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Re-Designed Care Could Reduce Postnatal Depression (pp 370, 380)

January 30, 2002

A UK study in this week's issue of THE LANCET highlights how a new model of postnatal care led by midwives and tailored to meet individual needs could reduce the risk of mental illness among women in the first four months after childbirth. A Commentary article also published this week concludes that the study has implications for the delivery of postnatal care in the USA.

Much physical and psychological illness after childbirth is not addressed by present postnatal care, which is based on routine examinations. Christine MacArthur and colleagues from the University of Birmingham, UK, assessed a new model of community postnatal care that was based on results of research and maternity care recommendations, and compared the effects of such care on women's subsequent health with women given conventional care.

Of 36 general practices in the West Midlands health region of the UK, 1087 women (53%) were recruited from 19 practices randomly allocated to intervention, and 977 women (47%) from 17 practices allocated to control. The new model of community-based postnatal care (given to women in the intervention group) meant that care could be tailored flexibly to individual needs. Care was led by midwives, including home visits and the final discharge consultation, and contact with general practitioners was based on referral. To ensure that specific needs could be identified, a symptom checklist was used at the first visit, at days 10 and 28, and at the discharge consultation at 10-12 weeks. The Edinburgh postnatal depression scale (EPDS) was also used to screen for depression at day 28 and at the discharge consultation. Care plans were made and visits scheduled on the basis of these results rather than on a predetermined schedule. Women in the control group were given conventional postnatal care (six or seven home visits by a midwife mainly during the first 10-14 days after birth, general practitioner [GP] home visits, health-visitor care after 14 days, and a check-up with a GP at 6-8 weeks).

Women's psychological health measures were substantially better in the group of women given the redesigned care than in the control group, with an overall 40% reduction in the risk of an EPDS score indicative of probable depression; however, physical health scores did not differ between women in the intervention and control groups. The investigators conclude that the redesign of care so that it is midwife-led, flexible, and tailored to needs, could help to improve women's mental health and reduce probable depression at 4 months after childbirth.

In an accompanying Commentary (p 370), Leah Albers from the University of New Mexico, Albuquerque, and Deane Williams from the American College of Nurse-Midwives, Washington DC, USA, conclude: "The findings should command the attention of clinicians and policymakers in the USA who function in a health-care system in which the limited content of postpartum care is seldom questioned. Reimbursement is typically limited to one visit; in fact, the standard of care for new mothers as described by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists is one office visit at 4-6 weeks. As in the UK and in Australia, postpartum depression affects 10-15% of new mothers in the USA; yet even when a mother is so extremely depressed that she murders all five of her children, as recently happened in Texas, there is no call to re-examine the system."

Lancet