Defining The Case For Routine Screening Of Postpartum Depression At Child
Health Clinics: An Evidence Based Approach To Maternal Child Health Policy

Meridy Black (Todd)
B.ScN., University Of British Columbia, 1988

Thesis Submitted In Partial Fulfillment Of
The Requirements For The Degree Of
Master Of Scienee
In
Community Health Seience

The University Of Northern British Columbia
February 2006

© Meridy Blaek, 2006

1^1

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11

ABSTRACT
In this study, systematic screening was explored at two-month and four-month
child health clinic visits for postpartum depression as a best practice approach to
reproductive mental health during the postpartum period. The study, which took place
over a period o f six months in the Prince George region of British Columbia, screened
207 new mothers. The study was delivered at two separate but allied primary health care
sites and involved the participation of health care staff. The study entailed screening new
mothers for postpartum depression using the Edinburgh Postnatal Depression Scale
(EPDS) screening tool at the two-month and four-month child health immunization
clinics. The study employed a mixed method research design. Twenty demographic
variables were analyzed to compare positive (>12), borderline (9-11), and negative (<9)
EPDS score of participant mothers. Pearson’s Chi-square test was performed to explore
the relationships between the demographic variables of the positive (>12) and negative
(<12) EPDS scores of participant mothers. T-tests were used to compare the mean value
o f the dependent variable (EPDS scores) with the independent variables. Spearman’s
correlation was used as a rank order correlation test between EPDS Scores and PHN twoquestion survey.
Following preliminary analysis of the questionnaire, survey, and EPDS data, two
separate focus group interviews were undertaken with women who had positive or
slightly below positive EPDS scores and with public health nurses. The study revealed 17
(8.2%) positive screening scores at two-months postpartum and 9 (4.7%) positive
screening scores at four-months postpartum for PPD using the EDPS. Therefore, the
study revealed an overall positive EPDS score of 25 over the total screening period.
There are at least six important areas for primary health care policy development in
relation to the findings of this study. These findings are consistent with findings from
other studies exploring screening for postpartum depression and have important
implications for mothers and their families.

Ill

TABLE OF CONTENTS
ABSTRACT................................................................................................................... ii
TABLE OF CONTENTS..............................................................................................iii
LIST OF TABLES.......................................................................................................... vi
LIST OF FIGURES........................................................................................................ vii
ACKNOWLEGEMENT................................................................................................viii
CHAPTER 1................................................................................................................... 1
Introduction.................................................................................................................... 1
Rationale for the Research............................................................................... 3
Prince George Maternity Home Visiting Program.......................................... 4
Best Practice Guidelines Relating to Reproductive Mental Health................ 5
Purpose of the Research................................................................................... 5
Statement of the Research Question................................................................ 6
Organization of this Thesis Report.................................................................. 7
CHAPTER 2...................................................................................................................8
Literature Review............................................................................................................8
Prevalenee of Postpartum Depression.............................................................8
Cultural Predisposition.......................................................................... 12
Screening Tools for Postpartum Depression....................................................13
Beck Depression Inventory................................................................... 14
Postpartum Depression Screening Scale.............................................. 15
Centre for Epidemiological Studies- Depression................................16
The Edinburgh Postnatal Depression Scale.........................................16
Aetiology of Postpartum Depression ..............................................................18
Biological Theories................................................................................ 18
Medical Model....................................................................................... 20
Feminist Theory..................................................................................... 21
Psychosocial Theory..............................................................................23
Attachment Theory................................................................................24
Interpersonal Theory............................................................................. .25
Self-Labelling Theory.......................................................................... .27
Explanatory Model.................................................................................26
Implications for Personal, Child, and Family H ealth..................................... 27
Mother-Infant Attachment Issues.........................................................28
Infant Development Issues................................................................... .29
Infant Interaction/Relationship Issues..................................................31
Spousal Issues........................................................................................32
Economic Costs
33

IV

CHAPTER 3................................................................................................................... 35
Research Design............................................................................................................35
Descriptive Research........................................................................................ 35
Mixed Research Methods................................................................................. 36
Triangulation.........................................................................................37
Sampling............................................................................................................ 37
Consecutive Cohert Sample Strategy................................................. 38
Purposive Sampling Strategy.............................................................. 39
Expert Sampling Strategy.................................................................... 39
Phase One of Study........................................................................................... 40
Implementation Process....................................................................... .40
Locating the Study at Child Health Clinics (CHC)........................... .42
Data Collection...................................................................................... 43
Data Management................................................................................. .47
Data Analysis........................................................................................ .48
Phase Two of Study.......................................................................................... 49
Focus Group Interview....................................................................... .49
Participant Mother Focus Group......................................................... 50
Data Collection...................................................................................... 51
Data Analysis......................................................................................... 53
Public Health Nurse Focus Group...................................................... 54
Data Collection...................................................................................... 54
Data Analysis......................................................................................... 54
Ethical Considerations...................................................................................... 55
Summary Comment............................................................................. 56
CHAPTER 4...................................................................................................................57
Findings..........................................................................................................................57
Demographics................................................................................................... 57
Results from Two-Month CHC........................................................................58
Borderline Scores................................................................................. 59
New Positive Cut-Off for EPDS Scores............................................. .60
Spearman Correlation Between EPDS Scores and PHN
Survey Scores at Two Months............................................................ 61
Results from Four-Month C H C ......................................................................63
Borderline Scores................................................................................. 64
New Positive Cut-Off for EPDS Scores............................................. .64
Spearman Correlation Between EPDS Scores and PHN
Survey Scores at Four Months............................................................ .65
Participant Mothers Focus Groups..................................................................66
Participant Mothers Focus Group....................................................... 66
Question # 1: How Do You Feel About Screening New Mothers
About Their Emotions During The Child Health Clinics?................67
Question # 2: What Do You Think About The Screening
Questionnaire That Was Used?........................................................... 74
PHN Focus Group Findings.............................................................................80

V

Question # 1: How Do You Feel About Screening New Mothers
About Their Emotions During the Child Health Clinics.....................81
Question # 2: What Were Some of Your “Most Salient”
Experiences With Being Participant to This PPD Screening
Study?.....................................................................................................89
Summary Comments......................................................................................... 92
CHAPTER 5....................................................................................................................93
Discussion..................................................................... .................................................. 93
Overview of the Study....................................................................................... 93
Summary and Interpretations of Findings........................................................94
Limitations of Study.......................................................................................... 98
Implications of Findings.................................................................................... 100
Policy Implications.................................................................................101
Recommendations for Future Research...........................................................106
Concluding Remarks..........................................................................................107
REFERENCES................................................................................................................108
Appendix A

Two and F our Month Questionnaire..................................................... 12 8

Appendix B

Public Health Nurse Survey...................................................................133

Appendix C

Participant Information Letter...............................................................134

Appendix D

Participant Informed Consent................................................................136

Appendix E

Definition of Terms.................................................................................137

Appendix F

Study Script............................................................................................. 138

Appendix G PHN Guidelines...................................................................................... 139
Appendix H

Focus Group Participant Letter and Consent........................................140

Appendix 1

Socio-Demographic Characteristics of Participants.............................143

Appendix J

Chi-Square Results................................................................................. 145

Appendix K

T-Test Results......................................................................................... 148

VI

LIST OF TABLES
Table 3.1

Participant Focus Group (N = 8)............................................................ 51

Table 4.1

Socio-Demographic Characteristics of Participants
(see Appendix I)

Table 4.2

Spearman Correlation Between EPDS Scores and PHN
2-Question Survey Scores at Two Months...........................................61

Table 4.3

Pearson Chi-Square Results at two and four months
(see Appendix J)

Table 4.4

Pearson Chi-Square Results.................................................................. .62

Table 4.5

T-Test Results at two and four months
(see Appendix K)

Table 4.6

T-Test Results......................................................................................... 63

Table 4.7

Correlation Between EPDS Scores and PFIN Two-Question
Survey Scores at Four Months..............................................................65

Table 4.8

Essential Themes: Experiences of Mothers with Screening............... 67
for PPD

Table 4.9

Essential Themes: Experiences of Mothers with Screening
Questionnaire......................................................................................... 75

Table 4.10

Essential Themes: Experiences of Public Health Nurses with
Routine Screening for PPD................................................................... 81

Table 4.11

Essential Themes: Experiences of Public Health Nurses who where
participant to this PPD screening research study................................89

v il

LIST OF FIGURES
Figure 4-1

Negative (<I2) and positive (>I2) Edinburgh Post-natal
Depression Scale scores at the two-month child health clinic
(N = 207)................................................................................................. 59

Figure 4-2

Negative (<9), Borderline (9-11), and Positive (>12) Edinburgh
Post-natal Depression Scale Scores at two-month Child Health
Clinics (N = 207).................................................................................... 60

Figure 4-3

Negative (<9) and Positive (>9) Edinburgh Post-natal Depression
Scale Scores at two-month ChildHealth Clinics (N = 207)...............61

Figure 4-4

Negative (<12) and positive (>12) Edinburgh Post-natal
Depression Scale cores at the four-month child health clinic
(N = 190)................................................................................................ 64

Figure 4-5

Negative (<9), Borderline (9-11), and Positive (>12) Edinburgh
Post-natal Depression Scale Scores at four-month Child Health
Clinics (N = 190)....................................................................................64

Figure 4-6

Negative (<9) and Positive (>9) Edinburgh Post-natal Depression
Scale Scores at four-month ChildHealth Clinics (N = 190)...............65

V lll

ACKNOWLEDGEMENTS
First, I would like to extend a sincere thank-you to every new mother in the Prince
George community who participated in the study. Your commitment to this research
initiative has informed us about PPD from your lived experience. This knowledge gained
will lead to a more supportive future for mothers who follow behind you. Also, I thank
Northern Health for approving this thesis research. I would like to acknowledge the
Michael Smith Foundation for Health Research for its financial support through its 2005
summer grant program.
Second, I thank my committee member Dr. J. Tousignant who instilled a sense of belief
in me from the origin of the thesis topic thru to the closing chapter. You have been a
remarkable teacher, one will standout in my mind forever.
Third, my supervisor. Dr. K. Kelly who has been instrumental in opening my eyes to the
field of health research and who struck a cord of interest within me that was previously
dormant. Her support has been very much appreciated.
My committee member, Lela Zimmer has dedicated her time to this process and has
provided support from the professional nursing practice perspective.
A more personal thank-you is extended to the nurses and staff who dedicated their time to
this study, without whom this research would not have come to fruition. I also thank all
of my former masters’ classmates who inspired me. To my friends who sustained years of
conversation with me about my thesis and never once shut me down, I thank-you.
Finally, to my family I owe a huge thank-you. First, I thank my daughter Hannah
who has been witness to this exigent process, 1 hope you can understand the magnitude of
the gift of time you have given me to complete this very imperative work. Second, I
thank my partner who has encouraged me relentlessly; he has listened, supported and
enabled me to see the vision of this thesis to completion. I thank my mother for being a
wonderful person. It is only now, after all these years that I can begin to understand some
of the complexities you faced as a new mother when you experienced life with so many
barriers, particularly during a time when no one knew how to help. To that end I enter a
quote you once gave me written by John Whitehead:
“

Children are the living messages we will send to a time we will not see”

Therefore, let us never forget that postpartum depression has left its mark thru history,
and it will continue to mark its pathway into the future, and thus may the work we do to
support new mothers in our com m unities always sponsor a high level o f consciousness,

as at the core of this very sensitive issue is the lives of our children... our future parents.

CHAPTER ONE
Introduction
Postpartum depression (PPD) is a mental health problem that carries substantial
risks for women, children, and families (British Columbia Reproductive Mental Health
Program [BCRMHP], 2002; Canadian Mental Health Association [CMHA], 2005;
Mauthner, 1999; Nicholson, 1999; O’Hara, 1997; Ross, Dennis, Robertson, & Stewart,
2005). It has been shown to undermine a mother’s confidence, estrange spouses, and
impair social functioning (CMHA, 2005; Dennis, 2003, 2004; Lee et al., 2003). Yet,
unless symptoms are severe and role dysfunction is substantial, PPD is often not
recognized by affected women, their families, and health care providers (Ballard, Davis,
Cullen, Mohan, & Dean, 1994; Chung, McColllum, Elo, Lee, & Culhane, 2004; Cooper
& Murray, 1998; Evins, Theofrastous, & Galvin, 2000).
The current literature identifies three distinct categories of PPD (Leopold &
Zoschnick, 1997; Ugarriza & Robinson, 1997). The most common is the “baby blues,”
also known as the maternity blues (Fossey, Papiemik, & Bydlowski, 1997, p. 18). The
baby blues are distinguished by sudden mood swings, which range from euphoria to
intense sadness; however, this condition has a relatively short duration and typically
disappears without medication (Yalom, Limde, Moos, & Hamburg as cited in Ugarriza &
Robinson, 1997). The most severe category of PPD is postpartum psychosis (Horowitz,
Damato, Solon, vonMetzsch, & Gill, 1995). The onset of postpartum psychosis is fast and
harsh, usually within the first two w eeks after delivery (Horowitz et al., 1995). Women
who suffer from postpartum psychosis may entirely lose touch with reality (Beck, 1992),
and they are often subject to hallucinations and delusions (Leopold & Zoschnick, 1997).

Moreover, PPD is characterized by feelings of sadness, despair, anxiety and
irritability (Gitlin & Pasnau as cited in Ugarriza & Robinson, 1997). The differences
between the baby blues and postpartum depression are based on the severity of the
symptoms, how long they last, and the fact that postpartum depression interferes with
day-to-day functioning to a greater degree (Gitlin & Pasnau, as cited in Ugarriza &
Robinson, 1997).
Recent research has shown that postpartum depression is usually unreported and
frequently undetected by health care professionals (Gaynes et al., 2005; Hagen, 1999;
Hanna, Jarman, Savage, & Layton, 2004; Ross, Dennis, Robertson, & Stewart, 2005),
“making the early detection of postpartum depression an important issue for all midwives
and nurses working with women in the prenatal and postpartum periods” (Hanna, Jarman,
Savage, & Layton, 2004, p. 191). According to Yonkers et al. (2001), missing the mark
on detection for PPD poses a risk for new mothers and their families alike, making this
issue a significant public health problem. Health care practitioners who deliver
postpartum health services need to know how to screen for the existence of PPD, as early
identification can be significant to the prevention of this potentially life threatening
illness (Ugarriza & Robinson, 1997).
Cariati (2001) argues for the implementation of routine screening protocols to
serve as a means of flagging mothers who are at risk for PPD and who will benefit from a
timely referral to a physician for a further in-depth evaluation. Miller (1999) supports the
notion o f screening for PPD, claim ing that early identification w ill lend itself to

preservation of the family structure and will further seek to divert women, their families

and infants from the potentially devastating consequences which can occur when PPD
remains unrecognized.
Rationale fo r the Research
Despite the recent upsurge in studies on postnatal mental health and several high
profile media stories such as the August 2000 tragic deaths of 37-year-old doctor
Suzanne Killinger-Johnson and her six-month-old baby, many women continue to suffer
needlessly from PPD because of deficient detection mechanisms. It is estimated that 10%
to 20% of new mothers across Canada experience various degrees of postpartum
depression (British Columbia Reproductive Mental Health Program [BCRMHP], 2002;
Health Canada, 2000; Stewart, Robertson, Dennis, Grace, & Wallington, 2005). A
reported 331,522 women gave birth in Canada between July 1, 2002 and June 30, 2003
(Statistics Canada, 2003). In the province of British Columbia, for this same time period,
40,134 women gave birth (Statistics Canada, 2003). For the city of Prince George, 1,023
women gave birth in 2003 (British Columbia Vital Statistics Agency, 2003). Based on
these figures, we can infer that PPD will disrupt the lives of 33,152 to 49,728 new
mothers on an annual basis in Canada. For the province of British Columbia, this number
would amount to 4,013 to 6,020 and in the community of Prince George between 102 to
153 new mothers would be affected. These numbers strongly illustrate the significance of
how many mothers may be affected from PPD and how infants and families bound to the
affected mother may be affected as well; hence the importance for early detection and
reliable screening procedures.
PPD may emerge during the first week postpartum and can carry over into the
postpartum period for up to two years (Gorman et al., 2004; Haller, 2005; O’Hara, &

Gorman, 2004; PsychDirect, 2005). PPD can affect women of all ages and races and can
develop after the birth of any child (O’Hara & Gorman, 2004; PsychDirect, 2005). The
implications of early detection remain significant for the immediate and long-term mental
health of the mother, her spousal relationship, and the cognitive and behavioural
development of her child. One way to explore the issue of PPD is to routinely screen all
postpartum mothers. As reported by Cox and Holden (as cited in Matthey, 2005, p. 253),
“in the absence of systematic screening, most postnatal mood disorders are not detected.”
Among various screening tests for PPD, experts consider the Edinburgh Postnatal
Depression Scale (EPDS) the best choice in terms of its ease of administration, validity,
specificity and sensitivity (Cox, Holden, & Sagovsky, 1987; Eppersen, 1999; O’Hara,
1995).
Prince George Maternity Home Visiting Program
The Northern Health Authority’s* public health maternity home visiting program^
in Prince George distributes resource booklets, which contain a self-administered EPDS
screening tool to all new mothers. Public health nurses (PHN) present the resource
booklet to new mothers within 48 hours of their discharge from the hospital. During the
60 minute home visit, the PHN is required to briefly review the 40 page resource booklet,
including the self administered EPDS screening tool; however, it is unlikely that a mother
in a depressive state will take the time to complete the EPDS screening tool (Beardslee,
2002; Misri, 2002; Saunders, 2003). The limited home visiting time creates a difficult
' Publicly funded health services in BC, with the exception o f the majority o f physician services,
som e allied health professional services (such as physiotherapy), pharmacare, and ambulance services, are
delivered under 6 regional health authorities.
^ The Maternity Visiting Program is a program for mothers, newborn babies and their fam ilies. It
provides postpartum support through home visits follow ing the birth o f the baby.

challenge for the PHNs who are required to complete a number of tasks, thus leaving
only a few minutes to cover the self-administered PPD screening tool. Moreover, the
literature on postpartum depression also reports that the EPDS is not an effective
screening tool for diagnosis of depression in the immediate postpartum period (Lee et al.,
2003). Mothers often report during their Child Health Clinic (CHC) immunization visits
that they misplaced the booklet or had forgotten that they had ever been given one.
(personal communication with mothers in CHC’S).
Best Practice Guidelines Relating to Reproductive Mental Health
In 2002, a working group consisting of several community stakeholders drafted
“best practice guidelines” relating to the early identifieation, assessment, treatment and
follow-up of women with reproductive mental health illnesses during pregnancy and the
postpartum period (Ministry Mental Health Services, 2002). The report recommended
that within a 5 year period the province should have universal sereening in place using
the EPDS.
Purpose o f the Research
Within the context of evidence-based health care (EBHC), this study is an
exploration of systematic screening for postpartum depression as a best practice approach
to reproductive mental health during the postpartum period. It entailed screening new
mothers for postpartum depression using an EPDS screening tool at the two-month and
four-month child health immunization clinics. EBHC is based on the premise that
relevant, high quality research should be a component o f health care decision-m aking
(Couzos & Murray 2003; Muir Gray, 1997). It involves continuously and systematically
searching, appraising, and incorporating contemporaneous researeh findings into clinieal

practice. The overall goal is improving patient care through life-long learning for the
client’s, serviee providers and the organization.
Statement o f the Research Question
A mixed methods research design, which combined quantitative and qualitative
data collection and analysis, was used for this study. As Creswell, Fetters, and Ivankova
(2004, p. 7) state, the use of “mixed methods or multi-method research” is gaining
acceptance and “holds potential for rigorous, methodologically sound investigations in
primary care.” A two-month and four-month questionnaire (see Appendix A), public
health nurse survey (see Appendix B), and the EPDS were used to collect data from 207
women from the Prince George Region^ at two-month and four month CHCs. Following
preliminary analysis of the questionnaire, survey, and EPDS data, two separate focus
group interviews were undertaken with women who had positive (>12) or slightly below
(<12) positive EPDS scores and with public health nurses. The specific research question
that guided this study was whether the systematic or routine screening for PPD using the
EPDS at two-month and four-month CHCs increase the identification of at “risk”
mothers? The research objectives include:
1. What are the number of mothers who screen positive (>12) on the EPDS at twomonth and four-month CHCs?
2. What are the number of mothers who have borderline (9-11) scores on the EPDS
at two-month and four-month CHCs?
3. How do the demographic characteristics of mothers who screen positive (>12) on
the EPDS scale eompare with mothers who screen negative (<12)?
^ Prince George region includes the city o f Prince George and surrounding areas with an estimated
population o f 80,000.

