Health Services Research Department, Institute of Psychiatry, London
Section of Perinatal Psychiatry, Institute of Psychiatry, London, UK
Research Unit 149, INSERM, Villejuif, France
Division of Psychiatry, University of Nottingham
Section of Perinatal Psychiatry, Institute of Psychiatry, London, UK
Cluain Mhuire Family Centre, Co. Dublin, Ireland
Department of Psychology, University of Minho, Braga, Portugal
Child and Adolescent Psychiatry, University of Zurich, Switzerland
Department of Psychiatry, University of Vienna, Austria
Section of Perinatal Psychiatry, Institute of Psychiatry, London, UK
University Department of Psychiatry, Centre Hospitalier Charles Perrens, Bordeaux, France
TCSPND Group*
Correspondence: Dr Dan Chisholm, Global Programme on Evidence for Health Policy, World Health Organization, 1211 Geneva, Switzerland. E-mail: ChisholmD{at}who.int
* TCSPND Group membership and funding detailed in Acknowledgements, p.
iv, this supplement.
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ABSTRACT |
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Aims Within the context of a cross-cultural research study, to develop and test methods for undertaking quantitative health services research in postnatal depression.
Method Interviews with service planners and the collation of key health indicators were used to obtain a profile of service availability and provision. A service use questionnaire was developed and administered to a pilot sample in a number of European study centres.
Results Marked differences in service access and use were observed between the centres, including postnatal nursing care and contacts with primary care services. Rates of use of specialist services were generally low. Common barriers to access to care included perceived service quality and responsiveness. On the basis of the pilot work, a postnatal depression version of the Service Receipt Inventory was revised and finalised.
Conclusions This preliminary study demonstrated the methodological feasibility of describing and quantifying service use, highlighted the varied and often limited use of care in this population, and indicated the need for an improved understanding of the resource needs and implications of postnatal depression.
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INTRODUCTION |
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It was within this context that a health services research component was incorporated into a cross-cultural study of postnatal depression. The main intent of the health services research was to complement the work on diagnosis and the assessment of motherhood experience by developing and applying qualitative and quantitative research tools for assessing the availability of and access to appropriate care, as well as the actual uptake of services by mothers with postnatal depression. In the absence of comparable international data on service provision or use for women with postnatal depression, our working hypothesis- informed by other international epidemiological studies of depression, such as the World Health Organization studies on pathways to care (Gater et al, 1991) and psychological problems in general health care (Üstün & Sartorius, 1995) - was that the provision of services for depressed mothers and recognition of their needs would vary across study sites, but take-up of such services would be universally low.
Transcultural Study of Postnatal Depression
The primary aim of the Transcultural Study of Postnatal Depression
(TCS-PND) was to develop (or modify), translate and validate research
instruments that could be used for future studies in the field of perinatal
psychiatry in different countries and cultures. The instruments were chosen to
assess key aspects of the maternity experience, namely clinical diagnosis, the
psychosocial context of pregnancy and motherhood, mother-infant interaction,
the child's environment, and health service structure, use and its associated
costs. The modified and translated research tools were then piloted in order
to assess their validity in a range of diverse perinatal population settings.
This paper specifically reports on the adaptation and piloting of a health
service utilisation measure, the Client Service Receipt Inventory (CSRI;
Beecham & Knapp, 2000), for use in studies of postnatal depression.
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METHOD |
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Sample
Eligible women were recruited in antenatal clinics or classes by a
researcher who obtained informed consent from those who agreed to take part.
Sample sizes in each centre varied from 20 to 60, with a total of 296 for the
study as a whole. An adapted version of the CSRI was administered to a
sub-sample of 136 women postnatally. Demographic characteristics of the centre
samples are described by Asten et al
(2004, this supplement).
Health services research component
An innovative aspect of this cross-cultural study was an interest in
developing methods for quantitative health services research, in particular
access and/or barriers to appropriate care and the actual uptake and cost of
service provision for women with postnatal depression. Data were collected at
both the population level of study sites and at the individual level of
sampled participants. At the level of the study site, we collated relevant
health-system data relating to health expenditures, the availability of mental
health resources and maternity leave arrangements.
