Disease Management & Health Outcomes

, Volume 11, Issue 1, pp 11–20 | Cite as

Strategies to Reduce Postnatal Psychological Morbidity

The Role of Midwifery Services
  • Debra Bick
Review Article


Psychological morbidity after childbirth is a major public health problem, with prevalence rates of depression ranging from 10–15%, depending on assessment times and diagnostic criteria. Depression can have long-lasting consequences for both the woman and her child, with increasing evidence of an association between maternal depression and effects on the child’s behavioral and cognitive development. A variety of interventions implemented during the antenatal, intrapartum and postnatal periods to reduce postnatal psychological morbidity have been evaluated. This paper summarizes the outcomes of studies that have evaluated interventions provided by midwives.

There is no evidence to suggest that changing routine antenatal visit schedules will benefit postnatal psychological health or to support the introduction of routine antenatal screening to identify women more vulnerable to postnatal depression. Evaluation of the role of the midwife in implementing recommendations for screening women to identify those at risk of recurrence of serious mental illness during and after pregnancy is necessary. Educational interventions, including those specifically tailored for women deemed more vulnerable to depression, have shown limited evidence of benefit, and further research in this area is warranted. There is currently little evidence to support postnatal debriefing by midwives, with some evidence to suggest this intervention may actually be harmful to psychological well-being. The widespread introduction of debriefing services to postnatal women, particularly in the UK, highlights the urgent need for further research into the definition and content of this aspect of midwifery care. Significant benefits to postnatal psychological well-being have been found following the implementation of new models of midwifery-led care. Such findings have important implications for the role of the midwifery services within the UK, as well as for maternity service provision in other healthcare systems. Further evidence is required to inform how midwifery care can best be provided to all women throughout the maternity episode to ensure the early detection and management of postnatal psychological morbidity. Preventative and management strategies of postnatal psychological morbidity should consider the direct and indirect costs to women, healthcare providers and funders.