4. What is the correlation between mothers who screen positive on the EPDS
screening tool and the PHN survey responses?
5. What are the perceived advantages/disadvantages of using routine screening for
identifying mothers at risk of PPD as perceived by mothers who screened positive
on the EPDS?
6. What are the perceptions of the public health nurses who administer the EPDS?
Organization o f This Thesis Report
In chapter 1 ,1 present the rational and purpose of the study. In Chapter 2 , 1 place
the study in context by providing an examination of the literature in regards to
prevalence, screening, and aetiology, and the social and economic implications faced by
women suffering with PPD. Chapter 3 presents the overall research design and
methodological framework for the study. Chapter 4 presents the findings of the
quantitative and qualitative data analysis. Finally, Chapter 5 presents my discussion of
the findings, limitations of the study, implications of the findings for policy and practice,
and future research in light of the study’s findings.

CHAPTER TWO
Literature Review
In this chapter, literature that is pertinent to this study is presented. Literature
searches were conducted using Alt-Health Watch, CINAHL (Cumulative Index to
Nursing and Allied Health Literature), Health Source: Consumer Edition, Health Source:
Nursing/Academic Edition, Humanities and Social Sciences Index, MEDLINE data
bases, the library’s general catalogue and electronic journal portal of the University of
Northern British Columbia library, and World Wide Web search engines. Additional
sources of literature were obtained by reviewing reference lists in published articles. An
initial literature search was conducted in September 2001 as part of a self-directed
readings course. A second search was conducted between September 2003 and June
2004.
The literature review is organized around four subject areas that address the
objectives of this study. These include prevalence and incidence statistics of PPD,
screening tools, aetiology and associated risk factors, and implications for personal, child,
and family health.
Prevalence o f Postpartum Depression
Mental health is influenced by a variety of determinants such as education,
income, employment, social support and environment etc. (Canadian Institute for Health
Information, 2005; Poland, Cobum, Robertson, & Eakin, 1998; Public Health Agency
Canada, 2003; Raphael, 2003). Research has shown that promoting good mental health
can reduce overall vulnerability and improve the general mental health of the population
(Pulliam & MacKenzie, 2003; Stephens et al., 1999; World Health Organization, 2004).

Defined as a mood disorder, depression ean be identified as a condition in an individual
who exhibits symptoms of fatigue, hopelessness, sadness, irritability, and helplessness
(Stephens et al., 1999).
Statistics Canada (2000) reports depression as a condition that is more prevalent
in women than in men. Statistics Canada’s (2000) National Population Health Survey
(NPHS) 1998-1999 reports that females aged 20 to 24 experience a probable 10%
prevalenee of depression while males in the same age range experience a probable rate of
4%. For women ranging in age from 25 to 34 the rate is 9% while it is 3% for men.
Reflecting upon this spectrum of age groupings and recognizing that these years also
signify childbearing years for women, it is theoretically possible that some women who
are pregnant are also depressed. Of notable significance in the NPHS of both 1994/95 and
1996/97 was that “women were more likely to experience recurring depressive episodes”
(Health Canada, 1999, p. 7). The prominent percent age differences in prevalence
between genders are accounted for through the rationalization that women likely
experience and cope with stress and life events differently than men and this variation
subsequently impacts how depression is revealed to the broader audience (Health Canada,
1999). Factors associated with reproduction such as the menstrual cycle, pregnancy, and
menopause are also thought to contribute to this difference (Altshuler, 2002; Gotlib,
Whiffen, Mount, Milne, & Cordy, 1989).
According to the American Psychiatric Association’s Diagnostic and Statistical
M anual o f M ental D isorders (DSM-IV-TR), sym ptom s o f major depressive disorder,

bipolar disorder, or brief psychotic disorder must occur within the first month after
childbirth to qualify as postpartum onset (American Psychiatric Association, 2000).

10

The postpartum period has been identified as a time when many new mothers are
susceptible to a range of emotional syndromes. The leading mental or emotional problem
for mothers following childbirth is postpartum depression (Wisner, Parry, & Piontek,
2002), and one of the most significant challenges during this time is to differentiate
between emotional issues and to correctly identify mothers suffering from PPD (Ugarriza
& Robinson, 1997).
The prevalence'* of postnatal depression has been studied extensively. Typically,
lower rates of depression are reported by researchers who use diagnostic interviews. For
example, Gotlib et al. (1989) examined prenatally and postnatally a heterogeneous group
of 360 using a self-report questionnaire to measure depression. Prevalence rates of
depression were 10% prenatally and 7% postnatally. Sample attrition and low reliability
of the Beck Depression Index (EDI) screening tool used were reported as reasons for the
reported rate of PPD. Mothers reporting sub-clinical scores on the EDI were re-screened
using the State of Anxiety and Depression (SAD) tool, which yielded an increased
diagnostic rate of 8.8% for PPD, but caution was advised not to generalize these results.
Interestingly though, these results did raise the overall prevalence rate of 13%. Socio­
demographic variables associated with depression during the prenatal period were not
consistent with those reported postnatally, except for women who had postpartum
depression, suggesting that there may be diverse variables influencing depression at these
two times. The use of self-reports generally results in much higher prevalence rates.

'* Some studies were reported as point prevalence, the percentage o f the population with depression
at a given point in time (e.g., at 24 weeks gestational age or 9 w eeks postpartum); others were reported as
period prevalence, the percentage o f the population with depression over a period o f time (e.g., during
pregnancy or from delivery to the end o f the first 3 months postpartum).

11

Studies assessing maternal blues report that 35-80% of mothers report psychological
distress within the first ten days after childbirth (Lee, 1997; Yamashita, Yoshida, Nakano,
& Tashiro, 2000). Yamashita et al. (2000) further reported that 42% of the women in
their study who experienced baby blues subsequently developed postpartum depression.
Epidemiological studies of postpartum samples have consistently revealed a
prevalence rate of 10% for non-psychotic depression in the early period postpartum
period (Cooper & Murray, 1998; Horowith et al., 1995). In one prospective study of 119
first time mothers, Kumar and Robson (1984) demonstrated that the incidence of
depression rises markedly in the first twelve postpartum weeks compared with either the
third trimester of pregnancy or the pre-pregnancy trimester (14% v 2.7%, or 5.2 relative
risk).
Lane et al. (1997) conducted a study in Ireland with 385 mothers, screening at
three days and six weeks postpartum. Fathers were also screened for postnatal depression.
Prevalence of PPD at six weeks for mothers was reported to be 11%, which was
recognized to be consistent with studies completed by Kumar and Robson (1984), Paykel,
Emms, Fletcher, and Rassaby (1980), Watson, Elliott, Rugg, and Brough (1984), Nott
(1987), and Glover et al. (1994), all of whom reported PPD rates between 10-20%.
Beck and Gable (2001) cite O’Hara and Swain (1996) in stating that
approximately 13% of mothers will experience PPD some time within the first year. Beck
(2001) highlights the magnitude of consequences resulting from prolonged delays with
identification o f PPD and initiation o f treatment, stating that in addition to the mother’s
own suffering, the relationship with her infant can be impacted resulting in altered
cognitive and emotional functioning.

12

Lastly, Canadian researchers Watt, Sword, Krueger, and Sheehan (2002)
conducted a cross-sectional study of early identification of postpartum depression, which
examined utilization patterns, health outcomes and costs associated with existing
practices in the management of postpartum women and their infants. The study looked at
a subgroup of 875 women who scored >12 on the EPDS. EPDS scores of >12 were found
in 4.3% to 15.2% of otherwise healthy women. None of these women were being treated
for postpartum depression. Best predictors of an EPDS score of >12 were lack of
confident support, lack of affective support, household income of < $20,000 , wanting to
stay in hospital longer, identification of learning needs while in hospital, self-identified
care needs for an emotional/mental health problem that have not been met, and mother’s
rating of own and baby’s health as fair or poor.
Cultural Predisposition
Anthropological study reports dating back to the 1960’s and 1970’s conducted in
Asia and Africa noted that PPD was rare and therefore a disorder likely culturally tied to
industrialized countries. Explanation for this variance was grounded in the belief that
social support and childcare practices that typically followed childbirth in these cultures
provided some protective barrier for the mother (Wile & Arechiga as cited in Miller,
1999). Ugarriza (2002) suggests that PPD is possibly linked to the cultural boundaries of
the industrialized Western Nations but adds that further study into the understanding of
cultural connections to the postpartum period of care for new mothers is warranted to
gain a broader scope of cultural influences and prevalence for PPD.
More recent literature reporting on Chinese postpartum practices (Eisenbruch,
1983), prenatal and postpartum customs of Vietnamese, Khmer and hill tribe Laotian

13

pregnant women (Lee et al as cited in Miller, 1999), Latino practices (Stem & Kruckman
1983) and on reserve practices for specific Native women (Carmthers, 1987) suggest that
when traditional practices are followed and support is in place, postpartum depression is
not an issue. For Schmidt (as cited in Miller, 1999), western culture and religion have
shaped a more individualistic responsibility for the individual. When additional variables
such as social isolation rooted in urban life and financial constraints are added, mothers
in Western cultures are subject to higher incidents of depression.
A number of epidemiological studies, however, have found variations in the rate
of postpartum depression in certain cultural samples. For example, a substantially lower
rate has been found in a Malaysian sample (Grace Lee, Ballard, & Herbert, 2001),
whereas in an impoverished urban South African postpartum sample the rate was found
to be as high as 34 % (Cooper et ah, 1999).
Screening Tools fo r PPD
The Beck Depression Inventory (BDI), the Postpartum Depression Screening
Scale (PDSS), the Centre for Epidemiological Studies-Depression (CES-D), and
Edinburgh Postnatal Depression Scale (EPDS) were the four instruments under
examination for selection with this research study. Criteria for selection included best fit
for use in the CHCs, with the given population and the time period selected. Additional
criteria included the tool that had the greatest validity and reliability as a first stage
screening instmment. It is important to point out that screening for postnatal depression is
an important first step in identifying w om en who are at risk o f having PPD. It is only an
initial step; after a positive screen, a depressive illness must be confirmed by a follow-up
diagnostic examination and determination by a clinician.

14

Beck Depression Inventory
The BDI is a 21-item depression severity scale with a reliability of 0.92, a
construct validity correlation with the Symptom Checklist 90-Revised of 0.76, sensitivity
of 100% and specificity of 89% with a cut-off score of 16 (Beek, Ward, Mendelson,
Mock, & Erbaugh, 1961; Burt & Ishak, 2002). Although the BDI scale was originally
designed to be administered by trained assessors, it is most often self-administered and
takes 5 to 10 minutes to complete (Gaynes et al., 2005). The validity of the tool was
established when comparisons were made between inventory scores and those based on
clinieal assessments (Beck et al, 1961). Beck (1996) remarks that this tool is reeognized
for its validity and reliability, but also points out that it has poor sensitivity in that it does
not identify postpartum women who are suffering with minor depression. Several other
studies discuss the potential for misleading results when the BDI is used as an exclusive
scale for postpartum depression, as certain questions on the scale may be deceptive for a
women following childbirth (Cox & Holden, 2003; Cox et al., 1987; Vieira, 2002).
The BDI-II, which has been validated for use in pregnancy (Holcomb et al.,
1996), was developed as an indicator of the presence and degree of symptoms correlated
with depression as defined in the DSM-IV, not as an instrument for specifying a clinical
diagnosis (Beck, 2001). The BDI-II consists of 21 items rated on a 4-point scale and
summed for a total score (range 0-63) (Beck, Brown, & Steer, 1996). Beck (1996)
recommended that scores in the following ranges reflect varying levels of symptoms of
depression, for non-pregnant adults scores o f 0 to 13 for minimal to no sym ptom s o f
depression, scores of 14 to 19 for mild symptoms of depression, scores of 20 to 28 for
moderate symptoms, and 29 to 63 for severe symptoms of depression.

15

However, Gaynes et al. (2005, p. 53) argues that “because of [the BDI-II] reliance
on somatic symptoms, some experts worry that it may produce higher scores and more
false-positive results in pregnant women than in other respondents.”
Postpartum Depression Screening Scale
The PDSS is an instrument recently developed specifically for identifying post­
partum depression based on studies undertaken by Beek (1992) and Beck and Gable
(2000). It is a 35-item Likert-type self-report instrument covering “sleeping/eating
disturbances, anxiety/insecurity, emotional liability, cognitive impairment, loss of self,
guilt/shame, and contemplating harming oneself’ (Hanna, Jarman, Savage, & Layton,
2004, p. 192). The tool is self scored by the mother, who uses a Likert scale ranging from
1 to 5 to indicate her degree of agreement or disagreement with each statement. Content
validity was demonstrated through the literature, clinical experts and a focus group (Beck
& Gable, 2000). When compared to two other instruments in subsequent research. Beck
and Gable reported that the PDSS had a specificity of 72% and a sensitivity of 91%,
which were higher than the specificity and sensitivity of the other scales (Hanna et al.,
2004). According to Hanna et al. (2004):
The PDSS has the advantage of enabling detailed information on seven symptom
subscales to be obtained. Scores for each of these can be examined to identify the
areas where women are experiencing problems so that the most appropriate action
can be taken. It also has the advantage of providing a mechanism to check for
inconsistent response patterns. A further advantage is the classification o f w om en

into three groups at varying risk of post-partum depression. The alpha reliability
scores for the seven scales indicated high levels of internal consistency, with a >

16

0.90 for five of the scales. These scores are similar to those reported elsewhere.
However, the instrument is long and quite time-consuming, both to complete and
to score, (p. 78)
Centre fo r Epidemiological Studies-Depression
The CES-D is a 20-item scale that evolved from existing instruments for assessing
depression (Horowitz et al., 1995). This self-report scale is easily administered and
completed in a few minutes. Other strengths of the scale are that it is easily scored and
that the measurement of symptoms intensity is connected to frequency of occurrence
(Horowitz et al., 1995).
Limitations of the CES-D scale are that it is not a diagnostic tool for depression
and therefore recommended to be used in conjunction with other screening tools. The tool
is refined to explore depressive symptoms and may therefore be self limiting in its utility
for use in the postpartum as it does not consider the postpartum adjustment period; there
remains potential for bias with questions that may be reflective of depression at other
times of life but may be a normal reaction in the postpartum, thus potential for false
positive scores. Finally, no items on the scale are specific to childbirth (Horowitz, et al.,
1995).
The Edinburgh Postnatal Depression Scale
The EPDS was developed by researchers Cox, Holden et al. (1987) and was
designed to allow screening of postnatal depression in the primary care setting. The
innovation for this screening tool was based on the acknowledgm ent that the existing
tools were limited in their capacity to detect depression in pregnant or postpartum women
(Cox et al., 1987). In 1983, Cox conducted a prospective study in Scotland and Uganda

17

which revealed rates of postpartum depression in the range of 13% and 10% in these two
populations of women. The statistics signified the need to act on the development of a
tool sensitive to pick up this mood disorder (Cox, & Holden, 2003).
The 13 item questionnaire was validated with a study sample of 60 women (Cox,
1986). The tool was found to successfully distinguish between women who did and did
not have depression. During a factor analysis of the questionnaire, it was realized that the
questionnaire could be reduced to 10 questions while maintaining its effectiveness. A
second validation of the 10 item questionnaire with 84 postpartum women was successful
in identifying women with major depression when cut off scores were rated at 12 or 13.
The following two questions are examples of the 10 questions found on the EPDS
screening tool:
Question 3 : 1 have blamed myself unnecessarily when things went wrong: yes,
most of the time =3: Yes, some of the time - 2, Not very often = 1; No, never = 0.
Question 10: The thought of harming myself has occurred to me: Yes, quite
often = 3; Sometimes^ 2; Hardly ever = 1; No, never= 0.
The specificity (the proportion of women with research negative diagnostic
criteria (RDC) who truly did not have depression) was rated at 78% while the sensitivity
of the EPDS, “the proportion of women with positive RDC who were true positives, was
rated at 86%” (Cox & Holden, 2003, p. 17). According to Mausner and Kramer (1985)
sensitivity is defined as “the ability of a test to identify correctly those who have the
disease” while specificity is “the ability o f a test to identify correctly those w ho do not
have the disease” (p.217).

18

The split half reliability of the EPDS was 0.88, “obtained by dividing items on the
scale into two halves, which were then compared; a high correlation suggested that the
test was measuring the same items” (Cox & Holden, 2003, p. 18). Literature reviews in
the United States maintain the EPDS has been recommended for use to aid the primary
care screening since it is a simple, self-rated screening inventory that can be administered
to the patient at the time of her postpartum check-up (Kendall-Tackett, 1994; Wohlreich
& Lydiard, 1994). It is also recommended that when the EPDS is the only tool used in a
research project, that a cut off score of 9 or 10 be used as a first-stage screening scale for
the purpose of identifying depression. The EPDS is a useful tool for initiating secondary
prevention for depression by identifying early onset of symptoms. Finally, it is
recommended to increase the cut-off score to 12 or 13 when using the EPDS as part of a
screening program within the primary care environment (Cox & Holden, 2003). Horowitz
et al, (1995) adds that the ten item EPDS scale can be completed in five to ten minutes by
self-administration and is easily scored. They point out that the statements on the scale
reflect the underlying content of PPD and that each response offers four options, which
are categorized according to length or severity of the symptom under question. While the
EPDS has documented reliability in certain populations, some critics have raised
concerns about the cultural specificity of its language (Beck & Gable, 2002; Mantel,
2003; PND Training, 2005). Finally, it is important to point out that the EPDS is “merely
a screen for depression that reveals dysphoria or low mood at the time of completion and
indicates a need for further assessm ent. It does not provide a differential diagnosis o f
mental disorder, nor can it replace clinical judgment. Screening gives an indication of a

19

women’s need for help and should be a precursor to diagnosis and intervention” (Cox &
Holden, 2003, p. 58).
Of the four screening tools examined in this review, the PDSS and EPDS have the
highest specificity and sensitivity in detecting minor and major postpartum depression
and have a detection rate of 94% and 78% respectively (Beck & Gable, 2000) compared
with 56% for the BDl-lI (Cox et al., 1987).
Aetiology o f Postpartum Depression
While the aetiology o f PPD is still debated, there is a general consensus in the
literature that PPD results from complex interactions among biological, psychological,
and social factors, though for any given individual one factor may be more important
(Stenier, 1990).
Biological Theories
Deregulation of neurotransmitters, altered levels of cortisol, prolactin, estrogen
and progesterone hormones following delivery, as well as thyroid disorders have been
postulated as having etiological connections to PPD (Birkhauser, 2002; Bloch,
Rotenberg, Koren, & Klein, 2000; Holden & Phil, 1991; Leopold & Zoschnick, 2003;
Sichhel &.Driscoll, 1999). In the study by Abou-Saleh (1998), the women who were
depressed immediately after delivery had significantly lower levels of prolactin. Also,
those who developed depression within 6 to 10 weeks of delivery had significantly lower
levels of prolactin and higher levels of progesterone than non-depressed women. In
another study conducted by Bloch et al. (2005), 1800 postpartum women were assessed
for risk factors for postpartum mood disorders during the first 2 to 4 days after delivery.
Bloch et al. (2005, pp. 16-17) reports that the results of this study help to advance the

20

“hypothesis that the aetiology for postpartum mood disorders may be related to
differential hormonal sensitivity.”
Leopold and Zoschnick (2003) report that while neurotransmitters show no
apparent influence on PPD, lower norepinephrine levels show some connection to the
intensity of PPD. While Hagen (1999, p. 20) notes that cortisol, prolactin, estrogen and
progesterone “appear to have surprisingly little to do with PPD in any case,” thyroid
dysfunction in the postpartum period is found to be a relatively common factor and may
very well be connected with depressive symptoms (Leopold & Zoschnick, 2003; Spinelli,
1998). For Sichel and Driscoll (1999), the measurement of thyroid levels is a critical step
in the treatment of PPD, since “5 to 9 % of women have abnormal thyroid levels
postpartum, and some of them are depressed as well” (p. 204). They argue that in order to
elucidate whether the depression is linked to the thyroid or the postpartum hormones,
testing is imperative.
Evidence suggests that biological and physiological factors are clearly at play
during the postpartum period. However, to what extent and in what way they contribute
to postpartum depression is not yet clearly understood (Beck, 2002; Bloch et al., 2005;
Leopold & Zoschnick 2003).
Medical Model
The medical model assumes that the physiology of childbirth is universal
(Sawyer, 1999) and as a result, PPD is regarded as a “disease” or “illness” (Mauthner,
1999). From the m edical m odel perspective, the etiological origins of PPD are linked to
genetic predisposition, past history and hormonal variation for individual women
(Nicholson, 1990).