At the level of the individual, we built on previous work relating to the economic evaluation of mental health care by adapting and developing the CSRI for use with postnatal women. The Client Service Receipt Inventory- Postnatal Depression (CSRI-PND) version is a derivation of the Client Socio-demographic and Service Receipt Inventory- European version (Chisholm et al, 2000), which in turn is an adaptation of the CSRI (Beecham & Knapp, 2001). We sought to bring together questions that would enable the comprehensive costing of care packages for women who are about to have or who have recently had a child, with a view to determining the excess need and service uptake of women with postnatal depression. Accordingly, we collected information on the current living arrangements and expenses of each participant (including income, employment and accommodation), and details of any use she might have made of a range of health care, social care and other services over a 6-month retrospective period (see Appendix). Unit costs for each of these services could then be calculated (although this was not undertaken in this study) and subsequently applied to the resource use data from the CSRI-PND, to give the total cost associated with each individual's use of services. The instrument also attempts to estimate some of the main economic knock-on effects of postnatal depression, in particular the impact on the income or productivity of the woman or household, and the extra inputs of informal caregivers. A final set of (more qualitative) self-report questions relate to potential barriers to accessing services. The modified instrument was translated into the language of each European centre and administered to a pilot sample at the postnatal assessment.
Other measures
The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I;
First et al, 1994) is
a semi-structured interview for making the major DSM-IV diagnoses
(American Psychiatric Association,
1994). A research version designed for use with non-patient
populations (SCID-I/NP; First et
al, 1996), was modified to produce an instrument for
assessing postnatal interviews, thus providing a continuous assessment of
depressive disorder from the beginning of pregnancy up to 6 months
postnatally. A combined variable of either major or minor depression with an
onset date within 6 months of delivery was used in this study. Rates of
postnatal depression differed between centres, from 2% (n=1) in
Zurich to 37% (n=5) in Paris. Rates in the other five centres were
all between 20% and 29%.
The Contextual Assessment of Maternity Experience (CAME) was developed to assess the psychosocial context of the maternity experience in different cultural settings (Bernazzani et al, 2004, this supplement). The CAME includes assessment of recent life adversity in eight domains (marital, social, parental, health, housing and financial, work, criminal and legal, and geopolitical) and of emotional support from partners and others in the woman's social network. Severe and non-severe levels of adversity occurring in any domain between the antenatal and postnatal interviews were distinguished. Levels of severe adversity varied from 30% in Vienna to 56% in Paris. A composite variable identifying poor support in the postnatal period given by the woman's partner, one very close other and all others in the woman's social network, was also used. Rates of poor support varied from 18% in Dublin to 70% in Porto.
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RESULTS |
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In each of the centres, women and infants are entitled to a certain amount of free postnatal care, although there is variation in the form of provision. In all centres a medical check-up is routinely offered to newly delivered women 4-8 weeks post-partum. In Dublin and London this would usually be done by a general practitioner, in Bordeaux, Paris, Porto and Vienna by either a general practitioner or an obstetrician/gynaecologist, and in Zurich by an obstetrician/gynaecologist. Midwives routinely make home visits during the first 7-10 days post-partum in Dublin, London and Zurich, whereas in Vienna midwives only visit women who leave hospital immediately after delivery. In some areas of France systematic home visits by midwives are routinely offered to every woman, but in other areas only to women at high risk. Porto has no home midwifery service.
A number of centres have distinctive services which appear to be unique to that country. In France all women are entitled to a prescription for a series of abdominal and/or perineal re-education sessions, conducted by a physiotherapist or a midwife. Also distinctive to France are mother and child protection centres which offer paediatric checks and vaccinations, as well as family planning consultation, and preventive and educational health services for families of children under 6 years old. In London a health visitor routinely visits at around 10-14 days post-partum and subsequently maintains a supportive and preventive role with the family through a child health clinic, general practice surgery or at home. In Zurich a network of advice centres provide guidance on babycare and emotional and psychological problems. In addition to a range of adult mental health services in each centre, there are perinatal liaison services in Dublin and London, and psychiatric in-patient facilities for mothers and babies in London, Bordeaux and Paris.
Socio-economic characteristics of sampled households
A series of socio-economic indicators elicited from the CSRI-PND are
provided in Table 4, including
home ownership, receipt of state benefits (including maternity leave) and
working status of sampled mothers and their partners. The proportion of
respondents primarily responsible for looking after the home ranged from
18-29% in Bordeaux, Dublin and Paris, to 75-95% in the other sites. There are
evident welfare system differences between participating centres, for example
over 80% of sampled mothers in Bordeaux, Dublin and Vienna were in receipt of
state benefits at the post-partum assessment, compared with less than 10% in
Porto and Zurich. Except in France, weekday childcare was most commonly
undertaken by the mothers themselves in their own homes; in Bordeaux and
Paris, babies were more commonly looked after by childminders in the mother's
home or at a local crèche nursery
(Fig. 1).
