 ed, TR).  Washington, DC. Barr, J.A. (2006).  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