21

The difficulty with the medical model, according to Mauthner (1999) is its
devaluation of women’s own perspectives and associated individualistic approach rooted
in deficiencies pertaining to the individual mother. For Mauthner (1999, p. 145), “Taking
the individual as the basic unit of analysis excludes looking at broader social, political,
economic and structural contexts and the ways in which they intersect with individual
women’s circumstances.” Beck (2002) acknowledges the limitations of this
individualistic theoretical model and its treatment approaches as having significant
consequences because women are prescribed one of three categories; hormone
replacement, anti-depressant medication or treatment using anti-eonvulsive methods.
Similarly, Nicholson (1998) argues that the medical model fails to accord sufficient
weight to the subjective feelings of women who experience emotional turbulence
following child birth. While the medical model discourse has been challenged to some
extent by social scientists as a model which fails to acknowledge the impact of additional
life stressors on an individual’s psychological well-being, there is still an attempt to
“medicalize” (Mauthner, 1999; Nicholson, 1998).
Feminist Theory
The feminist theory offers a diverse perspective to that of the medical model.
Feminist theory embraces the social realms of women’s worlds as reasons for problems
and further suggests that motherhood is challenged by the social, political and cultural
contexts in which we live. It maintains that mothers’ experiences of childbirth should be
examined and their voices listened to; to exclude those voices only serves to perpetuate
postpartum depression and the controlling forces of the medical model (Beck, 2001;
Lazarre, 1997; Mauthner, 1999).

22

Lazarre (1997, p. 283) asserts that the medical model imposes an “impossible
standard of the motherhood mystique,” which feminist authors maintain is the connection
to PPD. Mauthner (1995) affirms that there are limitations of “determinism” in the
medical model that undermine the full capacity of women as thinking, feeling and
experiencing human beings. Two additional points which give rise to conflict for the
feminists about the medical model are the blaming of mothers through the
individualization of PPD, and the blatant disregard for hearing women’s voices and
validating the realities of their experiences.
Feminist theory relates the concept of bereavement and loss to PPD (Nicholson,
1989). Justification for the concept of loss is embedded in the understanding that
childbirth and transition to motherhood require major psychological shifts which are
normal in response to these experiences, and that women need recognition and
opportunities to discuss their experiences to therapeutically make the adjustment and
move into this new stable role.
Smith as cited in (DeJoseph, 1997, p. 516) discusses postmodernism and the
feminist analysis of women’s depression following childbirth asserting that feminists
must “question gender and the relations of ruling.” Further, (Smith) recognizes that there
is no one truth and that there is no one single explanation for life occurrences. This opens
up opportunity for discussion about issues around depression and women and theories of
childbirth. In Rethinking Mental Health and Disorders, Ballou and Brown (2002) wrote:
Human behavior is increasingly being forced into the box o f biology. Hormonal,

evolutionary, and genetic models of behavior are more frequently being proposed

23

as explanations for all human behaviors, even in the absence of strong empirical
science to support such models...(p. xi)
Psychosocial Theory
Horowitz et al. (1995, p. 269) report, “psychosocial models suggest that history of
psychological difficulties and life stressors are important predictor variables” for PPD.
For Horowitz, potential psychosocial predictors include self-esteem, the mother-daughter
relationship, and separation from one or both parents in childhood or adolescence, and
low parental emotional support.
According to Murray and Cooper (1996), the major risk factors of etiological
significance for PPD are rooted in the psychosocial aspects and are identified as
unemployment, presence of marital conflict, occurrence of stressful life events, and
absence of social support from either spouse, friends or family, and history of depression.
Wisner et al. (2002) further propose that factors such as stressful life events, past
episodes of depression, and mood disorders in the family may also increase vulnerability
to PPD.
A meta-analysis of 44 studies conducted by Beck (1996) identified postpartum
depression predictors. Nine predictors were found to have significant relationships to the
occurrence with PPD. These include; prenatal depression, child care stress, life stress,
lack of social support, prenatal anxiety, infant temperament, maternity blues, marital
dissatisfaction and history of previous depression. Beck (2001) further reports on a meta­
analysis o f 84 studies that supported earlier findings o f predictors identified in her 1996
Study with the addition of four more factors: single marital status, low socioeconomic
status, low self-esteem, and unplanned/unwanted pregnancy.

24

A substantive theory based on grounded theory method evolved from a study
conducted by Beck (1993) that included interviewing 12 mothers diagnosed with PPD
and engaging them in discussion for their descriptions pertaining to the development of
PPD. In the four stage process identified as “teetering on the edge,” loss of control was
the overriding social psychological issue for these mothers (Beck, 1993). Beck (2002)
cites three additional theories: attachment theory, interpersonal theory and self-labelling
theory which offer yet further analysis to the premises discussed within the medical
model and the feminist theories as aetiology relates to PPD in new mothers.
Attachment Theory
Research in the field of adult attachment is relatively new and emerges from the
work of Bowlby (1988). Not only is the interaction between attachment and depression
complex, but there is also a lack of empirical evidence regarding the directionality of the
interaction between depression and attachment difficulties. For example, while insecure
attachment relationships in the formative years may predispose an individual to
depression later in life (Anderson, Beach, & Kaslow, 1999), depression may also lead to
difficulties in developing and/or sustaining positive and secure attachment relationships
(Sexson, Glanville, & Kaslow, 2001).
There is a preponderance of research that links effective, adequate parenting to
optimal attachment in children (Ainsworth, 1973; Baumrind, 1991; Bronfenbrenner,
1986, 2002; Murray, 1992). Several studies have reported that maternal depression
increases risk for inseeure attaehment particularly so i f the depression is severe and

chronic (Gaensbauer et al., 1984; Teti, Gelfand, Messinger, & Isabella, 1995).

25

However, research in the area of PPD has largely disregarded the possible
contribution of maternal attachment style. One of the few studies investigating the
relationship between attaehment style and postnatal depression was recently conducted
by Meredith and Noller (2003). In a sample of 74 mothers with infants and married to the
baby’s fathers, “those identifying themselves as depressed reported a more preoccupied
attachment style by comparison with their non depressed counterparts” (Meredith &
Noller, p. 672). To determine the link between the mother’s attachment style and her
level of depression, a discriminant analysis was carried out with the presence or absence
of depression as the grouping variable. The four attachment scales, secure, preoccupied,
fearful, and dismissing, formed the dependent variables. Results of this study suggest that
attachment style is related to PPD. While postpartum depression was not significantly
related to marital quality, a trend did emerge between attaehment style and marital quality
(Meredith & Noller, 2003). These findings also highlighted the importance of further
research to clarify the relationship between attachment style and postnatal depression
(Meredith & Noller, 2003).
Interpersonal Theory
Interpersonal theory proposes that the divergence between desired level of support
received during the transition to motherhood are the causative factors of PPD, given that
social human beings’ personalities are defined through interpersonal experiences. (Beck,
2002; Sullivan, 1953) The association between depression and marital disharmony is also
a factor considered by interpersonal theory (Beach & O ’Leary, 1992; Beach, Fincham, &

Katz, 1998; Briscoe & Smith, 1973; O’Hara, Neunaber, & Zekoski, 1984). Studies have
revealed, however, that the direction of causality is often difficult to elucidate, in that

26

typically there is difficulty ascertaining which came first: disharmony, or depression
(Beach, Sandeen, & O’Leary, 1990; Briscoe & Smith, 1973). For example, in one study
patients with higher marital satisfaction scores were less likely to suffer a clinically
significant return of their depressive symptoms (Hooley & Teasdale, 1989), whereas,
Marks, Wieck, Checkley, and Kumar, (1992) found that mothers who are dissatisfied
with their partners or whose partners are non-communicative are more likely to have a
relapse of their depressive illness after childbirth.
A Canadian study by Misri, Kstaras, Fox, and Kostaras (2000) investigated the
impact of partner support in the treatment of mothers suffering from postpartum
depression (PPD). Patients who met the DSM-IV criteria for major depressive disorder
with postpartum onset were randomly assigned to two treatment groups: the

group

(control group) consisted of patients only (n = 13), while 2"“*group (support group)
consisted of patients (n = 16) and their partners. Compared to the control group, the
support-group patients displayed a significant decrease in depressive symptoms and other
psychiatric conditions. Although this study had small number of patients, it is an
interesting finding that a simple intervention, such as including partners in psychoeducational discussions improved patients’ symptoms.
Self-Labelling Theory
Self-labelling theory asserts the enquiry of mental illness from a different
perspective, one that views it as “emotional deviance which results from unsuccessful
em otion management attempts” (Thoits as cited in Beck, 2002, p. 286). Thoit (1985)

implies that self-labelling theory is an activity that occur independent of the reactions of
other people. Rather, these people deviate from social norms and actively break the rules

27

without consideration for the meaning others may formulate about such activity. With
women who have postpartum depression, Taylor as cited in Beck (2002, p. 286)
maintains that the reason for this is that “feeling norms” and “expression rules” are
altered. When mothers feel a deviation from the expected reaction to what motherhood is
suppose to hold, “the shame and guilt experienced when the over-whelming rush of love
and instant maternal bonding they expected did not come right away” can be severe and
contributory to PPD (Taylor as cited in Beck, 2002, p. 286).
Explanatory Model
In contrast to these theories, the Pacific Post Partum Support Society (2005)
developed a multidimensional explanatory model. This explanatory model of PPD is
holistic in its scope and includes the dimensions of a woman’s personality, general losses,
physiological issues, and psychodynamic, anthropological and psychosocial capacity.
This all-inclusive model does not filter out any one explanation or aetiology for the
occurrence of PPD in mothers; rather, it supports the understanding that the world is a
complex place and that interaction with each level of life adds it own layer of experience
through which each person interprets particular and valuable meaning.
Implications for Personal, Child, and Family Health
PPD has important and significant outcomes for the depressed mother herself, her
infant and her family. The long- term consequences for mothers with PPD are largely
influenced by the duration of time that passes prior to the initiation of appropriate
treatment (England, Ballard, & George, 1994). In a study conducted by M cIntosh (1993),
it was concluded that of all the women who desired help, only 26% actively sought it
while the remaining mothers suffered in silence. The underlying silencing mechanisms

28

were “fearing shame and embarrassment at what they felt represented personal
inadequacy and failure” (Halopainen 2002, p. 40). Holopainen (2002) further notes that
seeking consultation for symptoms is not done because women lack understanding that
the symptoms are associated with depression. Additionally, he cites McIntosh (1993),
who raises the issue of the social stigma attached to being labelled as having a mental
illness, when diagnosed by either physician or psychologist. This social stigma, McIntosh
maintains, can raise negative feelings, such as anger or shame within mothers.
Mauthner (1995) explains that the isolation and loneliness experienced by
mothers with depression is not of a geographical nature, but rather it relates to removing
self from interactions in relationships. This action has negative consequences as
highlighted by Josefsson, Berg, Nordin, and Sydsjo (2001), who remarked that PPD can
impact a mother’s personal and social contexts, as well as her relationships with her
infant and her partner. They also highlighted the impact on an infants’ psychological and
intellectual development possibly rising from early exposure to the mother’s depression.
Mother-Infant Attachment Issues
Jennings, Ross, Popper, and Elmore (1999) highlight the reality that mothers who
are suffering with PPD have thoughts of harming their infants and that practitioners need
to routinely question mothers in order to determine their intentions regarding harm
towards the infant or self. Although infanticide is not the most common side effect of
PPD, it is the most horrific (Kendall-Tackett, 1994).
A subtler but similarly destructive effect o f PPD is the emotional distancing that

can occur between mother and infant, which undeniably affects the relationship (KendallTackett, 1994). Righetti-Veltema, Conne-Perréard, Bousquet, and Manzano (2002) note

29

that because mothers are typically the primary care giving figures with which infants first
communicate, a mother’s affective mood plays a critical role in both the development of
her infant and in the mother-infant relationship. PPD negatively impaets this relationship
and often goes unrecognized by the mother herself. Kendall-Tackett (1994, p. 11) report
“Research reveals that maternal depression is similar to maltreatment in its effects on
children’s development.”
A study by Teti et al. (1995) highlighted the quality of early attachment and
maternal depression with the findings that the security of infants and preschool children
were influenced by maternal depression. The study stresses that it is the severity and
chronicity of maternal depression that must be eonsidered in context of the issues of
attachment and ultimate outcomes for children.
Another study by Murray, Fiori-Cowley, and Hooper (1996) determined that
infant attachment had less eonnection to the substance of early face to face contact with
the mother experiencing depression, but more connection to the mother’s own experienee
from her childhood attachment with her mother.
Infant Development Issues
Murray (1992, p. 547) reports that infants of postpartum depressed mothers
demonstrated cognitive delays in the domain of “object concept tasks.” Murray (1992, p.
547) refers to Piaget’s object concept tasks as tasks, which are “designed to elicit infant
cognitive schemas regarding the independent existence of objects by requiring the infant
to search for objects undergoing a series o f displacem ents in or under one of two identical

occluders.” Murray (1992) further asserts that when a mother experiences depression, it
affects her ability to engage with the infant, thus impacting the mother-infant interaction:

30

The adaptations required of the mother by the young infant appear to pose
particular difficulties when maternal depression occurs in the context of
vulnerability in the area of the mother’s own unmet dependency.. .Thus the
potentially precarious nature of the mother’s capacity to relate appropriately to
her infant....this suggests that difficulties in relating to the infant are not confined
to periods of infant distress, but may also be apparent in other forms of contact,
such as play, that demand intimate involvement, (p. 229)
Murray’s (1992) findings support other study results cited in the article, which
reveal that the quality of mother-infant relationship is influenced by postpartum
depression. In the same study, language development and lowered mental development
were negatively influenced from mothers experiencing postpartum depression who were
from lower social status and who had male infants.
Murray and Cooper (1996) indicate that adverse child outcomes seem to have
more association with the context of altered interactions between the depressed mother
and her infant than with the mother’s depressive indicators.
A study conducted by Field et al. (1988) explored the behaviour of 74 infants 3 to
6 months of age during face-to-face interactions with their depressed mothers, and then
with non-depressed women. Field et al. (1988) concluded that overall interactions
between the depressed mother and infants were less positive. Of further concern, they
reported that when the infants of depressed mothers interacted with the non-depressed
women, the behaviour of the infants did not change. In an earlier study by Field et ai.
(1985), it was found that the depressed mothers’ moods fluctuated more, which in turn
had an influence on the infant’s behaviour. Field et al. (1985) remarked that mothers

31

experiencing depression had more self-limiting attitudes about raising a child and they
were less engaging with their infants.
The importance of early detection of PPD with new mothers is defended in these
research studies. The benefits of early detection and subsequent early intervention can
determine the well-being of the baby. Weinburg and Tronick (1998) maintain that the
socio-emotional development of infants is impacted by the responses of their depressed
mother. They add that “clinicians need to be aware of mother-infant interaction
difficulties... as they emerge early in life... adding the importance of evaluating the
relationship and coping ability” (p. 59).
Beck (1995) reports on a meta-analysis of the effects of PPD as it relates to long­
term consequences, adding that the literature has repeatedly given attention to the short­
term effects for infants. In terms of infant outcomes, Beck (1995) concluded that there
was a negative effect on development for the infants over one year of age. Although the
very long-term outcomes were not reported, it can be speculated that chronic exposure to
negative interactions would play a role in determining the child’s emotional development.
Infant Interaction/Relationship Issues
Campbell, Cohn and Meyers (1995) explored the impact of postpartum
depression, experienced within the first two months, on the mother-infant relationship in
first time mothers, and findings indicate there was no influence. Of significance,
however, was their discovery that for depression which persisted through the first sixmonth postpartum, results showed relational impact in terms o f ability to be positive

during play and competency with infant feeding. This study supports the importance of

32

screening for PPD with new mothers at more than one interval of time, with screening at
two and four months there is a greater probability that more mothers will be identified.
In contrast to Campbell et al.’s (1995) findings at two months, Cohn, Campbell,
Matias, and Hopkins (1990) studied face-to-face interactions between two-month-old
infants and mothers who did and did not have PPD. Their findings report that there were
more intrusive negative effects displayed during the face-to-face interactions for mothers
with PPD and that boys experienced less positive interactions than did girls.
Beck’s (1996) phenomenological study of 12 mothers with PPD and their
interactions with their children signified the predominant struggle of coping with
childcare responsibilities. When a mother’s responsibilities extended to more than one
child, Beck (1996, p. 103) reported that “detrimental relationships” surfaced with older
children as the demand surpassed the mother’s capacity, periodically escalating to
uncontrolled anger.
Social and professional support can serve to divert negative mother-infant
interactions and relationships and reduce potential for abuse when early detection
screening practices are in place through Child Health Clinics. Health professionals can
foster positive relationships with new mothers and make timely referrals to supporting
community agencies which will serve to promote positive mother-infant relationships and
attachment.
Spousal Issues
Mothers experiencing PPD can influence the outcom es for partners (Boath, Pryce,

& Cox, 1998). Holden and Phil (1991) discuss how a mother’s pattern of mood variation
can create a home environment that is tense and stressful for the whole family. They

33

further describe how lack of knowledge about what mother’s behaviour represents can
serve to aggravate the couple’s relationship. Misri et al. (2000) support the view that a
mother experiencing PPD will impact family and marital relationships. Partners are
acknowledged for the period of adjustment they transit through at the time of the birth but
when there is fragility around marital adjustment, this has been identified as one of the
key risk factors influencing PPD. Lane et al. (1997) reported a prevalence of depression
in fathers of 1% at six weeks postpartum. Holopainen (2002) discusses how partners can
experience problems during the adjustment period, but overall, their key role revolves
around supporting the new mother, thus impacting her ability to manage.
Economic Costs
A study conducted by Petrou, Cooper, Murray, and Davidson (2002) examined

the economic costs of PPD in a specified cohort of 206 British women who had been
identified as being within a high risk category of developing PPD. Results from the study
revealed that the cost differential which included both social and health care was “392.10
pounds between women with and without post-natal depression” (p. 511). On reflection
of the annual birth rate in Great Britain and in consideration of a PPD rate of 13%, Petrou
et al. (2002) maintain that the “national economic burden of the condition to the public
services amounts to approximately 35.7 million pounds per annum” (p. 511).
Petrou et al. (2002) discuss the results of the study, highlighting the professional and
political priorities for PPD that includes discussion about primary and secondary
prevention interventions. Petrou et al. (2002) further suggest investigation take place that
focuses on the allocation of financial resources, which are both cost effective and
clinically effective. Excluded from these findings are data pertaining to the actual loss of

34

any economic income related to employment and productivity for a mother living with
PPD.
Stephens and Joubert (2001) report on the economic burden of mental health in
Canada from a study done in 1998. The study reveals costs of social workers and
psychologists, which totalled $278 million with an added cost of $ 6 billion due to
“reduced productivity associated with depression and distress over the short term” (p. 1).
Stephens and Joubert (2001) call attention to the magnitude of the financial burden that
Canada possesses in dealing with its citizens’ mental health issues: $14.4 billion.
This review highlights the importance of early detection and treatment by primary
care teams. It also suggests that preventive interventions might prove particularly
profitable.