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The majority of mothers in the European centres (64-91%) described themselves as usually employed. At least 80% of their partners were working at the time of the assessment. Except in Porto, the majority of women classified their own (as well as their partners') type of work as non-manual or professional.
Service use among mothers
In-patient care
The average length of admission to a maternity ward was similar (4-5 days)
in the European centres. However, not all childbirth admissions were picked up
by the CSRI-PND, as some interviews were conducted beyond the service use
period of 6 months post-partum. Admission to a general psychiatric ward or to
a mother and baby unit was uncommon in these small sampled populations, and
was reported for only one woman in Zurich.
Out-patient care
Use of out-patient health and social care services by the sampled
populations in each of the participating centres is reported in
Table 5. Contacts with
individual providers were grouped into the following service categories:
mother and child health; primary health and social care; and mental health.
Although not subjected to formal tests of statistical difference on account of
the small number of observations available, there are notable variations
between centres in the proportion of women receiving care, as well as in the
frequency of contact. For the proportion of women having a service contact
with an obstetrician or midwife, the wide variation may be largely attributed
to the fact that some interviews were carried out more than 6 months
post-partum (the service use period specified in the CSRI-PND). In all other
cases, observed variations in the uptake of services reflect the diverse care
practices or opportunities offered within the local health systems of the
participating centres. For example, there are marked differences in the
proportion of women in receipt of specialist postnatal nursing care (ranging
from none in Dublin to 100% in London, where all women had contact with a
health visitor), or contacts with a primary care nurse or worker (ranging from
none in London to almost 90% in Paris).
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Among those who did use a particular service, there are notable differences between centres, such as number of primary care doctor contacts (ranging from 1.1 visits per person over 6 months in Vienna to 5.2 visits per person in London). Contacts with a psychiatrist ranged from 0.8 consultations in Bordeaux to 1.9 in London. In a number of other centres (Paris, Porto, Vienna and Zurich), contact with any mental health service provider (psychiatrist, psychologist, other mental health worker) was essentially absent. The only centres in which there was an appreciable use of mental health services were Dublin and London, each with a different pattern (psychiatrist and group support activities in Dublin, and a mix of psychiatrist, psychologist and other mental health worker contacts in London). Finally, a high rate of other care contacts was observed in the two French centres (mainly kinesiology).
Given the variety of services available in each centre, contacts with
professionals were collapsed into two broad categories of primary care (which
included maternal and infant health and social care) and mental health care
(Table 6). In univariate
analyses, contact with any primary care professional ranged from around 60% of
women in Vienna and Dublin to 100% in London and Paris
(2(6)=14.50, P=0.02), and contact with any mental
health professional ranged from none in Vienna and Zurich to 45% of women in
Dublin (
2(6)=29.49, P<0.0001). In the case of
mental health professionals, centre differences appeared to be partly
attributable to differences in rates of postnatal depression, since contacts
with a mental health professional were more likely for women with a diagnosis
of depression (
2(1)=10.37, P=0.001). There were also
large differences between centres in mean number of contacts with both primary
care and mental health professionals (Kruskal-Wallis test:
2(6)=48.21, P<0.0001,
2(6)=27.59,
P<0.0001, respectively). Again, in the case of mental health
professionals, differences seemed to be partly attributable to varying rates
of postnatal depression, since women with depression had a higher mean number
of contacts with mental health professionals (z=2.88,
P=0.004). Women with severe adversity also had more contacts with
mental health professionals (z=3.01, P=0.003). Contacts with
primary care professionals, on the other hand, were not related overall to
either postnatal depression or adversity, but women with poor social support
had more contacts with primary care professionals (z=2.70,
P=0.007).
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As a further indication of the potential of the CSRI-PND to distinguish different levels of service use according to particular characteristics of users, comparisons were made of contacts with the two categories of professionals (primary care and mental health) while controlling for centre effects. Mean numbers of contacts were compared for those with and without depression, those with and without marked or moderate adversity, and those with and without poor social support. For mental health services only the differences between centres remained significant. However, for primary care services, in addition to significant main effects of centre, there were significant main effects of both severe adversity (F(1)=6.69, P=0.01) and poor social support (F(1)=9.2, P=0.003) and an almost significant main effect of depression (F(1)=3.60, P=0.06). These preliminary results seem to indicate that whatever the type and level of services offered within a country, women with adversity, poor social support and depression use primary care services more intensively than women without such problems.
