Elizabeth Rochin, PhD, RN, NE-BC

“When they finally wheeled me up to the NICU to see my baby, he was attached to so many pumps and machines. I couldn’t even see his hands and feet. This clearly was my fault… I must have done something wrong. I couldn’t even touch him to reassure him I was here for him. I didn’t know what to do. My first reaction was to not become attached … I was so afraid I was going to fall in love with my baby and then he would be gone. And the guilt associated with not wanting to be attached to my new baby was overwhelming.”—A.B., Mother of a NICU Baby

Review any annual cause calendar, and you find a myriad of dates that recognize one issue or another throughout the year…World Water Day (March 22); World Cancer Day (February 4); World Penguin Day (April 25)…however, October 10th of each year highlights World Mental Health Day, and this day is quite applicable for the Neonatal Intensive Care arena.

Before entering the NICU space, it is of paramount importance to highlight the recent findings in California that illustrate the urgency of understanding maternal mental health through the lens of maternal morbidity and mortality. Researchers in California (Goldman-Mellor & Margerison, in press) reviewed 300 records (2010 – 2012) of women who died within one year after giving birth. The second leading cause of death was drug-related, and the seventh was by suicide. Two-thirds of the women who died had at least 1 visit to an Emergency Room or hospital before they
died. In other words, these women had entered the healthcare system, and there may have been real opportunities to meet their mental health needs prior to their deaths. Screening for depression may have provided insight into their despair.

Mothers of preterm infants are 40% more likely to develop PPD than the general population (Cherry et al, 2016). In other words, if a NICU has thirty (30) beds, it is conceivable that twelve (12) of the mothers in the unit are suffering from Postpartum Depression, which in turn can impact their ability to actively engage with the care of their newborn and engage in bedside rounds as the focal member of their newborn’s care team.

So, what can we do as a multidisciplinary NICU care team to better identify PPD and assist mothers who are coping with their own healthcare and emotional care needs, in addition to the stressors of having a newborn in the NICU?

1. Data-Driven Decisions: NPIC profiled 288,336 births during the time period April 2018 – March 2019. During this period, 40,165 deliveries were linked to a newborn with an admission to a NICU or Special Care Unit. Of these women, only 24 were discharged with the ICD-10 diagnoses of O90.6 (Postpartum Mood Disturbance, i.e., dysphoria, blues, sadness) or F53.0 (Postpartum Depression). These findings would support the development of PPD after discharge, and during their stay in the NICU within the context of the studies provided. It is critically important that we are screening all mothers appropriately and coding PPD appropriately prior to discharge. These numbers reflect real mothers who were diagnosed with PPD even before their discharge home. NPIC ‘s focus in 2020 and beyond is to ensure that our data has a robust and sustained focus on racial/ethnic disparities, and the social determinants of health (SDOH) that may have an impact on PPD and other maternal complications.
2. Access to Routine Postpartum Care: Chen and colleagues (2019) conducted a qualitative study identifying some of the barriers to NICU mothers accessing postpartum care, which included distance to clinic, a stronger focus on their newborn’s health and changes to their own insurance/ability to pay. What resources do you currently
   have in place to support a new mother’s ability to care for herself while she is making every effort to care for her newborn? If a mother finds herself far away from her provider, what options exist to provide care closer to the NICU, particularly for mothers with high-risk postpartum health concerns, such as postpartum depression, hypertension, anemia, etc.?
3. Identification of Postpartum Depression: In addition to routine postpartum care, it is essential to understand and identify those women and mothers at risk or who display signs of PPD early, or during their stay in the NICU. The American Academy of Pediatrics recommends universal PPD assessment at the one-month, two-month, four-month and six-month well assessment visits. However, if NICU stay exceeds one or more of these specific intervals, who is asking the mother if she has been assessed for PPD? What resources currently exist in your facility to assess mothers for PPD who will not be visiting their pediatrician for routine well assessment visits?
4. Supporting the Father/Significant Other: While most of the efforts surrounding PPD are directed towards the
   mother, there is little doubt that the father/significant other must be considered in the NICU. North American studies of paternal postpartum depression estimate that 13% of fathers experience some level of PPD after the birth of their child (Cameron, Sedov & Tomfor-Masden, 2016). Studies have also revealed that a father’s depressive symptoms may mimic the mother’s symptoms, and risk factors included perceived lack of support from the nursing staff, younger gestational ages, and longer periods of hospitalization (Roque et al, 2017). While naturally most time and resources are dedicated to assessment of PPD in mothers, it cannot be overstated that the impact on the mother may directly impact the father/significant other. And the cycle continues.

It is critical that we continue to collect data on PPD, follow it where it leads us, and continue to build upon best practices that continue to emerge for women experiencing PPD. It is imperative that a broad spectrum of resources and services are available in the Neonatal Intensive Care Unit that support the identification of and reduction of preventable maternal morbidity and mortality, including Postpartum Depression. It would be ideal to consider every NICU a care environment within which every day is World Mental Health Day.

References:

Cameron, E.E., Sedov, I.D, & Tomfohr-Masden, L.M. (2016). Prevalence of paternal depression in pregnancy and the
postpartum: An updated meta-analysis. Journal of Affective Disorders, 206, 189-203

Chen, M. J., Kair, L., Schwarz, E.B., Creinin, M. & Chang, J. (2019). Postpartum care for mothers of preterm infants requiring intensive care: A qualitative study. Obstetrics & Gynecology, 133, (58S). doi: 10.1097/01.AOG.0000559018.82693.b3

Cherry, A.S., Blucker, R.T., Thornberry, T.S., Hetherington, C., McCaffree, M.A. & Gillaspy, S.R. (2016). Postpartum depression screening in the neonatal intensive care unit: Program development, implementation and lessons
learned. Journal of Multidisciplinary Healthcare, 9, 59-67. doi: 10.2147/JMDH.S91559

Goldman-Mellor, S. & Margerison, C.E. (in press). Maternal drug-related death and suicide are leading causes of maternal death in California. American Journal of Obstetrics & Gynecology. https://doi.org/10.1016/j.ajog.2019.05.045

Roque, A.T., Lasiuk, G.C., Radunz, V. & Hegadoren, K. (2017). Scoping review of the mental health of parents in the nicu. Journal of Obstetric, Gynecologic and Neonatal Nursing, 46, 576-587.

The authors have no conflicts of interests to disclose.