35

CHAPTER 3
Research Design
The selection of a research design is one of the most important decisions
researchers makes in order to answer their research questions (Creswell, 2003; Grotty,
1998). As noted by Riessman (1994), the primary objective when approaching research is
to plan a method of inquiry that fits the problem statement, research context, and
objectives of the research question. Because this study was intended to explore
systematic screening for PPD as well as the experiences of new mothers with the self­
administered and structured screening approach to PPD detection, a descriptive mixed
method research design was used to guide the research process.
Descriptive Research
According to Royce, Thyer, Padgett, and Logan (2006), descriptive research is an
appropriate design choice for studies seeking “to better understand the characteristics or
needs of clients being served at a participating agency” (p. 2). Researchers conducting
descriptive studies seek an accurate accounting of events that most people including
researchers and participants observing the same event would agree is accurate (i.e.,
descriptive validity), and an accurate accounting of the meanings participants attributed
to those events that those participants would agree is accurate (i.e., interpretive validity)
(Maxwell, 1992). For Grimes and Schulz (2002, p. 145), “good descriptive
research...should answer five basic “W” questions—who, what, why, when, and where—
and an implicit sixth question, so what?”
Descriptive studies have both strengths and weaknesses. From a strengths
perspective, the data are already available and thus inexpensive and efficient to use, and

36

few ethical difficulties exist. However from a limitations perspective, temporal
associations between putative causes and effects might be unclear and a dangerous pitfall
is that the investigators might draw causal inferences when none is possible.
Mixed Research Methods
Mixed methods research refers to those studies that integrate one or more
qualitative and quantitative techniques for data collection and/or analysis (Babbie, 1998).
The overriding reason behind mixed method research is that neither quantitative nor
qualitative methods are in themselves adequate enough to address the research objectives
(Tashakkori & Teddlie, 2003; Trochim, 2001). A hallmark of mixed method research is
that it enables evaluation researchers to be more flexible and holistic in their investigative
techniques. Mixed methods research also helps researchers to validate quantitative results
by linking the information extracted from the qualitative phase of the study to further
analyze quantitative data (Madey, 1982). In addition, by using both quantitative and
qualitative techniques investigators can seek convergence and corroboration of findings
(Onwuegbuzie & Leech, 2004) and “zoow in to microscopic detail or to zoom out to
indefinite scope” (Willems & Raush as cited in Onwuegbuzie & Leech, 2004, p. 771).
In recent years, mixed method approaches to research have been increasingly
recognized (Creswell, 2003). Johnson and Onwuegbuzie (2004, p. 15) explain “mixed
methods research offers great promise for practicing researchers who would like to see
methodologists describe and develop techniques that are closer to what researchers
actually use in practice.” Given my comm itm ent to evidence-based primary health care, I
embrace the notions of mixed method research as an approach that offers the best chance
of answering the research question.

37

Triangulation
Mixed methods are also considered a form of triangulation (Denzin & Lincoln,
1998). Begley (1996) describes five types of triangulation; data, investigator, theoretical,
methodological, and unit of analysis. She supports that triangulation is merely the
combination of different methods of investigation and is a narrow one, and recommends
that nurse researchers increase their utilization of the four less frequently used types. For
the purpose of this study both methodological and investigator triangulation will be used.
Methodological triangulation. Methodological triangulation involved the use of
quantitative and qualitative data collection strategies. The quantitative and qualitative
data was collected in sequential phases (Creswell, 2003). More specifically, the
sequential explanatory strategy (Creswell, 2003) is “characterized by the collection and
analysis of quantitative data followed by the collection and analysis of qualitative data.”
(p. 215). In this study the quantitative and qualitative data collection and analysis (Phase
One) served as a basis for the focus group discussion (Phase Two).
Investigator triangulation. Investigator triangulation entailed the use of two co­
evaluators in the qualitative data analysis phase of the study. Each evaluator took
independent notes during the focus group session. The findings from each evaluator were
then compared. Because the different evaluators arrived at the same conclusion, validity
was established and further investigation was not warranted.
Sampling
This study employed three different non-probability sampling strategies. First, a
consecutive cohort sample or reliance on available subjects strategy (Babbie, 1998) was
used to select participants for Phase One of the study. Second, a purposive sampling

38

strategy (Schutt, 2004) was used to invite mothers who scored 11 or greater on the EPDS
to take part in a focus group. Third, an expert sampling strategy (Trochim, 2001) was
used to select two co-evaluators to assist with the qualitative data analysis.
Consecutive Cohert Sampling Strategy
All new mothers registered by Vital Statistics from October 2004 to March 2005
and who were resident of the Prince George region were invited to participate in the
study.
Inclusion criteria. Mothers who gave birth at Prince George Hospital (PGRH) and
mothers who resided in the Prince George region were entered into Northern Health’s
database. This registry of new infants to these mothers constituted the preliminary list of
potential study participants. Inclusion criteria consisted of mothers 19 years of age and
older who had an adequate literacy level in English so as to comprehend the participant
information sheet. Given the study January 2005 start date and July 2005 end date,
infants bom between November 2004 and January of 2005 formed the group of motherinfant dyads to be consecutively included as potential participants for this study.
Calculation o f sample size. Historically, the birth rate for Prince George is 1000
births per year, which is approximately 83 births per month. The average CHC
attendance rate for the two and four month child health immunization clinics are
consistently 85% about 70 mothers. Based on a conservative uptake rate of 80%, a further
calculation defined the strategy for attaining a target sample size of 200 participants. It
was anticipated that each month of the study (n=70) mothers would consent to
participate, then in three months the sample size would be about 210. This sample size of
200 was targeted to achieve a power calculation of 0.880, which would be sufficient in

39

power to conduct the descriptive statistics which would be generated in the quantitative
analysis. To generate the targeted number of participants for the focus group which was 7
(+/-) 2, the study screened participants from January 2005 to May 2005. Based on the
current literature, which iterates that the prevalence of PPD is 13%, it can be speculated
that of the 200 mothers participating, 26 will screen positive. From this 26, the researcher
projected that this size would be adequate to achieve the targeted participant number for
the focus group.
Purposive Sampling Strategy
Purposive sampling is a method where the participants are selected by the
researcher subjectively (Babbie, 1998). The focus group sample for this study was limited
to nine women. Focus group size is variously recommended as six to ten (Morgan, 1988),
seven to ten or as broadly as four to twelve (Krueger, 1994). Morgan (1988) concluded
that the greatest range of acceptable size is four to twelve. Because more than nine
women scored above 11 on the EPDS scale, the following criteria were used to select a
broad range of participants:
a)

range of age

b)

range of academic experience

c)

range of race and cultural backgrounds

d)

range of social status

Expert Sampling Strategy
In selecting the co-evaluators a list of health professionals with either research
experience or specific expertise within the field of PPD, was established. The two reasons
Trochim (2001) identifies as beneficiary for using expert sampling are that this creates

40

evidence to validate the type of sampling selected and facilitates the inclusion of opinions
from those regarded as experts.
Phase One o f Study
The study began in January 2005. Phase One consisted of three waves of data
collection. The first wave of data collection involved the group of participants screened in
January 2005 at the two-month CHC and re-screened in March 2005 at the four-month
CHC. The second wave of data collection involved the group of participants screened in
February 2005 at the two-month CHC and re-screened in April 2005 at the four-month
CHC. The third wave of data collection involved the group of participants screened in
March 2005 at the two-month CHC and re-screened in June 2005 at the four-month CHC.
A small number of participants screened at the two-month CHC in April and May were
re-screened at their four-month CHC in July 2005.
To maintain the rigor of the research process, participant mothers attending the
two- month and four-month CHCs were closely checked to ensure that their infants met
the requirement age range of less than three months at the two-month CHC and less than
five months of age at the four-month CHC. If participant mother’s infants did not meet
these age requirements, their mothers’ were omitted from the study as PPD may present
differently outside the two and four month time intervals.
Implementation Process
A series of three meetings were initiated by the researcher prior to the
implementation of the research study to clarify the roles and responsibilities of public
health personnel (records staff, health aide staff, and public health nursing staff) involved
in the collection of data for the study.

41

First meeting. The first meeting involved the records staff. At this meeting, it was
explained to the records staff that their main task was to create “pop-up alerts” (for a
definition of terms see Appendix E) on the client files for the infants whose mothers had
volunteered to participant in the study. The “records staff’ were also responsible for
ensuring that the file code numbers were correctly transferred from the appointment list
into the “iphis database”.
Second meeting. The second meeting was held with health aide staff. At this
meeting it was explained to the health aides that they were given the responsibility to
receive mothers and infants at the “check-in” for CHC and to inform mothers about the
study and to collect voluntary participation consent forms. In addition, health aide staff
took on the responsibility for checking the appointment list at each clinic and to check off
infants who attended. They also ensured that the “study envelope box” was on site for
each clinic that envelope numbers were recorded on the appointment sheet, and that
coded envelopes matched the coded number on the appointment sheet at the four-month
re-screening appointment. On a daily basis, at both research sites,^ the participant
mothers’ code numbers located on the clinic appointment lists were corroborated by the
health aides. This procedure helped the health aides to monitor study participants
returning for their four-month re-screen.
Third meeting. The third meeting concerned the public health nurses. At this
meeting a power point presentation describing the purpose and design of the study was
presented. Following the presentation, the responsibilities of the PHNs were reviewed.
These included reviewing the EPDS screening scores, completing the PHN two-question
survey, and making certain that appropriate referrals were completed for positive screens
’ The research was carried out at the Health Unit and the Family Resource centre.

42

on the EPDS. Following the presentation, the team of PHNs were given an opportunity to
hold a confidential vote to reject or support the implementation of the study. The
unanimous result of the vote was to support the implementation of the study.
A study script was developed and mounted on a poster board that was positioned
at the entry to both clinic sites for all potential participants to read (see Appendix F). This
script served to acquaint potential study participants concerning the context of the study
and highlighted its ethical parameters. Potential participants were concurrently informed
that ethics approval had been achieved from U.N.B.C. and Northern Health Ethics
Review Boards.
Locating the Study at the Child Health Clinics
At the outset of the study CHCs were held in three locations, one central and two
outreach sites at the north and south sections of the city. Following the opening of a
Family Resource Centre (FRC) in February 2005, the outreach clinics were closed. This
move altered the overall delivery sites for CHCs to the health unit and FRC exclusively.
The Health Unit delivered four half-day CHCs per week with four nurses at each
clinic with each PHN working six appointments. The maximum potential for booked
appointments per month at the Health Unit was estimated at 370. The FRC offered three
CHCs per week with two PHNs at each clinic, each with six appointments. In a fourweek period, the maximum potential for booked appointments at the FRC was 144.
The overall total capacity for booked appointments between both sites was 514 per
month. This number has been determined by com bining both birth rate and the number o f
immunization appointments required for an infant to complete the primary immunization
series. The study goal was met as the number of participants was achieved during the

43

proposed time frame. The start date for this study was determined following the
achievement of ethics approval with the Northern Health and U.N.B.C. Further, Northern
Health management personal were in agreement with the study start date of January 10*'’
2005, as were all other involved participant groups.
Data Collection
In Phase One of the study, all new mothers who attended the two-month CHC and
who met the inclusion criteria were invited to complete the EPDS and a short
demographic questionnaire. The questionnaire was modified for use during the fourmonth re-screening clinic visit. The four-month questionnaire included questions that had
potential for change over the two-month time interval. It also contained a no change
column corresponding to each question for ease of response. In addition to the EPDS and
the two and four month questionnaire, participants were also asked to respond to a Public
Health Nurse (PHN) survey. The PHN survey asked: How would you best describe how
you felt about yourself today as a new mother? And, How do you feel about looking after
your baby? A five point Likert scale was used to measure the response. The two question
qualitative survey was administered by the PHNs at the two and four month CHC visit.
The two-month CHC. All mothers who entered the Health Unit or the FRC for
their infants’ two month CHC appointments were met by the health aides who informed
them of the study and invited their voluntary participation. Mothers were handed the
participant information letter and instructed to read the letter and if interested in
participating, to sign the consent form witnessed by the health aide. The health aide then
handed over a large coded envelope containing the EPDS form and two-month
questionnaire. Affixed to the same envelope was a small detachable label with the

44

identical code number to that on the envelope. This label was detached and adhered to the
space adjacent to the infant’s name on the appointment sheet, and once this step was
completed, the participant mother could be linked via the code number entered into the
infants “iphis” file. At the completion of each clinic, the researcher’s copy of the
appointment sheet with coded numbers affixed adjacent to infant’s names and the
participant consent forms were sent to the student researcher’s office in a sealed
envelope. The FRC consents and appointment sheets and study envelopes were sealed
and sent to the researcher in a labelled file via inter-office mail.
A master log book was established to record the date of the clinic that the mother
signed onto the study, the mother’s name, the infant’s name and date of birth, the code
number associated with the mother and the scheduled date for the four-month re­
screening appointment. This master logbook was a critical tool for tracking study
participants returning for the four-month re-screening. This logbook was the single
source, which directly linked the infant to mother to study code number. This logbook
was stored in the locked filing cabinet. It will be shredded with all other study data two
years following the completion of the study.
Once the consent forms had been signed, the participant mothers were handed the
coded envelope, provided with a clipboard, pencil and a choice of seating in the waiting
area to complete the study forms prior to being called in for the clinic appointment with
the PHN. Completion of the EPDS and questionnaire took approximately ten minutes,
w hich in m ost instances was adequate since the public health nurses typically required

ten minutes to source the infant’s “iphis” file on the database and organize immunization
vaccines prior to calling the clients in for the appointment. Therefore, requesting

45

participants to complete the study forms prior to entry for the appointment with the PHN
did not delay the appointment time.
Partieipants presented their envelope eontaining the completed EPDS and
questionnaire to the PHN who reviewed the EPDS sheet for the score and checked the
questionnaire for completion. The coded number on the envelope was transferred onto
the survey form by the PHN who in turn posed the two survey questions to the
partieipant. On completion of the survey, the EPDS, questionnaire, and survey forms
were placed back into the envelope, which was then sealed. Eaeh publie health nurse was
responsible to deliver the completed envelopes to the “study envelope storage eontainer”
in the researcher’s offiee at the conelusion of clinic.
Every PHN was provided with a research copy of the PHN guidelines (see
Appendix G), which were established to guide the action taken in the event of a positive
EPDS score >12. This protocol involved an assessment by the PHN of the participant’s
emotional state and instructions to the participant to connect with their family physician.
In addition, participants were informed that the PHNs would be notifying the family
physieian of the screening outeome. Furthermore, all of the participants were handed a
list of community resources, which served to augment the physician referral.
At the completion of each CHC, a cross analysis was undertaken by the researcher
to ensure that all of the envelopes given out to participants were returned. A further check
was conducted to ensure that mothers with positive scores were referred to their Family
Physieians. In the five cases where study envelopes were not returned, success was
achieved in tracking the PHN who had seen the participant. In three of the five cases the

46

envelopes were retrieved, in the remaining two cases the mothers had departed the clinic
with the envelopes and they were not returned.
To facilitate the identification of participant mothers returning to each clinic site,
the researcher printed a copy of the clinic appointments every morning prior to clinic and
met with the health aide at the Health Unit or called the health aide at the FRC, working
that clinic, to assure identification of study codes for that day and to affirm that the health
aide had the correct four month coded envelopes ready in the site specific study envelope
box.
A weekly email memorandum was sent to the PHNs at both sites which listed the
number of booked two and four month appointments for each clinic day. This initiative
kept the PHNs current and alerted to the study specific workload. Also included in that
memorandum was a continuous update of the number of participant study mothers and
the outstanding number needed to reach the targeted sample size.
The four-month CHC. Participants returning for their infant’s four-month
appointments were identified by the health aide when viewing the researcher’s copy of
the appointment sheet which had infant names and associated code numbers highlighted
in orange. Again, the process was that as the mother was handed her coded envelope, the
detachable and identically coded label was removed and placed beside the typed code
number adjacent to the infant’s name. This was a secure method of inspecting that the
accurate code number and envelope was exchanged.
During the four-month re-screening process participants were seldom missed at
the “check-in”. PHNs added another level of screening when accessing the infant’s
“iphis” database file as they were promptly alerted by the pop-up file with the associated

47

study code. This immediately prompted the PHN to inquire about the screening envelope.
In cases where the study envelope was missing, the health aide was notified and the
appropriately coded envelope was retrieved from the study box and given to the mother.
PHNs followed the same process as outlined above for the two month CHCs. Once the
four month appointment had been attended, that date was documented in the log book to
signify completion and the participant’s name was stroked out in orange. The pop-up
alerts created on the infant’s “iphis” database file were removed electronically prior to
the subsequent clinic appointment.
Data Management
All data (results of EPDS, attached questionnaires and PHN survey) was entered
on ACCESS and analysed with SPSS. A coding summary sheet describing the variables
under investigation, a description of the variables, and variable coding scheme was
developed and maintained. All data collected were confidential and only viewed by the
research team. All data entry was checked twice to ensure a high level of accuracy.
Hard copies of the completed scale, questionnaire and PHN survey were
maintained at the Health Unit in a secure and locked filing cabinet. As soon as the initial
data was received, it was checked for accuracy using the following criteria as outlined by
Trochim (2001):
Are the responses legible?
•

Are all-important questions answered?

•

Are the responses com plete?