In four of the participating centres (Dublin, London, Paris and Vienna), an additional set of qualitative questions was included in the interview, which aimed to elicit perceived barriers to appropriate care (Fig. 2). Commonly expressed constraints to accessing services included the perceived lack of quality or responsiveness of health care providers to their needs; a concern about medication side-effects, should anti-depressant pharmacotherapy be prescribed; and other reasons, in particular lack of time or inability to find a childminder.
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Service use among newly born children
Health care services used by the infants of sampled mothers are reported in
Table 7. In all but one centre
(Paris), admission to a paediatric ward was seen in no more than one in ten
babies. Visits to a paediatrician, however, were common, ranging from 55% to
95%, except in London (14%). The number of visits was notably higher in
Bordeaux, Paris and Vienna (a mean of more than one visit per month) than in
other centres. Finally, a noteworthy finding was that in all centres, an
appreciable proportion of babies had been taken to the emergency department of
the local hospital (as high as about 40-50% in Vienna and Porto, and close to
15% elsewhere).
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DISCUSSION |
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Cross-cultural differences in service access, provision and use
There are widespread differences between the participating centres of this
study in the availability and utilisation of services for new mothers and
their babies. Concerning service availability, we still have only rudimentary
quantitative data on specific care components relevant to the needs of women
with postnatal depression, with most national data specified by expenditure or
occupational category rather than by disease or health condition. Even so, it
is apparent from Table 3 that
there are considerable differences at the national level in the availability
of health professionals such as psychiatrists, psychiatric nurses and social
workers, who might care for women with postnatal depression.
With respect to the uptake of services, the sample sizes for each centre were small and therefore potentially unrepresentative of the wider population, but on the basis of these preliminary data there do appear to be diverse care practices or opportunities offered within the local health systems of the participating centres, in terms of both general medical services and more specialist postnatal or mental health care. Among these small samples, there appears to be differential uptake of primary care services by women with severe adversity, by those with poor support and, to a lesser extent, by those with postnatal depression. Further use of the instruments described in this supplement in future observational and experimental studies of postnatal depression can be expected to enable such comparisons to be made in larger, more representative samples.
Implications for health services research and policy
This preliminary study has demonstrated the methodological feasibility of
describing and quantifying service use, highlighted the varied and often
limited use of care in this population, and indicated the need for improved
assessment of the resource needs and implications of postnatal depression.
However, this is only a first step towards a more comprehensive understanding
of the full range of service components that require consideration. Using the
matrix model developed by Thornicroft & Tansella
(1999) to conceptualise the
wider mental health service framework
(Table 8 relates this model to
postnatal depression), it is apparent that there remain a number of
outstanding issues or service components which fall beyond the scope of this
study yet which merit greater attention by researchers and policy-makers
alike. In particular, there is a requirement at the province/district level to
undertake population-level needs assessment, develop operational policies and
undertake treatment outcome studies of postnatal depression. Integration of
these activities with the methods proposed in this paper offers the prospect
of improving the visibility and availability of appropriate services, while
also generating an evidence based on the relative cost-effectiveness of
interventions for effectiveness postnatal depression.
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APPENDIX |
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Housing
Usual place of residence, size and occupancy of household, adequacy of
accommodation for raising a small child.
Employment and income
Assessment of any periods of maternity (and paternity) leave taken or
permitted, employment situation and income level of both the mother and her
partner, and number of days the mother, her partner and two closest
relatives/friends have been absent from/unable to work or carry out usual
activities owing to postnatal illness. Key outputs from this section are
estimates of overall household income and forgone work/productivity.
Use of services
Checklist of key out-patient (and in-patient) services that the mother may
have had contact with over a retrospective period of 6 months, including
contacts with obstetricians, midwives, primary health care workers, social
workers and specialist mental health service professionals. The total number
of contacts (or in-patient days) in the previous 6 months is elicited,
together with the usual location and average duration of contacts. A corollary
to these questions concerning actual rates of use concerns potential barriers
to service access or use, such as geographical distance, financial cost,
service quality, provider responsiveness and stigma. Different levels of
access to care across the participating sites may have an important bearing on
the uptake of services.
Child care and paediatric services
The final section documents the normal care arrangements for the new child,
together with any use of paediatric services over the 6-month retrospective
period.
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Clinical Implications and Limitations |
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LIMITATIONS
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