  1. 1.
    Kumar R, Robson K. A prospective study of emotional disorders in child-bearing women. Br J Psychiatry 1984; 144: 34–47.CrossRefGoogle Scholar
  2. 2.
    Cooper PJ, Campbell EA, Day A, et al. Non-psychotic psychiatric disorder after childbirth: a prospective study of prevalence, incidence, course and nature. Br J Psychiatry 1988; 152: 799–806.PubMedCrossRefGoogle Scholar
  3. 3.
    Seeley S, Murray L, Cooper PJ. Postnatal depression: the outcome for mothers and babies of health visitor intervention. Health Visit 1996; 69: 135–8.Google Scholar
  4. 4.
    Hoffbrand S, Howard L, Crawley H. Antidepressant drug treatment for postnatal depression (protocol). Available in The Cochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 2. Oxford. Update Software 2002.Google Scholar
  5. 5.
    Coghill SR, Caplan HL, Alexandra H, et al. Impact of maternal postnatal depression on cognitive development of young children. BMJ 1986; 292: 1165–7.CrossRefGoogle Scholar
  6. 6.
    Sharp D, Hay DF, Pawlby S, et al. The impact of postnatal depression on boys’ intellectual development. J Child Psychol Psychiatry 1995; 36: 1315–36.PubMedCrossRefGoogle Scholar
  7. 7.
    Hay DF, Pawlby S, Sharp D, et al. Intellectual problems shown by 11 year old children whose mothers had postnatal depression. J Child Psychol Psychiatry 2001; 42: 871–9.PubMedCrossRefGoogle Scholar
  8. 8.
    MacArthur C, Lewis M, Knox EG. Health after childbirth. London: The Stationery Office, 1991.Google Scholar
  9. 9.
    Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based study. Br J Obstet Gynaecol 1998; 105: 156–61.PubMedCrossRefGoogle Scholar
  10. 10.
    Saurel Cubizolles MJ, Romito P, Lelong N, et al. Women’s health after childbirth: a longitudinal study in France and Italy. Br J Obstet Gynaecol 2000; 107: 1202–9.CrossRefGoogle Scholar
  11. 11.
    Oakley A, Rajan L, Grant A. Social support and pregnancy outcome. Br J Obstet Gynaecol 1990; 97: 155–62.PubMedCrossRefGoogle Scholar
  12. 12.
    Stamp GE, Williams AS, Crowther CA. Evaluation of antenatal and postnatal support to overcome postnatal depression: a randomized, controlled trial. Birth 1995; 22 (3): 138–43.PubMedCrossRefGoogle Scholar
  13. 13.
    Hayes BA, Muller R, Bradley BS. Perinatal depression: a randomised controlled trial of an antenatal education intervention for primiparas. Birth 2001; 28: 28–35.PubMedCrossRefGoogle Scholar
  14. 14.
    Brugha TS, Wheatley S, Taub NA, et al. Pragmatic randomised controlled trial of antenatal intervention to prevent postnatal depression by reducing psychosocial risk factors. Psychol Med 2000; 30: 1273–81.PubMedCrossRefGoogle Scholar
  15. 15.
    Elliott SA, Leverton SJ, Sanjack M, et al. Promoting maternal health after childbirth: a controlled trial of primary prevention of postnatal depression. Br J Clin Psychol 2000; 39: 223–41.PubMedCrossRefGoogle Scholar
  16. 16.
    Sikorski J, Wilson J, Clement S, et al. A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. BMJ 1996; 312: 546–53.PubMedCrossRefGoogle Scholar
  17. 17.
    Turnbull D, Holmes A, Shields N, et al. Randomised controlled trial of efficacy of midwife-managed care. Lancet 1996; 348: 213–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Reid M, Lang G, Murray G, et al. A two centre pragmatic randomised controlled trial of two interventions. Edinburgh: Scottish Office Chief Scientist Office, 1999.Google Scholar
  19. 19.
    Morrell CJ, Spiby H, Stewart P. Costs and effectiveness of community postnatal support workers: randomised controlled trial. BMJ 2000; 321; 593–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Lavender T, Walkinshaw S. Can midwives reduce postpartum psychological morbidity? A randomised trial. Birth 1998: 25; 215–219.Google Scholar
  21. 21.
    Small R, Lumley J, Donohue L, et al. Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth. BMJ 2000; 321: 1043–7.PubMedCrossRefGoogle Scholar
  22. 22.
    MacArthur C, Winter H, Bick DE, et al. The effects of re-designed community postnatal care on women’s health four months after birth: a cluster randomised controlled trial. Lancet 2002; 359: 378–84.PubMedCrossRefGoogle Scholar
  23. 23.
    Oakley A. Measuring the effectiveness of psychosocial interventions in pregnancy. Int J Technol Assess Health Care 1992; 8 (1): 129–38.PubMedCrossRefGoogle Scholar
  24. 24.
    Oakley A, Hickey D, Rajan L, et al. Social support in pregnancy: does it have long-term effects? J Reprod Infant Psychol 1996; 14: 7–22.CrossRefGoogle Scholar
  25. 25.
    Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1990; 150: 782–6.CrossRefGoogle Scholar
  26. 26.
    Clement S, Candy B, Sikorski J, et al. Does reducing the frequency of routine antenatal visits have long-term effects? Follow up of participation in a randomised controlled trial. Br J Obstet Gynaecol 1999; 106: 367–70.PubMedCrossRefGoogle Scholar
  27. 27.
    Green J, Murray D. The use of the Edinburgh Postnatal Depression Scale in research to explore the relationship between antenatal and postnatal dysphoria. In: Cox J, Holden J, editors. Perinatal psychiatry. London: Gaskell, 1994: 180–98.Google Scholar
  28. 28.
    Johanson R, Chapman G, Murray D, et al. The North Staffordshire Maternity Hospital prospective study of pregnancy-associated depression. J Psychosom Obstet Gynaecol 2000; 21 (2): 93–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Evans J, Heron J, Francomb H, et al. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001; 323: 257–60.PubMedCrossRefGoogle Scholar
  30. 30.
    Stamp GE, Williams AS, Crowther CA. Predicting postnatal depression among pregnant women. Birth 1996; 23: 218–23.PubMedCrossRefGoogle Scholar
  31. 31.
    Webster J, Linnane JW, Dibley LM, et al. Improving antenatal recognition of women at risk for postnatal depression. Aust N Z Journal Obstet Gynaecol 2000; 10: 409–12.CrossRefGoogle Scholar
  32. 32.
    Forman DN, Videbech P, Hedegaard M, et al. Postpartum depression: identification of women at risk. Br J Obstet Gynaecol 2000; 107: 1210–7.CrossRefGoogle Scholar
  33. 33.
    Lewis G, editor. The fifth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press, 2001.Google Scholar
  34. 34.
    Shields N, Reid M, Cheyne H, et al. Impact of midwife-managed care in the postnatal period: an exploration of psychosocial outcomes. J Reprod Infant Psychol 1997; 15: 91–108.CrossRefGoogle Scholar
  35. 35.
    Wessely S. Commentary: reducing distress after normal childbirth. Birth 1998; 25: 220–1.PubMedCrossRefGoogle Scholar
  36. 36.
    Rose S, Bisson J, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Available in The Cochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 4. Oxford: Update Software 2002.Google Scholar
  37. 37.
    Davidson LL, Garcia J, Parsons J. Psycho-social interventions in maternity care: the need for evaluation [letter]. BMJ 2000; 321: 1043–7.CrossRefGoogle Scholar
  38. 38.
    Bick D, MacArthur C, Knowles H, Winter H. Postnatal care: evidence and guidelines for management. Edinburgh: Churchill Livingstone, 2002.Google Scholar
  39. 39.
    Bick D, MacArthur C. The extent, severity and effect of health problems after childbirth. Br J Midwifery 1995; 3: 27–31.Google Scholar
  40. 40.
    Brown S, Lumley J. Physical health after childbirth and maternal depression at six to seven months postpartum. Br J Obstet Gynaecol 2000; 107: 194–2001.Google Scholar
  41. 41.
    Hodnett ED. Caregiver support for women during childbirth. Available in The Cochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 4. Oxford: Update Software, 2002.Google Scholar
  42. 42.
    Albers L, Williams D. Lessons for US postpartum care [commentary]. Lancet 2002; 359: 370–1.PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 2003

Authors and Affiliations

  • Debra Bick
    • 1
  1. 1.RCN InstituteRadcliffe InfirmaryOxfordUK

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