Is all relevant contextual information included? (ie. age, education)

48

Data Analysis
Because this study was descriptive in nature, the quantitative analysis consists of
univariate and bi-variate descriptive statistics displayed graphically in figures and tables.
The intent of the data analysis is to develop a better understanding of the power of routine
screening for PPD. The variables that are re;
a)

number of participants

b)

age of participants

c)

academic background

d)

language spoken

e)

marital status

f)

family income

g)

employment status

h)

activity of self-care

i)

social support

j)

planned pregnancy

k)

number of children

1)

happiness with pregnancy

m)

resource booklet use + EPDS

n)

results of EPDS scores

o)

age of baby

P)

gender ofbaby

q)

feeding method

r)

mother’s confidence

49

s)

childcare stress

t)

history of depression

Bivariate analyses were used to describe the relationships between the women
with positive EPDS and the women with negative EPDS scores and the various
independent variables reported on in this study. The bivariate analysis includes
frequencies, Chi-square, T-tests, and Spearman’s correlations.
Phase Two o f Study
The second phase of this study sought to explore the views and perceptions of
women whose EPDS scores fell in the positive and borderline range about being screened
for PPD at the two and four month CHCs. It also sought to explore the views of the
public health nurses on their experience with the screening process.
Focus Group Interview
Focus groups are widely used in health research as well as in other disciplines to
gain perspectives, enlightenment, and insight into the minds of participants as they
discuss topics of interest to the research (Creswell, 2003). Individuals who participate in
focus group sessions are not restricted by the “A, B, C” choices provided by the typical
survey researcher (Krueger & Casey, 2000). Partieipants generally are allowed to say
anything they would like to in focus groups sessions. Focus groups therefore, are
considered to be naturalistic (Krueger & Casey, 2000). They can provide trustworthy
naturalistic data that also lead to important insights about human behaviour, however, as
explained by Fern (2001), focus groups are not set up to generalize in the same way as
survey research.

50

Stewart and Shamdasani (1990, p. 15) describe the more common uses of focus
groups as:
obtaining general background information about a topic of interest;
generating research hypotheses that can be submitted to further research and
testing using more quantitative approaches;
.

stimulating new ideas and creative concepts;

.

diagnosing the potential for problems with a new program, service or product;

.

generating impressions of products, programs, services, institutions, or other
objects of interest;

•

learning how respondents talk about the phenomenon of interest which may
facilitate quantitative research tools; and

•

interpreting previously obtained qualitative results.

According to Stewart and Shamdasani (1990), focus groups should grow directly
from the research questions that were the impetus for the research. When formulating
questions for the focus group, Stewart and Shamdasani suggest two principles must be
considered:
1. questions be ordered from the more general to the more specific.
2. questions of lesser importance should be asked early in the process (build trust
and safety of members), while those of a greater significance should be placed
near the end (1990, p.61).
P articipan t M other Focus G roup

The researcher planning for the mother’s focus group included background
reading on focus group moderating skills, context setting, selection of participants, and

51

development of a questionnaire or interview guide. Mothers selected to participate in the
focus group were individually contacted by phone and given the location and time of the
focus group three weeks prior to the scheduled date. A follow-up phone call was also
made two days prior to the focus group with all nine mothers confirming their attendance.
Participant Selection. Nine of the 17 mothers whose EPDS scores were greater
than or equal to 11 were invited to participate in the focus group (see Table 3.1). The
group consisted of three mothers with positive scores at two months, three mothers with
positive scores at four months, and three mothers who scored within the borderline range
9 to 11 at both two and four months. The selection process involved drawing random
code numbers from the lists of positive scores, which including the borderline group, at
two months and four months. Eight of the nine selected participants attended the focus
group. The participant that did not show up had a positive score at two months.
Table 3.1
Participant Focus Group {n = 9)
Positive Score at Two
Month CHC
n=2

Positive Score at Four
Month CHC
n=3

Borderline Score at Two
and Four Month CHC
n=3

Data Collection
Two community-based focus group researchers were invited to attend the focus
group to act as recorders. This allowed the researcher to focus on moderating the
discussion. In addition to flip chart note taking by the two recorders, the session was also
audio taped. The focus group questioning guide was built upon the key research findings
that emerged from the analysis of the quantitative data.

52

Lunch was provided prior to the start of the focus group. The participants were
presented with a $25.00 honorarium when they arrived at the focus group to cover
transportation and ehildeare costs. A list of community resources was also handed out at
the completion of the focus group in the event that an emotional issue arose for
participants during the focus group discussion.
The focus group was conversational in nature and framed by the opening
invitation to partieipants to speak openly and freely about how they experienced the
screening process. The focus groups lasted approximately two hours, on average. As the
principle moderator of the focus group, I was mindful of the role of the facilitation
process in relation to the nature and quality of the data eollected (Vaughn, Schumm, &
Sinagub, 1996). On this note, Charles Baseh (1987, p. 415) points out how important it is
for the moderator to “create a non-threatening supportive climate that encourages all
participants to share views, faeilitating interaction among members, and interjecting
probing comments, transitional questions and summaries without interfering too
brusquely with the dialogue.” As moderator, I paid close attention to issues of power and
domination by keeping traek of who spoke and for how long. I facilitated interaction by
inviting each participant to make comments. I also posed probing questions to draw out
different points of view. Following the conclusion of the focus group, participants were
afforded an opportunity to comment on their focus group experience. Overall, the
partieipants reported that they found the conversation thought provoking and stated that
they gained personally from their involvem ent.

53

Data Analysis
The process of analysis involved a four step procedure. First, immediately
following the completion of the focus group, the moderator and recorders met in a private
location to compare notes and identify thematic statements or meaning units that seemed
particularly revealing about the experience of mothers with the structured PPD screening
process. The researcher completed the session with the two recorders by documenting the
thematic statements in a data analysis log book.
Second, the audiotape was later transcribed verbatim within 48 hours. Third, the
transcript was read by the researcher several times along with the thematic statements
recorded in the log book. Fourth, the transcript and thematic statements were reflected on
formulating a list of essential themes. According to van Manen (2003, p. 78), a theme is
not a “frequency count or coding of selected terms in transcripts of texts.” Rather, a
theme is the “experience of meaning” and “at best a simplification” of the summary of
the significant factor (p. 87). It is also not an “object one encounters at certain points or
moments in a text,” but is a way of “capturing” the phenomenon one is trying to
understand (p. 87). In describing how themes come to “be,” van Manen (2003) explains
the “needfulness or desire to make sense,” “the sense we are able to make of something,”
“the openness to do something,” and, finally, “the process of insightful invention,
discovery and disclosure” (p. 88). It is within this context that van Manen (2003, p. 90)
states, that themes “are not objects or generalizations; metaphorically speaking they are
more like knots in the webs of our experiences, around which certain lived experiences
are spun and thus lived through as meaningful wholes.” The thematic analysis was
completed when no more new themes emerged.

54

Public Health Nurse Focus Group
A second focus group was held two months following the completion of the study
and included five PHNs. These PHNs were selected based on years of experience,
location of worksite and program work related to PPD.
Moderating the focus group. The focus groups were moderated by the researcher.
Most scholars agree that moderators are not expected to be experts in the topic of
discussion; and if they are, it is important that they do not insert opinions into the
discussion (Baker & Hinton, 1999; Krueger, 1998; Vaughn et al., 1996). Probes were
used to clarify questions in the groups when members were quiet or not responding. The
process included introductions, purpose of the focus group, followed by warm-up
questions, which facilitated discussion. Following this brief warm-up period, terms that
were used in the group talk were mentioned and clarified, as needed. Participants were
informed that their responses are neither right nor wrong. Questions were then addressed
and the agenda was followed closely to respect time lines and competing schedules.
Data Collection
Data from focus group interviews are primarily collected in two forms; field notes
and written transcripts (Kreuger & Casey, 2000). For this study, field notes were taken by
the researcher and two evaluators. Using a flip chart, the moderator had the opportunity
to take notes during the focus group while the two co-evaluators used note pads. The
focus group discussion was also recorded.
Data Analysis
Data analysis was undertaken immediately following the participant mothers
focus group. Each co-evaluator along with the researcher generated a list of themes from

55

their field notes. The audiotape was replayed to assist in the theme building process. Each
evaluator shared their notes to check for group consistency and to build consensus on the
themes.
The PHN focus group was facilitated solely by the moderator and drew from the
audiotape of the session as well as field notes. After completing a comprehensive review
of the audio-tape, the moderator developed a summary report which she sent to all PHN
participants and checked in with each one for them validation. All were in agreement of
the defined themes.
Ethical Considerations
The proposal for this study was submitted to and approved by the U.N.B.C. Ethics
Review Board. All participants were provided with an information letter (see Appendix
C) that outlined the process and purpose of the study and warned of potential risks.
Participants were assured of the voluntary nature of their participation and that complete
confidentiality and anonymity could not be guaranteed because of the number of people
involved in the data collection process and possible recognition in the focus group.
Participants were also presented with a consent form that was signed prior to their
participation in the face-to-face interview (see Appendix D). The partieipant information
sheet stated that women who showed signs of experiencing depression would be given
immediate assistance and consultation to connect with their family doctor. The study
script (appendix F) further stated that mothers seen to be experieneing thoughts of selfharm or those in her household, would be reported to their family doctor by the PHN. In
addition, the PHN guideline (appendix G) specified that in the event a mother refuses to
seek assistance, that the attending PHN would initiate contact with her family doctor.

56

Summary Comments
This chapter demonstrated that the mixed methods used to collect and interpret
data in this study were congruent with the philosophical underpinnings of descriptive
research. The mixed method approach permitted me to gather and interpret data in a
manner that suited both the research question and my theoretical stance towards evidence
based practice grounded in the lived experience of new mothers and public health nurses
delivering primary are services.

57

CHAPTER 4
Results
The major objective of this research project was to explore systematic screening
for PPD as an evidence-based best practice approach to reproductive health during the
postpartum period. The target participant sample size of N=212 for this study, which
began on January 10, 2005, was achieved on May 19, 2005. Out of 264 mothers attending
the CHCs over this five month period 227 (86 %) met the study inclusion criteria. O f the
37 mothers who did not meet the inclusion criteria, six had significant language barriers,
ten had infants that were too old, four infants were brought in by other caregivers, ten
were under 19 years of age, one indicated that she was living in lower mainland, and six
were due to administrative errors.
Of the 227 eligible mothers, 18 choose not to participate and two were simply
missed upon the intake recruitment process. Therefore, of the 227 (86%) eligible 207
(91%) of those mothers voluntarily chose to participate in the study. Furthermore, of the
207 participant mothers who completed the two-month study forms, 190 (91%) continued
on to complete the 4-month study forms. Seventeen participant mothers did not complete
the four-month study forms for a variety of reasons including: fathers brought infants
(n=3), immunization completed out of town (n=2), unknown reasons (n=3), and
administrative errors (n=9).
Demographics
The socio-demographic characteristics of participants («=207) are summarized in
Table 4.1 and can be viewed in full in Appendix I. The participants ranged from 19 to 43
years of age with the majority (46.9%) falling between 25-30 years of age. Most (92%)

58

spoke English as their first language. While fifty-five percent of the participants were
married, 30% were partnered, and 11% were single. Household income was reported to
be less than $20,000 for 20% of the participants, while 37% reported incomes between
$21,000 and $64,000, and 35% reported annual incomes above $65,000. Employment
history prior to the birth revealed that 55% had worked full time, while 18% had worked
part-time and approximately 22% were unemployed. 62% of participants graduated from
high school, technical or trade school, 17% had attained a university degree, and 14% had
less than high school graduation. Most (78%) of participants responded to the questions
inquiring about the activities they performed to take care of themselves. The single most
reported activity which participants engaged in was walking at 46.3%. Under half
(48.3%) of participants described having time to themselves; 7.2% indicated that they had
time to go out with friend while 23.6% reported having time for more than two activities
and 8.1% reported engaging in three activities including reading, listening to music and
taking a relaxing bath. Just over half (52 %) of mothers had one child, 34% had two
children and 11% and three or more children In terms of the pregnancy itself, 60% of
participants revealed that this was a planned pregnancy while 35% it was unplanned and
the remaining 5% had no response. More than half ( 53%) of mothers reported no prior
history of depression, 16% reported a history in the last two years, 13% reported having
been depressed within the past two-five years, and 13% reported having had depression
greater than five years ago.
R esults fro m Two M onth C H C

At the two-month CHC, 17 (8.2%) of the participants screened positive and 190
(91.8%) screened negative on the EPDS (see Figure 4.1). While the probable number of

59

positive scores based on the extant literature was hypothesized to be 13%, there are
several reasonable explanations for the resulting lower frequency. Reasons under
consideration include: the absence of privacy in the questionnaire setting and with form
completion when accompanied by another adult, and readiness to disclose, and an invalid
cut-off point.
200

190

S' 150

I 100

I»

17

Ne g EPDS Score

Pos B^DS Score

(< 12 )

(>12)

EPDS Scores

Figure 4.1. Negative (<12) and positive (>12) Edinburgh Post-natal Depression
Scale scores at the two-month child health clinic (N - 207)
Borderline Scores
Although the EPDS has been identified as a valid instrument for use in primary
care settings, test scores can fluctuate which raises the issue of people scoring below the
identified positive score range who are exhibiting early signs of postpartum depression.
The purpose of assigning a borderline category was to ascertain the frequency of
occurrence of borderline scores relative to the positive scores. Borderline scores were
defined as those scores between nine and eleven on the EPDS. Consequently, three
categories of scores were calculated (see figure 4.2).

60

200

158

S' 150
3 100

32

50
0

--- -------- ,-------------------- J Z I -----------Neg EPDS Score
(<9)

Borderline EPDS
Score (9-11)

17
---------------^ J = l -----Pos EPDS Score
(> 1 2 )

EPDS Scores

Figure 4.2. Negative (<9), Borderline (9-11), and Positive (>12) Edinburgh Post-natal
Depression Scale Scores at two-month Child Health Clinics (N = 207)
Within these three categories, 158 (76.3%) participants had negative scores, 32
(15.5%) participants had borderline scores, and 17 (8.2%) participants had positive
scores. It is possible to speculate that a percentage of the participants who had borderline
scores could potentially be experiencing depression, but are not detected with the defined
cut-off score on the EPDS.
New Positive Cut-Off for EPDS Scores
On examination of the borderline scores a further analyses was structured to reset
the cut-off score marking the boundary between positive and negative. The intention of
this new grouping was to account for potential bias as the critical identifying number was
on the screening sheet. Further, and according to Cox and Holden (2003), a cut-off of 9
or 10 is likely to identify most cases of depression when the EPDS is the single measure
for first level screening. The new cut-off scores revealed that 158 (76.3%) of participants
had negative scores while 49 (23.7%) of participants had positive scores. A 23.7%
positive rate surpasses the cited rate of PPD in the literature at 10-20% (see Figure 4.3).

61

200

>, 150

i.

..........

'

"

'

..........

4 S

'

'

'

■ «........................

50
0

Neg EPDS Score (<9)

Pos EPDS Score (à9)
EPDS Scores

Figure 4.3. Negative (<9) and Positive (>9) Edinburgh Post-natal Depression
Scale Scores at two-month Child Health Clinics (N - 207)
Spearman Correlation between EPDS Scores and PHN Survey Scores at Two Months
Correlations provide an analysis of a relationship between two variables and the
strength of that relationship. Spearman’s correlation was selected to address concerns
about whether the variables were evenly distributed and whether the sample size was
adequate. Categorical classifications of correlations serve to specify the specific strength
of the relationship, a small relationship reflects correlations between 0-0.33, a moderate
relationship reflects correlations between 0.34 to 0.66, while a strong relationship reflects
correlations of 0.67 and greater (see Table 4.2).
Table 4.2
Spearman Correlation Between EPDS Scores and PHN 2Question Survey Scores at Two
months

l.EPD S
2. PHN- Confidence

1

2

3

—

0.306**

-0.468**

—

3. PHN- Anxiety
**

Correlation is significant at the 0.01 level (2-tailed)

—

62

Table 4.2 illustrates that there was a small, but statistically significant correlation
(r=306, p<0.01) between EPDS score and the confidence level of new mothers. There is
also a moderate, but statistically significant negative correlation (r=-.468, p<0.01)
between the EPDS score and a mother’s anxiety with baby care.
Positive and negative EPDS scores at two months. Pearson’s %^ was done to
explore relationships between the demographic variables and the presence or absence of a
positive screening score. All of the following variables were not significantly different
between these two groups; age, education, marital status, socio-economic status,
employment history, resource booklet EPDS, gender of infant, feeding type for infant and
participant visit accompaniment (see Table 4.3 illustrated in Appendix J). Significant
Chi-square results are listed in Table 4.4.
Table 4.4
Pearson Chi-Square Results
Variable
Regular exercise
Time to self
Planned
Pregnancy
Mood in
Pregnancy
History of
Depression

Chi-sq. Value
5.058"
5.453”
3.937

Sig.
0.025
0.02
0.047

Alpha
.05
.05
.05

8.807"

0.032

.05

14.452'*

0.002

.05

“ indicates 1 cells have an expected count leas than 5
’’ indicates 1 cells have an expected count less than 5
indicates 2 cells had an expected count less than 5.
indicates 3 cells in calculation had counts less than 5

These results indicate that women who exercised regularly and who had more time
to themselves were less likely to have positive EPDS scores. Women who were more

63

likely to have a positive EPDS score at two months were those mothers who did not plan
the pregnancy, were not happy during the pregnancy and had a history of depression.
Positive and negative EPDS scores at two months. T-tests were executed to
compare the mean value of the independent variables within each of the two groups,
mothers who screened positive and mothers who screened negative. Non-significant
results are illustrated in Table 4.5 (see Appendix L) and significant results shown in
Table 4.6 below.
Table 4.6
T-tests Results
Variable
Number of minutes for self
People to talk to
Parity

T-test
-2.385
2.041
^T952

Sig.(2-tail)
0.018
0.043
0.004

Significantly different (e <0.05)

These results indicate that women who had positive EPDS score had less time to
themselves. Women with positive scores had fewer people to talk to, and had fewer
children, on average, then did women who had negative EPDS scores. The exhaustive
results can be viewed on table 4.5 in appendix L.
Results from Four-Month CHC
At the four-month CHC 181 (95.3%) of participant mothers («=190) scored
negative while 9 (4.7%) scored positive on the EPDS (see Figure 4.4).

64
181

200
S' 150

I 100
P

SO
0

Pos EPDS Score

Neg EPDS Score
(< 12)

(>1 2 )

EPDS Scores

figure 4.4. Negative (<12) and positive (>12) Edinburgh Post-natal Depression
Scale scores at the four-month child health clinic (N = 190)
Borderline Scores
Borderline scores were analysed again at four months and these results can be
seen in Figure 4.5 below. Twenty participants (10.0%) had borderline scores at the fourmonth screening, which was a (5%) reduction from the two-month screening.

200

161

S' 150
3

100

£
it

50

20

------------ --------------------Neg EPDS Score
(<9)

9

------------ ----Borderline EPDS
Score (9-11)

..-................,-'.1.......................'
Pos EPDS Score
(&12)

EPDS Scores

Figure 4.5. Negative (<9), Borderline (9-11), and Positive (>12) Edinburgh Post-natal
Depression Scale Scores at four-month Child Health Clinics (N - 190)
New Positive Cut-Off for EPDS Score
The new positive cut off of nine on the EPDS was analysed again at four months
to consider for potential response bias. What remains of interest is that there is a slightly
higher percentage of participants scoring negative at four months (80.3%) than at two
months (76.3%). Further, while 23.7% of participants scored positive (>9) at two months,
at four-months the new cut-off reveals that 15.0% of participant mothers scored positive

65

within the new cut-off score of nine. Continued screening at the four month interval
remains paramount (see Figure 4.6).
200

>. 150

Ë
I 100
£

u-

29

50

--------------- ,-------------------------Neg EPDS Score (<9)

Pos EPDS Score (29)
EPDS Scores

Figure 4.6. Negative (<9) and Positive (>9) Edinburgh Post-natal Depression
Scale Scores at four-month Child Health Clinics (N = 190)
Spearman Correlation between EPDS scores and PHN survey scores at Four months
The four-month EPDS screening based on cut-off score of 12 revealed a moderate
and significant correlation ( r = .455, p < .01) with maternal confidence (see Table 4.7).
This indicates that mothers with higher EPDS scores have lower levels of confidence as
mothers. Meanwhile, a small but significant correlation (r = -.382, p<.01) was observed
between mothers positive EPDS score based on cut-off of 12 and anxiety about infant
care. The more negative the anxiety score the higher the EDPS score, indicating that
mothers with higher EDPS scores have more anxiety with infant care.
Table 4.7
Spearman Correlation Between EPDS Scores and PHN 2Question Survey Scores at
Four-Months

l.EPDS
2. PHN- Confidence

1

2

3

—

0.455**

-0.382**

—

3. PHN- Anxiety
** Correlation is significant at the 0.01 level (2-tailed)

—

66

There were no significant Pearson Chi-square results between the presence or
absence of positive EPDS scores and categorical independent variables at four months.
T-test results revealed only one significant difference between women with
positive and negative scores on the number o f people they had to talk to (t=l .912, p=
0.057). A complete summary of results at four-months can be seen in tables 4.3 and 4.5
and viewed in full in Appendix J and K.
Results from Focus Groups
The findings are presented for each of the two focus group interviews. Findings
from mothers representative of the mother’s focus group is presented first, followed by
the findings from the public health nurse’s focus group.
Participant Mothers Focus Group
In order to grasp the basic experiences of mothers with routine PPD screening at
two and four month CHCs, mothers who screened positive or in the borderline range
were interviewed Emphasis was placed on a critical examination of the experience of
screening for PPD for participants. This was accomplished by completing a thematic
analysis of the focus group interview. The focus group discussion was guided by two
probing questions. The first question explored how participants felt about screening for
PPD at child health clinics. The second question asked participants to provide feedback
on the effectiveness and usefulness of the questionnaire.
Extracts from the transcribed text and flip chart note have been selected to
illustrate each theme including any differences o f perspective or nuances within them.

67

Question # 1: “How Do You Feel About Screening New Mothers About Their Emotions
During The Child Health Clinics?
Five themes (see Table 4.8) were revealed by the data generated by the first
question. For the purpose of illustration, the themes have been separated. However, eaeh
theme is an aspect of the experience that is linked with and dependent on the other
themes.
Table 4.8
Essential Themes: Experiences of Mothers with Routine Screening for PPD
Essential Themes

Thematic Statements

Sense of safety

safe place; not a judgemental standpoint; you feel better about
being honest and truthful; get help without having to ask for it;
at CHC it is a good focused time; CHC is a good setting for
doing this screening.

Sense of care

they took a lot of time with me; happy to see that something is
being done, that it mattered; it’s nice that someone does want to
hear about it....that someone cared, it meant a lot; it felt good
to have someone pay attention to those questions.

More time to talk

I wanted to have more time to talk...I felt it was kind of
rushed; If the nurse talked to you after (baby) had the
needle....you have to wait for a few minutes anyways; you
kind of feel like the rug has been pulled out from under
you....your just there by yourself; they took a lot of time with
me actually. ..I was really lucky. Lots of time was spent that
way so, I was very comfortable and had good
experiences.. .done the questionnaire before the vaccination,
have (baby) get the vaccination, then go talk to the nurse about
the questions; it was better to have it before ... .after (baby) got
the shots, I wanted to be with him.

Paternalistic attitude
of partners

I’m basically looking after kids, taking care of the house,
driving around lots, cooking the meals and making sure the
kids have homework done.. .bath time and bedtime and then
I’m tired...I just want to go to bed; he goes to work all day and
you’re still doing all the stuff you named even if you’re not a
single mother..... he comes home and you’re pretty much

68

Lack of support from
Doctors

looking after him too but people don’t think of it that
w ay....they’re like ...you have him to help. He’ll help me
when he feel like it... .when we get visitors he takes the baby
and carries the baby around and I have “your so lucky to have a
guy to help you out” ... I’m like, oh ya... .1 don’t have the heart
to tell them he is just doing that to show off; and it’s just like
her husband, “ what did you do all day?”; sometimes he’ll
come home from work and I think he thinks that I sit on the
couch all day
so he’d come home and he was like, so how
many boxes did you get unpacked today?...and I’m like pardon,
they forget that ya not just unpacking boxes, just watching
baby... ; when you’re single, you get more attention ..I know
my parent are more inclined to help me because I don’t have
any help, I don’t have any perceived help of husband,
boyfriend or live-in partner...So, they’re inclined to help me,
friends of the family are more inclined to help m e.. .you know
what I mean
I can understand what she is saying.__________
Doctor’s don’t explore beyond “I’m fine”...male doctors don’t
know.. .had to switch Dr. for pregnancy and liked that Dr. but
wasn’t allowed to stay with him, he understood my pregnancy
my regular doctor didn’t know how I was feeling and I just
didn’t care to tell him as he hadn’t been there in the pregnancy;
Don’t see Dr. after the initial postpartum visit....Child Health
Clinic is a good setting for the screening.___________________

Seme o f safety. The opening question initiated discussion concerning the safe
environment of child health clinics. It was perceived as a place where mothers’ could
disclose feelings without fear of humiliation or embarrassment. Comments made by
participants include:
I think it is a safe place to tell how you ’re really feeling. Because lots o f times you
d on’t want to tell your husband and your mom because you feel that maybe you ’re
not doing as good a job as you could be.
***

..for me, it was a safe place to say, you know, that I ’m not doing so good.
***

69

...sometimes you feel like everyone’s judging and watching you and its kind o f
nice to know that maybe other people are feeling the same way you are.
%%%
...it’s kind o f nice to know that not everyone is having a walk in the park.
***

When it comes from a medical standpoint, not a judgemental standpoint, which
makes you feel better about being honest and truthful because you know i t ’s to
help you, not to judge you or anything.
These comments reveal the prevailing societal expectations that a new mother
should inherently be happy. These unspoken and deep rooted cultural values do not
reflect the reality of the challenges some mothers face in the scope of their transition to
the role of motherhood. The perpetuation of this mode of thinking undermines the ability
of some mothers to tell their true feelings. However, in the presence of public health
nurses, the environment was perceived as safe for mothers to talk honestly about how
they are doing.
Sense o f care. In exploring and describing their experiences, all of the participants
spoke about feeling a sense of care.
They took a lot o f time with me actually. I ’m not saying that it didn ’t upset me
when they said maybe I should talk to my doctor, but they took the time so, I was
very comfortable. I was ju st happy to see that something was being done; that it
mattered.
***

70

I t ’s ju st nice that it matters...that i f you were ju st having some things that to most
would seem very insignificant but very big in our live at this point and that
someone wanted to know about it and that it mattered.
***

I t ’s nice where someone does want to hear about it. It was nice that someone
cared; that meant a lot.
***

It felt good to have someone pay attention to those questions.
Caring as a construct is fundamental to the nursing profession with nursing care
being descriptive of what nurses do. Public health nurses inherently reveal their unbiased
sense of caring through their daily practice. This prevailing attitude is clearly
communicated with new mothers’ and therefore, aides in facilitating the construction of a
setting where mothers feel they will be heard and their statements will be valued.
Mothers expressed their open appreciation for having a valid sounding board with the
nurse to iterate their feelings. Public health nurses who spent time with the mother
discussing her feelings conveyed the message of unconditional caring for what these
mothers were experiencing.
More time to talk. The third theme that emerged from the data was termed “more
time to talk”. Many of the participants spoke about how the experience of completing the
EPDS at the CHCs opened up a whole new level of awareness about having someone to
talk to about their feelings.

71

I wanted to have more time to talk to the health nurse. I felt kind o f rushed. Once I
had done it and they (PHN) reviewed it, it was like, oh, maybe you 're not feeling
so good, maybe you should go to talk to your doctor.
***

It would be nice to have a little more time to talk to somebody. Iju st found that
they were in a rush to get through their day too.
***

One participant talked about the competing agendas of wanting to focus on the
child’s needs and feeling guilty about using up this time on herself:
I t ’s a combo, you ’re there fo r your child—your child’s getting shots and you ’re
totally concerned with that and then to have them ask you personal questions on
top o f it— it ’s hard to think about yourself too.
While screening for PPD at CHC places additional demands on PHNs, (i.e., public health
nurses are required to immunize infants while they simultaneously addressed the EPDS
screening scores of mothers), the benefits for the mothers are difficult to dismiss.
Discussion concerning when would be a better time for public health nurses to talk to the
mothers about their emotions during child health clinics revealed a range of preferred
choices.
I think it would be nice i f the nurse talked to you after they give the needle
because we have to wait fo r a few minutes anyway—that would give us a chance
to talk with the nurse.
***

72

I think if I ’d done the questionnaire before the vaccination then went to talk to the
nurse about the questions that would have been better.
***

I think after my baby got the shots I was more, wanted to be with him. So, for me,
it was better to have it before.
Paternalistic attitude o f partners. The fourth theme that emerged from the data
was the paternalistic attitudes of the participants’ partners. One participant commented;
When my baby was born and having to deal with the other kids, doing the
household chores, cooking, and everything else on top o f that, it was too
overwhelming fo r me, it was too much. Because I had a c-section the doctor told
me not to lift anything heavier than baby, no driving or anything. I ’m basically
taking care o f the house, driving around lots, cooking the meals and making sure
the homework is done and everything by 8 or 9 pm I just want to go to bed. I ’m
tired. He ’II help me out when he feels like it. When he comes home, he wants to
relax. When we do get visitors he takes the baby and I have “your so lucky to
have a guy to help you out ’’ Actually, I don’t say nothing at all and he just drinks
it all in. I don’t have the heart to tell them h e ’s just doing that to show o ff but
that’s how it is fo r me, I just let it slide, even though it irritates me and annoys
me.
***

While he 's at work everyday and ju s t because yo u ’re still g oin g out w ith him,
doesn ’t mean that he does anything. He goes to work all day and you ’re still
doing all the stuff that you just named even i f you ’re not a single mother. Then he

73

cornes home and you ’re pretty much taking care o f him too. But people don’t
think o f it that way,.

I swear sometimes he ’II come home from work and I think he thinks I sit on the
couch and watch TV all day. They forget that maybe when you look around the
house, it doesn’t look like a lot but i t ’s not just unpacking, just watching baby.
Prevailing paternal attitudes of partners lead to a dismissal of understanding to the
workload issues of a new mother. Continued perceptions that there should be a balanced
or equal distribution of labour was overwhelming these mothers to the point where they
shut down communication. Mothers recognized that partners did not get the message;
they could not comprehend the extreme challenges this new role of motherhood was
imposing upon them and its consequences.
Lack o f support from Doctors. The fifth and final theme that emerged from the
data was the experience of participants with their doctor in the postpartum period. For
example, one participant indicated that:
***

Doctor’s do n ’t explore beyond the “I ’m fine ” reply.
Another participant spoke about her fear in speaking to her doctor:
/ had to switch Doctor’s when I was pregnant, I liked the doctor while I was
pregnant but wasn ’t allowed to switch permanently. My regular doctor didn’t
know how I was and I didn’t w ant to tell him as he had not fo llo w e d me in the
pregnancy.

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This final statement summarized the general attitude of all of the participants
concerning their doctors:
I think the child health clinic is a good setting fo r the screening, better than the
Doctor’s office, I haven’t been back there since my initial postpartum visit.
The participants seemed to be affirming that the exploration of their emotional health was
limited and did not extend past their accommodating reply of fine. There was also the
issue of physicians who did not do deliveries and who therefore handed over their
patients to a physician who had delivery privileges. This physician would follow the
mother through the pregnancy and up to 6 weeks postpartum at which time the mother
and infant would be transferred back to the attending care of the family physician.
Mothers who endured this transfer of function to other attending physicians, had a
fragmented perception of the family physician’s true interest in their emotional health.
Thus, these mothers chose to remain silent despite their need for emotional health support
on transferring to their primary physician.
I found the thematic analysis of the borderline and positive score focus group
to be very helpful in shedding additional light on the participants’ experience of
undergoing routine screening for PPD. The findings also demonstrated that the practice
of reflection was both powerful for developing personal insight into one’s lived
experience and an effective tool for revealing the totality of the participants’ experience
with PDD.
Q uestion # 2: What D o You Think A bout The Screening Q uestionnaire That Was Used?

Six themes (see Table 4.9) were revealed by the data generated by the second
question.

75

Table 4.9
Essential Themes: Experiences of Mothers with Screening Questionnaire
Thematic Statements
Good thing, catch people who may slip through the cracks; was
in the booklet but forgot; recalled seeing it in the booklet but
wouldn’t necessarily use it on own; It’s important to not just
check at 2 months because sometimes postpartum comes 6
months later, so it’s important to have intervals; important to
keep cheeking back because your life changes;
Overwhelming guilt about anything I did for myself; found
Validating
myself crying and apologizing a lot; felt needed a legitimate
reason to be away from baby, then its okay;
Need to be okay to take time; doing everything except for
More of a focus on
yourself; time for yourself; better mom when take care of
self care
yourself; important that mom’s have time for themselves.. .offer
as moms can’t always ask; new moms need to understand that
self-eare is important;
Please don’t put the critical numbers on the sheet....influenees
Don’t want to know
score; missed some questions on purpose by seeing your score &
on their own
what it means, you know there will be consequences, better to
have nurse explain score;
knew what I had to get for a score so people wouldn’t think I’m
Fear of label and
consequences
crazy..... influenced by results; scared there would be
consequences like being put under a mieroscope; fear that they
may take my kid away; admitting I have a problem.
Lack of understanding The first time I did it I was by myself, the second time I was
with my husband........ I didn’t want to alarm him at all...I kind
by partners
of led that I was feeling better than I actually was; I would have
to agree..... same with my husband, the first time I went, I
changed my answers based on the fact that he was sitting there;
nothing out there to help them understand.
Essential Themes
Reliability

Reliability. Participants were in agreement that the current self-administered
approach to PPD screening where mothers are presented with a resource booklet upon
visitation by a PHN, was not likely to happen. One participant said:
Think no one cares, it is good i f someone takes the time to ask how you re doing.
Other participants acknowledged receiving the resource booklet with the PPD
screening tool contained in its pages but had forgotten it was there. So, in this case they

76

would not have known to resort to this booklet for the screening tool. Others remarked
that despite its availability to them, there was a distinct possibility that it would not be
implemented.
It was in the booklet received but I had forgotten.
***

I recall seeing it (self-administered PPD screening tool) in the resource booklet
but wouldn’t necessarily use it on my own as there is too much going on.
Applying a reliable method for PPD screening will serve to close the gap among
women who are currently being missed. Mothers who are slipping through the cracks are
subject to the risk of missing timely referrals to mental health services.
Child health clinic is a focused time, you are focused on you and baby, and have a
clearer picture, it is a good time to do it.
***

Good thing—can catch people who may slip thru cracks, let mom know you care.
A further testimony to the benefits of EPDS screening in the CHC setting is the
capacity to screen at more than one interval of time. Re-screening for PPD has particular
significance as this spectrum disorder can occur anytime within the first year following
birth. Mothers were aware that the significance of ongoing screening is a good thing as
life events can turn a mothers’ world around immeasurably. Thus, when feeling fine at
the two-month child health clinic it may not necessarily be true for the four month
screening during child health clinic.
I think it ’s important to keep checking back because your life changes, your
feelings change, so it was helpful fo r me to see the growth, at two months when I

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got asked those questions, 1 started bawling and I thought I ’m falling apart. And
at 4 months, it was like I ’m getting better. It made me feel better about myself and
I ’m feeling better about my responsibilities.
***

So much happens in those couple months, with them, with you, so i t ’s definitely
easier to keep it, sure.
***

...some mothers feel really good at two months and by 4 months, they ’re starting
to not feel so good about themselves anymore. So i t ’s important not to just check
at the 2 months, you ’re doing fine so forget about it. Because sometimes
postpartum comes 6 months later, its ’ important to have intervals.
Validating. Mothers experienced the pressures of their new role when they had an
overwhelming need to justify their personal time or time away from baby. It was
perceived that being absent from motherly responsibilities was acceptable if it was for
reasons other than those of a personal nature.
Felt overwhelming guilt i f do thing fo r myself.
%

I found myself crying and apologizing a lot fo r taking own time.
***

Had time away from baby fo r reason felt was valid.
More o f a focus on self-care. The concept o f self-care emerged as a need for new
mothers upon their recognition that to be more effective in this new role, time-out would
be vital. The job description of mother has no timelines, no boundaries and no regulation.

78

From the outset of this new role, mothers need to give permission to them to take
personal time. It was acknowledged that personal time would lend itself to an enhanced
performance in the role of mother.
New moms need to understand self-care is important.
***

You ’re a better mom when you take care o f yourself.
***

Worst thing you can tell a mom is your selfish... doing everything except for
your self...you need to be you.
***

important that m om ’s have time fo r themselves so offer, we can’t always ask.
Don 7 want to know on their own. The EPDS screening tool handed out during the
CHC was identical in format to the copy found in the Maternity Home Visiting Resource
Booklet. The decision to utilize the same copy was for purposes of consistency. This
copy included the possible range of scores, identifying the demarcation of a positive
score. When a positive score was attained, mothers were advised to connect with support
serves immediately. Self-recognition that one’s score was greater than that within the
normal limits in some cases lead to altering of score totals. For example, one participant
said:
Please don 7 put the critical numbers on the sheet, it influences score.
Other participants agreed adding:
/ missed some on purpose.

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Seeing what score will be you know there is going to be consequences.
***

Better to have the nurse explain the score.
Fear o f label and consequences. Positive EPDS score results struck a fear among
these new mothers. This generated a series of unfounded thoughts about the outcome of
their status as a mother. Mothers were worried about societal application of a label and
further about the consequences for their infants. A preferred approach to conducting the
EPDS screening during CHC would be to have mothers complete the form and hand it
over to the public health nurse for scoring and consultation.
I knew what I had to get fo r a score so people wouldn't think Fm crazy.
...influenced by results, don’tp u t scores on the questionnaire.
***

I was scared there would be consequences. That I would be put under a
microscope.
***

Ifeared that they’d take my kid away.
***

New moms are struggling and trying their best and how could I be a sad mom
when this is all I ever wanted?
To neutralize the feeling of fear while completing this tool it was suggested that
mothers could be supported differently thru com m ents w hich resonated the elem ent of
earing.

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Tell them its fo r your personal benefit, to help you go through some o f the
changes in your life, not to critique you as a parent. The nurse can tell you this
when they give you the questionnaire.
Lack o f understanding by partners. Sheltering true emotional feelings from one’s
partner was a common theme. Mothers felt a need to conceal what they were
experiencing for reasons that their partners lacked insight into understanding. When
partners where present at the CHC with mothers the scoring on the EPDS tool was
influenced.
...when Ifirst did it, I was by myself and the second I went in fo r shots, my
husband was with me and ju st because he was so concerned about it, I didn't
want to alarm him.
***

I kind o f let on that 1 was feeling better than I actually was.
***

I would have to agree, same with my husband, first time I changed my answers
based on the fa ct that he was sitting there. God forbid that he found out that it
wasn’t going as well as.
***

There is a gap fo r partners, nothing out there to help them understand.
PHN Focus Group Findings
The purpose of the PHN focus group was to explore the perceptions of the public
health nurses about the using the CHCs as a setting for routine screening for PPD.
Similarly to the participant focus group, the PHN focus group was guided by two probing

81

questions. The first question explored how PHNs felt about using the two and four month
child health clinics as an effective approach for screening for PPD. The second question
asked PHNs to provide feedback on their experience with the research study.
Question # 1: “How Do You Feel About Screening New Mothers About Their Emotions
During The Child Health Clinics?
Five themes (see Table 4.10) were generated from the first question.
Table 4.10
Essential Themes: Experiences of Public Health Nurses with Routine Screening for PPD
Essential Themes
Brought the issue to
the surface

Need for privacy

Potential
influence of the
visible rating score

Thematic Statements
1 think it worked well, prior to, we weren’t doing anything to
detect emotional health of mothers; The tool gave them an idea of
what they should be knowing to look for; I think it worked well
because a few moms who scored quite high on here wouldn’t
have been helped; I don’t know if they were in denial or they just
hid their feelings.. .but you couldn’t tell just sitting talking about
immunization with them; Having the tool, they realized “oh my
goodness, I never even thought that there was something that
wasn’t normal...or 1 shouldn’t be feeling this way; This tool is
very good in that it validates what a lot of women are feeling.
I can see it being a little problem though, if women think that
they’ll be discussing it and everybody will be hearing about
it....they may not be as honest about it on here as they would if
they knew they were going to discuss it with a nurse in a more
private area; there are loud noises all around you and your just
feeling tense; it’s not a comforting area to let your guard down; It
would have been really interesting to see what women would be
like in private rooms, to see their answers because in the
auditorium they could hear the other mothers being questioned. I
think some of the numbers could have been different. I had one
mom who was severe and she attended the clinic with her partner
and I had to ask him to leave the room for me to talk to her
privately; I just felt she had answered the questions without
understanding what she was answering...so I had to go over it
with her.. .and it got bigger and bigger .. .she revealed a lot of
information to me at that time.
For people who are trying to act like everything is just perfectly
fine, it might make them subconsciously more honest to not see
the score ....they would not be trying to avoid trying to score 12

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Dedication of time
requirement

A level of
uncertainty in
dealing with PPD

or more; I like the idea of having the score there; I’m not
sure....as a lady admitted to hospital for having severe thoughts
about herself and baby scored zero on this tool; I wonder if it
would have made a difference if this was taken off; I mean, by
looking at this you can tell what sort o f is a normal reaction. Your
only going to get the answers they want to give you.. .if there not
ready to share they they’re not going to share no matter what....in
their heart they may be a three but on paper they may be a zero.
There in such a rush, so much paper work; They either haven’t
started or trying to finish and not a lot of thought went into the
questions, so in order to move forward they needed to complete it
so you give 5 minutes and then go over the questionnaire; If we
are going to be screening at the two months then we should look
at extending the appointment time. It’s too bad we couldn’t
incorporate it in the 15 minutes wait time; What about a specific
nurse to screen in a private room?; I think you would get more
honest answers and you’d have more comfortable women.. .its
more peaceful for them because their babies are not crying, they
have not been immunized yet; I think it would be a good way to
use the 15 minutes;_______________________________________
It would be nice to have someone from mental health to come and
do that because they would know the next step to take, whereas
we would refer them to that person. If your going to do it, you
want to do it right.. .you don’t want to do if off the side of your
desk....and that’s what I feel it would be, because there’s already
so much your doing.. .it would be a real benefit if we could work
something like that out; When I realized I had a mom who scored
high and she didn’t want help because she thought there was
something wrong with her and she didn’t want it... .it seems like
your poking your nose into someone else’s business.. .1 did
eventually convince her that I needed to talk to her doctor and she
needed to talk to her doctor, .it was rough as I really felt like
everybody has their own level of what’s okay and I guess I felt
like she was dealing with it, no matter what the score was
so, I
really had to fight with myself about what was right and what I
had to do as a nurse but that was difficult for me as she was really
upset.___________________________________________________

Brought the issue to the surface. This first theme was a defining moment for
Public health nurses as they where quick to reveal that utilizing the CHC immunization
appointment to conduct the EPDS screening was an opportune time. It further served to

83

define the case for screening during these intervals of time as they acknowledged that it
was likely not being done on a routine basis thru family physicians postpartum visits.
I think it worked well, prior to this we weren’t doing anything to detect the
emotional health o f mothers.
***

I think it worked quite well, because a few moms who scored quite high on here
that you wouldn’t have known just sitting, I don’t know i f they were in denial, but
you couldn’t tell ju st sitting talking about immunization with them.
***

I think doing it at CHC worked really well, moms didn’t really have any idea what
they could be looking fo r or what they should be noticing about emotional health;
doing the tool gave them an idea o f what they should be knowing.
Another PHN remarked about the opportunity provided with the use of the tool for new
mothers, it serves to validate what they may very likely be feeling: "were not hiding
things under the rug anymore ”. This statement further infers that the nurses are not
bypassing the issue, but taking it into the practise setting and approaching the mother’s
emotional health issues as a critical piece of the holistic health model.
Need fo r privacy. This second theme identified by the PHNs gave rise to the
importance of the provision of a setting which was conducive to disclosing emotional
health issues. Interestingly, PHNs working in the setting with private offices were
confident that it enhanced the opportunity for conversation with the new mother while
PHN’s working in the open auditorium setting with dividers between work stations
acknowledged that privacy was an issue and often comments from the adjacent station

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could be heard. PHNs were concerned that this may have influenced the opportunity for
disclosure of a new mothers’ true emotional health status.
1 can see it being a little problem though, i f women thinking they ’II be discussing
it and everybody will be hearing about it, they may not be as honest about it on
here as they would i f they knew they were going to discuss it with a nurse in a
more private area... there are loud noises all around you and your just feeling
tense... it’s not a comforting area to let your guard down
***

It would have been really interesting to see what women would be like in private
rooms, to see their answers because in the auditorium they could hear the other
mothers being questioned, I think some o f the numbers could have been different
***

It was really nice to sit in the private office
Despite not having a private setting to conduct the screening, PHNs working in
the auditorium setting recognized the ethical implications inherent in not pursuing the
screening routinely with these mothers and resolved that the proeess would likely identify
some mothers being ehallenged.
***

It would definitely be an advantage to have it done in a private setting, but we
don’t have that choice in the auditorium. It is still a good thing to do even i f we
don’t have the privacy as your going to get some, you may not get as many but
your still going to get some.

85

Privacy as a theme also extended to being alone with the nurse during the
screening process. PHNs were astute in identifying that the presence of one’s partner may
influence full disclosure with the mother in the CHC setting.
***

I had one mom who was severe and she attended the clinic with her partner and I
had to ask him to leave the room fo r me to talk to her privately....!just felt she
had answered the questions without understanding what she was answering...so I
had to go over it with her... and it got bigger and bigger ...she revealed a lot o f
information to me at that time.
%%

/ had one mom who scored fairly high and the guy was just like ” oh, sh e’s just
fine and the mom was trying to tell him,
no its more than that ”.
***

. ..when she came in and she went over her score when I looked at it ...and then
talking to her, she was contradicting herself, so the written word compared to the
verbal word was different and the difference was that the partner was there;
.keeping mom in the room fo r a few extra minutes and I had the partner leave
with the baby and was then able to validate what was on the written paper instead
o f what she was verbally saying.
P oten tial influence o f the visible ratin g score. This third them e related to the fact

that the identifying positive score for the EPDS screening was printed on the screening

86

tool sheet itself. The concern under discussion by the nurses was whether this was best
practice to have the score visible to the mothers as it may lead to response bias.
***

For people who are trying to act like everything is just perfectly fine, it might
make them subconsciously more honest to not see the score, they would not be
trying to avoid trying to score 12 or more.
***

I ’m not sure.... as a lady admitted to hospital fo r having severe thoughts about
herself and baby ...she scored zero on this tool...! wonder i f it would have made a
difference i f this was taken off....I mean by looking at this you can tell what sort
o f is a normal reaction.
Other insights were that screening tools were only valid when a mother was truly
ready to disclose regardless of what the form may say. In this case, it is suggestive that
the mother has the control to reveal or not to reveal as she will also understand that there
will be consequences relative to her scoring positive.
***

you ’re only going to get the answers they want to give you... i f they are not ready
to share then they they ’re not going to share no matter what....in their heart they
may be a three but on paper they may be a zero ”.
Finally, one other PHN adds her comment without explanation.
H ike the idea o f having the score there

Dedication o f time requirement. The element of time surfaced repeatedly with the
PHN’s specifically because the CHC are designed to flow within a set time frame. Thus,

87

with the addition of screening and possibly dealing with a mother who scores positive,
which requires the initiation of a referral, this offsets the time frame adding to the stress
of workload and productivity. Nurses had a wide range of ideas as to how the screening
might be conducted alternatively.
...there in such a rush, so much paper work..Jhey either haven’t started or trying
to finish and not a lot o f thought went into the questions^ so in order to move
forward they needed to complete ...so you give 5 minutes and then went over the
questionnaire ...not all times ..hut in the auditorium you noticed hooks and the
back up... i f we are going to be screening at the two months then we should look
at extending the appointment time.
***

I t ’s too bad we couldn’t incorporate it in the 15 minutes wait time.
***

I think it would be a good way to use the 15 minutes after
***

l^hat about a specific nurse to screen in a private room, dental room ~1 think you
would get more honest answers and you ’d have more comfortable women... its
more peaceful fo r them because their babies are not crying, they have not been
immunized y e t...
Other suggestions to deal with the competing time requirement included a deferral
of follow-up for positive screening mothers. However, such practice gave rise to ethical
issues with the nurses.

88

Instead o f doing the nurse client thing where you don’t have
confidentiality ...there could he a phone call to them ...like to have a visit...come
to the home or the health unit
***

Ethically, it would be hard fo r me not to address something at that time.
***

/ feel when you opened it up le t’s carry it on, when she gets home it’s not going to
be the same
^^^

At the same time is the best time
A level o f uncertainty in dealing with PPD. The fifth theme underscores the
importance of training PHNs to be prepared to handle the critical role they play as front
line health professionals with identifying the emotional health of new mothers. While
some nurses believed that the allocation of time was warranted to do the work effectively.
Others suggested that there is a hierarchy of priorities for workload and that this issue
could be handed over to the experts.
***

...it would be nice to have someone from mental health to come and do that
because they would know the next step to take, whereas we would refer them to
that person....
***

89

I f your going to do it, you want to do it right you don’t want to do i f o ff the side o f
your desk....and that’s what Ifeel it would be, because there's already so much
your doing...it would be a real benefit i f we could work something like that out
***

When I realized I had a mom who scored high and she didn’t want help because
she thought there was something wrong with her and she didn't want it.... it seems
like your poking your nose into someone else’s business... I did eventually
convince her that I needed to talk to her doctor and she needed to talk to her
doctor...it was rough as I really felt like everybody has their own level o f w hat’s
okay and I guess I felt like she was dealing with it, no matter what the score was.
So, I really had to fight with myself about what was right and what I had to do as
a nurse but that was difficult fo r me as she was really upset.
Question # 2: What Were Some o f Your "Most Salient ” Experiences With Being
Participant to this PPD Screening Study?
Four themes (see Table 4.11) were generated from the first question.
Table 4.11
Essential Themes; Experiences o f Public Health Nurses with being participant to this
PPD screening research study
Essential Themes
Surprised at how well
mothers can hide it

What we were doing
wasn’t working

Thematic Statements
It just surprised me how well people can hide it.. .how they’re
feeling; 1 never would have known unless she did what she
did, because this lady was really well educated, well dressed;
She came in by herself with her baby and then she scored
positive which was really surprising....because she didn’t look
like she was suffering at all.
She filled it out and hadn’t even noticed that it was in the
teddy bear book...she filled it out and scored...she said ”I
didn’t realize that some of these feelings were not

90

The importance of
screening

Validated by a mother

normal” . ..she had been too busy or had not thought about
looking in the book.. .or whatever...it made me realize that
when we go out there for visits, they’re too busy with feeding
or.......she probably didn’t even look at the book as far as that
page goes...it was the biggest revelation ...
I was quite shocked that she had suffered with two previous
pregnancies and nobody picked up on it; They didn’t share it
with the doctor; The doctor didn’t ask specific questions as to:
how is motherhood, mood, how are you feeling, are you
getting out?; So, they suffered in silence and 1 was quite
shocked that just this little piece of paper and that little bit of
discussion was the first time that he had ever had anybody talk
to him about i t ....... he was very confident after we talked in
great detail,.. .he was confident in recognizing those same
symptoms again....he felt he could do something to help his
wife ...she started to come around a little bit more when we
were talking and they both agreed that they would definitely
be calling if those feelings arose again.
One mom said it was a good idea and she was happy we were
doing this screening...she had scored low but had postpartum
depression with her first baby and made this comment “good
for you guys for doing this for everybody when they come in”.

Surprised at how well mothers can hide it. PHN’s were surprised at the ease by
which health issues can be camouflaged. A further revelation was to learn that emotional
health issues know no boundaries.
It just surprised me how well people can hide it... how they ’re feeling. I never
wouldn’t know unless she did what she did, because this lady was really well
educated, well dressed...she came in by herself with her baby and then she scored
( ) ..it was really surprising....because she didn't look like she was suffering at
all.
What we were doing wasn’t working. The second theme was another insight for
the PHN’s as it brought awareness to a process, which was not functional. The current
screening practice, is designed to be self-administered in the resource booklet, was not
working.

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She filled it out and hadn’t even noticed that it was in the teddy bear book...she
filled it out and scored...she said ”I didn’t realize that some o f these feelings were
not normal”...she had been too busy or had not thought about looking in the
book...or whatever...it made me realize that when we go out there fo r visits,
they ’re too busy with feeding or

she probably didn’t even look at the book as

fa r as that page goes... it was the biggest revelation...
The importance o f screening. The significance of this honest face to face
discussion with parents by a PHN was the most revealing. It provided comfort to the
family in knowing that their emotional health issue were finally being heard and
validated. It is evidence of the critical importance for screening by PHN’s during CHC’s
as families have fallen thru the cracks in the past.
This was their third baby; ...1 was pointing to the tool in the teddy bear
book....Dad was asking all kinds o f questions in regards to it...I read him a few
questions...! was quite shocked that she had suffered with two previous
pregnancies and nobody picked up on it... they didn’t share it with the doctor; the
doctor didn’t ask specific questions as to: how is motherhood, mood, how are you
feeling, are you getting out? ...so, they suffered in silence and I was quite shocked
that ju st this little piece ofpaper and that little bit o f discussion was the first time
that he had ever had anybody talk to him about it...he was very confident after we
talked in great detail, ...he was confident in recognizing those same symptoms
again...he f e lt he cou ld do som ething to help his wife.
Validated by a mother. The fourth and final theme shared by a PHN was about a
mother’s testimony o f her past experience. What resonates through this theme is that

92

there should be equity with practice and that one standard o f practice should apply to all.
This mom said "it was a good idea and she was happy we were doing this screening...she
had scored low but had postpartum depression with her first baby ” and made this
comment "goodfo r you guys fo r doing this fo r everybody when they come in ”....
Summary Comments
These findings indicate that the postpartum period is a vulnerable time for
women. The relevance of these findings for treatment and policies for the CHC delivery
system are discussed in the following sections.

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CHAPTER 5
Discussion
In this chapter the study is summarized and the overall findings are discussed in
light of the current literature. The limitations of the study are presented followed by the
implications for primary health care practice, education, and policy. Recommendations
for future researeh and summary comments close out the chapter.
Overview o f the Study
The primary purpose of this study was to explore systematic screening for
postpartum depression as a best practice approach to reproductive mental health during
the postpartum period. A secondary purpose was to investigate demographic
characteristics between women who sereen positive with women who screened negative
on the EPDS scale. The third purpose of the study was to examine the perceived benefits
or drawbacks of using a routine PPD screening tool from the participant mothers
perspective, as well to hear the pereeptions of the public health nurses responsible for
reviewing the results of the routine PPD screening at the two-month and four-month
CHCs. This study used a descriptive mixed method research design to provide a more
comprehensive picture and balanced perspective of each aspect of the inquiry.
The instrumentation used in this study included the EPDS, a short démographie
data collection questionnaire, and a PHN survey utilizing the Likert scale. Two-hundred
and seven mothers completed the two-month EPDS, questionnaire, and survey
instruments. From this group 190 went on to com plete the four-month EPDS,
questionnaire, and survey instruments. Twenty demographic variables were analyzed to
compare positive, borderline, and negative EPDS score of participant mothers. Pearson’s

94

Chi-square test was performed to explore the relationships between the demographic
variables of the positive and negative EPDS scores of participant mothers. T-tests were
executed to compare the mean value of the independent variables within each of the two
groups, mothers who screened positive and mothers who screened negative. Spearman’s
correlation was used as a rank order correlation test between EPDS Scores and PHN twoquestion survey.
Finally, two focus group interviews were conducted to examine the perceived
benefits or drawbacks of using a routine PPD screening by participant mothers and
perceptions of public health nurses responsible for reviewing the results of the routine
PPD screening at the two-month and four-month CHCs. The interviews were transcribed
and analysed using thematic analysis.
Summary and Interpretations o f Findings
As the literature review revealed, the postpartum period is a vulnerable time for
women to become depressed (BCRMHP, 2002; CMHA, 2005). The data suggest that as
many as 10-20% of pregnant women have a new episode of either major or minor
depression during pregnancy during the first four months postpartum (BCRMHP, 2002;
Health Canada, 2000; Stewart et al., 2005). This study falls within the parameter of that
range when both two and four month EPDS screening scores are combined. At the twomonth CHC 17 (8.2%) and at the four-month CHC nine (4.7%) participant mothers
screened positive for PPD using the EDPS. Of the nine participants that had positive
scores at the four-month screening interval, eight were new detections as they had not
scored positive at the two-month screening interval. Therefore, the study revealed an
overall positive EPDS score (n=25) over the total four month period. Moreover, if we

95

were to eombine the two and four month positive score (n=25) with the two and fourmonth borderline (9-11) score (n=52), the projected positive (n=77) EPDS screening rate
would reach 40%. This study provides further evidence that PPD is a major health issue
for new mothers.
The findings from this study support the conclusions found in other studies that
explored risk factors associated with the onset of PPD. For example, this study found that
mothers who scored positive were more likely to have fewer children than those who
scored negative (t= -2.95, p<.004) similar to the findings of the Johnson and Apgar
(2004) study. The study also found that mothers who reported as having no time for self
(X^ = 5.45, p<0.05), as having fewer people to talk to (t=2.04, p<.05), had no regular
exercise (X^ =5.05, p<0.05), and reported fewer total number of minutes to self per
week(t= -2.38, p<.05) were more likely to score positive (Beck, 2001; Cooper & Murray,
1998; Gotlib et al., 1989). Further, the study found that mothers who reported having an
unplanned pregnancy (X^ = 3.93, p<0.05), as feeling sad during the pregnancy (X^ = 8.80,
p<0.001), and reported having a history of depression (X^=14.45, p<0.002) were also
more likely to score positive (Beck, 2001; Cooper & Murray, 1998; Lane et al., 1997;
Wisner et al, 2002). Finally, the two-question PHN survey was correlated with the EPDS
scores at the two and four month intervals. Both sets of results were small and moderately
significant at the 0.01 level. The higher the EPDS score the lower a mothers self
confidence, while the higher the EPDS score the more negative her anxiety score and the
more anxious she was about infant care (Beck, 2001).
Moreover, the findings of this study support the conclusions of previous studies
that call for increased screening, support, and treatment of maternal depression. It is

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important to point out that the large number of women who scored positive or fell within
the borderline group on the EDPS screening tool came as a surprise to the public health
nurses. Had the screening not taken place at the CHCs, the commonly held assumption
that mothers actually take the time to complete the self-administered PPD screening tool,
which is provided to them at the 48 hours post hospital discharge PHN home visit, would
have gone unchallenged. The focus group interview with participant mothers further
revealed that they did not complete the self-administered PPD screening tool for a variety
o f reasons ranging from “I forgot”, “no time”, “forgot it existed”. Many of the mothers
openly confessed that they were not even aware what they were feeling was indicative of
being in a PPD state. These findings are consistent with the general literature which
suggests that mothers in a depressive state often do not recognize their symptoms as
depression (Whitton, Warner, & Appleby, 1996) and do not take the time to complete the
EPDS screening tool (Beardslee, 2002; Misri, 2002; Saunders, 2003). It is particularly
difficult for mothers with new infants to separate symptoms of depression, such as
fatigue, early morning awakening, or weight loss, from the normal adaptation to life with
a new infant. Therefore, we need to maintain a closer watch over these women.
An additional finding that emerged from the participant mothers’ focus group
interview was the significance of routine screening for PPD at the two-month and fourmonth CHCs. The few studies that have examined routine screening for PPD show that a
mother is more likely to complete the screening tool when given direct support by health
care professionals (Solberg, Korsen, Oxman, Fischer, & Bartels, 1999). Many of the
mothers reported that their doctors do not take the time to inquire about their mental
health. Mothers have further expressed a reluctance to disclose their feelings without

97
having the question asked first by their physician. Further, physicians may
unintentionally minimize a mother’s distress in an effort to be reassuring. There is also
the pressure of managed care to evaluate more patients in a limited amount of time, and
mental health issues frequently receive cursory attention from even the most thoughtful
physicians.
Alternatively, public health nurses have an important role to play not only in
ensuring the physical well being of newborns and mothers in the postpartum period, but
also in early detection of PPD. For at least some mothers, screening for PPD as part of
the two-month and four-month CHCs may afford an earlier opportunity for prompt and
effective interventions including additional social support.
Not only did the mothers recognize the importance of routine screening at the
CHCs, but the public health nurses also had several key discoveries. For example, many
of public health nurses revealed that they were surprised at how well the mothers hid
their feelings and without the screening taken place at the CHCs they would not have
picked-up on it. This of course raises several other concerns for the nurses including the
need for additional education on PPD.
Another key finding from the study was the lack of support services for mothers
who screen positive for PPD. For example, many mothers spoke about the lack of support
from their partners, friends, family doctors, and the community at large. Feeling
unsupported was the basic psychological problem mothers experienced during the
postpartum period.

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Limitations o f Study
There are several limitations to this study. First, there are issues of sampling. Non
probability sampling limits generalizability of findings because the sample is not a
random selection of all women in the population who we may be interested in studying
(Babbie, 1998). Although a sample size of 200 was sufficient enough in power to
generate descriptive statistics and the targeted number of participants for the focus group,
there was no provision in this study to obtain a stratified random sample to ensure that
small groups within the population were included. The sample also excluded mothers
under 18 years of age. Excluding this age group was a study limitation as the literature
reports a higher overall percentage of PPD in this group. Therefore our study results
could have been diverse.
Second, the data collection took place from January to July and did not control for
seasonal effects. Results could have been varied had the study been conducted over 12
months as rates of depression may change throughout the year.
Third, the EPDS screening tool has not been validated in this paediatric setting
(i.e., CHCs). This may have affected the results as no prior EPDS screening had been
done in this setting at the place to confirm that it would work.
Forth, participant participation was largely dependent upon the cormeetion
between the health aide who was receiving mothers into the CHC area. There was some
question as to whether mothers agreeing to be participant would influence the response of
the next mother in line for her appointment, thus, raising the issue of responder bias.
Fifth, other expressed limitations by mothers where the privaey issue of having to
complete the forms in the open auditorium when other people where not engaged in the

99
same task thus leaving some mothers feeling conspicuous. Along the same line of
privacy, was mother’s accompaniment to the appointment with an adult whether it was
her partner or friend, this was also acknowledged as a limitation in terms of bias for
response on the forms. The issue of privacy surfaced again in the actual clinic setting
with the public health nurse, as freestanding barrier walls, which provided limited
auditory and visual privacy, separated workstations. It was established that this
environment was not entirely conducive to disclosure of sensitive and personal
information.
Sixth, the PHNs did not always have the necessary time to spend with
participants. The time requirement allotted for a CHC appointment created some
additional stress when the screening study started. Public health nurses were required to
immunize infants, while simultaneously addressing the EPDS screening scores of
mothers, which, in some cases required the implementation of a referral process. When a
nurse was delayed because a mother had a positive score, which required an action plan
for the mother, this delayed her subsequent appointment and placed her behind in her
work. To counter this anticipated delay, every PHN involved in the study received
advance orientation to the research process, steps to follow with scoring results, referral
contact numbers and a back-up plan for clinic delays. What became clear through this
process was that nurses were openly dealing with this issue face-to-face in the clinic
setting for the first time, which was in some instances stressful. The nurses felt rushed
and were compelled to process things in a timely manner, which could have affected the
results.

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Seventh, a further limitation was operating the study from two sites and
coordinating the follow-up of the participants for the four-month re-screening. The
researcher could not be present at both sites simultaneously and had to rely on telephone
communication daily to the alternate site to validate participants presenting for re­
screening on that appointed CHC schedule.
Eight, all screening tools have their limitations, and the EPDS is no exception.
The specificity of the EPDS tool is reported to be 86% while the sensitivity is 78%, (Cox
& Holden, 2003). They further suggest that to detect a higher percentage of women with
depression and to lower the number of missed detection to under 10%, the cut-off score
would be reduced to 9 or 10. However, caution was exercised when the decision was
made to use a higher more conservative cut-off, so as not to be over inclusive with
mothers having false positive scores.
Ninth, a further issue identified by the mothers was having the critical identifying
score on the screening sheet itself. Some mothers admitted that knowing this in advance
influenced their scoring responses. This copy of the tool was identical to the tool printed
in the resource booklet, which was given to each mother on a maternity home visit. For
purposes of consistency and for minimizing false positive scores, the critical number
remained on the tool for the duration of the study. Mothers' preferred suggestion was to
have the critical score off the screening tool and have time allocated for consultation with
the nurse to review the scores together.
Im plications o f Findings

These findings have implications for primary health care policy makers,
educators, service delivery practitioners, and the public. They can be used to guide the

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development of practice and policy recommendations and have the potential to reduce
costs to the social and health care systems through appropriate and timely service
delivery.
Policy Implications
There are at least six important areas for primary health care policy development
in relation to the findings of this study. These findings are consistent with findings from
other studies exploring screening for postpartum depression and have important
implications for mothers and their families.
Evidence based practice. While the contribution of evidence-based research in
addressing many of the complex health problems currently facing individuals and
communities is well documented, there is an increasing demand for practice-based
research. As Epstein (2001) asserts, evidence-based approaches to knowledge building
and utilization can leave practitioners feeling alienated from the research process, with no
incentive to assess and change their practice behaviors based on knowledge generated
through evidence-based studies. Rather, a practice-based research approach brings
practitioners into the center of the research process, thereby increasing the utilization of
knowledge derived from research. Yegidis and Weinbach (2002) also report that “a
practice-oriented and practice-informed researcher is likely to produce research findings
that will have value and be of benefit to those who deliver services to clients” (p.8).
The entire children and family team was directly involved with the
implementation of the study. The collection of data was integrated into the day-to-day
activities of public health nurses and administrative personnel. Involvement of the PHNs
in this study greatly enhanced their capacity to conduct research in primary care settings

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and to translate research findings into practice. One of the early promises of practicebased research in primary care is that research conceived and conducted in practice
settings could follow a short feedback loop back into practice and thus shorten the usually
laborious translation process of applying the research results to the practice of primary
care.
This study, which informed practice based research grounded public health nurses
with a solid understanding to defining the case for why screening for PPD should be
integrated as a standard approach during child health clinics. Nurses now view the entire
issue though a new lens, one which is focused and which will provide that clarity of
understanding what the best practice approach is, one that could inform a new policy for
this health unit.
Recommendation #1 :
Building practice-based research capacity will inevitably involve changing the
culture of the organization from a bureaucratic orientation to an environment where
research is a valued, expected, and enjoyable activity. The expectation should be for all
public health nurses and managers to be involved in some way in the generation of new
knowledge. Primary health care organizations can facilitate this culture change by
explicitly valuing scholarship and research, by instilling an appreciation and
understanding of research among nursing students and public health nurses by supporting
the development of practice-based research studies.
E arly detection a n d routine screening o f PPD. These findings demonstrate the

importance of early detection and routine screening of maternal depression. As shown in
the review o f the literature postpartum depression can occur any time during the first 12

103
months after delivery; therefore, screening for PPD should occur on a routine basis. As
shown in this study eight of the nine mothers who scored positive for PD at the fourmonth CHC did not score positive at the two-month CHC. As stated by Strass (2002), not
only are public health nurses in an ideal situation to screen new mothers in the early
postpartum period, they are also the professionals who possess the working knowledge
and skill set to link families to referrals and supportive community services. Routine PPD
screening practices at the two and four-month CHCs will likely promote an
understanding by new mothers that health care delivery is comprehensive, accessible,
timely and most of all sensitive to their emotional needs. Further, it is speculated that as
mothers come to be witnesses of this change in practice, they will likely be confident that
this is a safe and accepting environment for disclosure of emotional health issues, a place
that is a truly supportive practice environment, one that invests in the shared governance
model for community health.
Recommendation #2:
The public health care authority should integrate routine screening protocols and
educational mechanisms for staff training and client education related to postpartum
depression (PPD) into their standard practices of care for prenatal and postpartum
mothers.
Postpartum depression education fo r new parents. The findings of this study have
also increased understanding about the threat postpartum depression has on the mother’s
and father’s health, marriage, friendships and careers, as well as the baby’s welfare. Yet,
the findings of this study revealed discrepancies between prenatal parent support services
and subsequent perceptions of support actually received by mothers and their partners in

104
relation to postpartum depression. The findings show that fathers/male partners were not
perceived to be supportive, and that they lacked insight into the new mothers’ reality.
Recommendation #3:
Parent education about PPD during prenatal classes can make families more
aware of the risk factors and signs to watch for during the early postpartum weeks. It is
recommended that a review of the prenatal education program be undertaken with the
intent to increase awareness of PPD risk factors for both the pregnant women who attend
the classes and their partners. As one participant stated “my prenatal class did not even
mention postpartum depression”.
Increase emphasis on pre-postnatal support services. In addition to prenatal
education programs, there is need for secondary prevention programs targeted to mothers
already experiencing depressive symptoms in order to improve parenting and child
development outcomes. Participant mothers clearly noted their frustration over the lack
support groups available in Prince George area.
Recommendation #4:
To improve access and support for all new mothers in urban and rural regions of
the north, one avenue for future development would be exploring the option of linking to
the Women North Network. This initiative could be the site of a future pilot project for a
postpartum support group, one that included mothers on a steering committee as well as
being involved as part of a self-help model.
Standard curriculum fo r medical students. Medical students need to develop a
broader understanding of maternal depression after the birth of a baby. The findings
suggest that family physicians are not consistently inquiring about mothers emotional

105
health during the postpartum check-up, there remains to be a gap in health care service
delivery.
Recommendation #5:
The northern medical program could include a component of training for their
family practice residents specific to reviewing the emotional health of new mothers
during the postpartum follow-up period.
Continuing competency requirement. The research revealed that many of the
public health nurses were uncertain about their level of competency in dealing with the
outcome of a positive score on the EPDS. While there is an assumption that public health
nurses are “competent” upon graduation, the reality is professional practice is a lifelong
journey. What comes to our conscious awareness is that there are issues with the transfer
of knowledge into the practice setting.
Recommendation #6:
Nurses have a professional obligation to develop and refine the competencies needed for
safe, ethical and effective practice. There needs to be some thought invested into
maintaining a continued competency with handling postpartum issues. For example,
public health nurses are required to write competency exams every two years exclusively
on the subject of immunization. However, when the scope of practise is broader than this
one field, how is the competency in other facets of the day-to-day work measured?
It must be noted, however, that the findings and recommendations of this study
have limited application to other contexts, and therefore one cannot generate axioms that
are widely applicable to other situations. What this study does yield, however, are
interesting insights into suggested areas for further research, specifically those using

106
qualitative designs as a basis for developing insight and gaining understanding into
proeess-issues of distance education.
Recommendations fo r Future Research
The study has identified a number of promising areas for future research. These
areas are discussed briefly. The first recommendation for future research involves
adolescent mothers. The results of this study were limited to women 19 years of age and
older. To have excluded the adolescent population was not an oversight but rather a
testimony of the importance of this younger population group of mothers who truly
warrant researeh initiatives, which are designed to address their specific issues. The
complexity of moving thru adolescent years is a stressful transition in today’s world,
adding an infant to that situation can compound the life stressors. In order to begin to
understand why depression manifests itself in this group at a higher reported percentage,
it is logical that research design would consider the cohort specific determinants of health
as defined by young mothers themselves.
A second recommendation and one, which builds on, this researeh study, is to
explore with the mothers who scored positive in the study their experience and utilization
of referral services to family physicians. What their pereeptions were of how their
emotional health issues were addressed and whether this improved their health outcomes.
What further recommendations would they have to build upon or improve this referral
process?
A third recommendation would be to explore culturally appropriate approaches
for screening mothers from diverse cultures.

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Concluding Comments
While this study was an exploration into systematic screening for postpartum
depression as a best practice approach to reproductive mental health during the
postpartum period, it has given rise to a remarkable learning experience. As a public
health nurse and masters student I was successful in bridging the theoretical world to the
front line practice setting in conducting this applied research pertaining to PPD screening.

108
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Appendix A
2 Month Demographic Questionnaire
A BO U T YOU:
Please check the boxes that best apply to you:
1)

What is your age grouping? (mark only one box)
□

1 9 -2 4

□

3 7 -4 2

□

2 5 -3 0

□

4 3 or over

□

3 1 -3 6

2)

What is the highest level of education you have achieved?__

3)

Which language do you speak most often at home:_________

4) How would you describe yourself? (mark only one box)

□
□
□
□
□

Single
Separated/Divorced
Married
With partner (less than 2 yrs)
With partner (together more than 2 yrs)

5) Your family income before taxes is? (mark only one box)
□
□
□
□
□
□

Under $20,,000
$21,000 to $31,000
$32,000 to $42,000
$43,000 to $53,000
$54,000 to $64,000
$65,000 or more

6) Which of the following employment categories applied to you before the baby’s
birth? (mark only one box)
□
□

Full time
□
Part- time
□
Other_________________________________

Unemployed

7) Please mark all of the activities that describe how you take care of yourself? (mark all
that apply)

□
□
□
□
□

regular exercise
Walk
Swim
Run
Other

times per week for about

minutes

129

□
□
□
□
□

time to yourself
times per week for about
Read
Listen to music daily
Relaxing bath
Other_________________________________

minutes

8a)

How many people (partner, close friends or relatives) do you have that you can
talk to if something was troubling you?
,______ (state number please)

8b)

Of the people who are close to you, how regularly would you talk to them?
(check all that apply)

□
□

Daily
□ Weekly □ Every 2 Weeks □
Other_________________________________

Monthly

ABOUT YOUR PREGNANCY

9a)
9b)

Was this a planned pregnancy?
How many children do you have?

10)

Using the 5 point scale below, which number would best describe your general
mood during the pregnancy? (circle that which best applies to you)
1
very hap p y

11)

□ Yes
□ No
___________(state number please)

2
3
4
5
*....................*.........................*...................not at all happy

Before you were pregnant, was there a period of time in your life when you
experienced depression? (check that which applies)
□

never

□

0 to 2 years ago

□

2 to5 years ago

□

more than 5 years

12) The resource booklet you received from your public health nurse during your
home visit had a copy of the Edinburgh Postnatal Depression Screening (EPDS)
tool in it; did you happen to fill it out?
□
□

Yes: How many weeks/month (s) after birth_________________
No

If you did fill out the EPDS, did you have a score of 12 or greater?
□

Yes

□

No

□

Uncertain

If your score was 12 or greater, did you contact anyone of the resources listed in
the booklet?
□ Yes □ No
If Yes: Please list the resources you contacted___________________________

130

A BO U T BABY

13)

Age of baby

14)

Gender of baby:

□

15)

breastfeeding or □

formula feeding or □

Girl

□

Boy
both? (mark only one box)

Thank you for your help!

131
4 Month Demographic Questionnaire

A BO U T YOU:
1)

What is your age grouping? (mark only one box)

□
□
□

□
□

19-24
25-30
31-36

Yes

□

□

No Change

□

No Change

□

No Change

□

No change

No

5) Please mark all of the activities that describe how you take
care of yourself? (mark all that apply)
□
regular exercise
times per week for about_____ minutes
□ Walk
□ Swim
□ Run
□ Other
□
□
□
□
□

No Change

Under $20,,000
$21,000 to $31,000
$32,000 to $42,000
$43,000 to $53,000
$54,000 to $64,000
$65,000 or more

4) Please indicate if you have returned to work since your two month
clinic visit? (mark only one box)
□

□

Single
Separated/Divorced
Married
With partner (less than 2 yrs)
With partner (together more than 2 yrs)

3) Your family income before taxes is? (mark only one box)
□
□
□
□
□
□

No Change

37-42
43 or over

2) How would you describe yourself? (mark only one box)
□
□
□
□
□

□

times per week for about
time to yourself_
Read
Listen to music daily
Relaxing bath
Other

minutes

132

6a) How many people (partner, close friends or relatives) do you have that
you can talk to if something was troubling you? (state number please)

6b) Of the people who are close to you, how regularly would you
talk to them? (check all that apply)
□
□

Daily
□ Weekly □ Every 2 Weeks □
Other_________________________________

□

No change

□

No change

□

No change

Monthly

6) The resource booklet you received from your public health nurse
during your home visit had a copy of the Edinburgh Postnatal
Depression Screening (EPDS) tool in it; did you happen to fill it out?
□
□

Yes: How many weeks/month (s) after birth_________________
No

If you did fill out the EPDS, did you have a score of 12 or greater?
□ Yes
□ No
□ Uncertain
If your score was 12 or greater, did you contact anyone of the resources listed in the
booklet?
□ Yes: Please list the resources you contacted____________________________
□ No
A BO U T BABY

13)

Age of b a b y ___________

14)

Gender o f baby: □

15)

Is baby: (m ark only one box)
□ breastfeeding or □

Girl

□

Boy

formula feeding or □

both?

Thank you for your help!

133
Appendix B
PHN Survey

□ 2 month
Code #:
EPDS score #
alone,

with partner,

□

Month: J F M A M J

4 month

Clinic: M T W Th
C ity________________
with another adult

FRC
(Please ask mothers the following questions using the exact written words)
1. How would you best describe how you feel about yourself today as a new mother?

On a scale of 1 to 5, where 1 is totally confident and 5 is not at all confident, how do
you feel about yourself as a new mother?

1
totally confident

2
*.

3
*

. *.................. not at all confident

2. How do you feel about looking after your baby?

On a scale from 1 to 5, where 1 is very anxious and 5 is not at all anxious, how do
you feel about looking after your new baby?
1
very anxious

2
*.

3
*

. *..................not at all anxious

* If Positive EPDS score (12 or >) please check off referral action taken:
□ Community Response Unit (C.R.U.)
□ Physician
□ Crisis Line
□ Public Health On-call/FFP
□ Other: (state)____________

-Thank you

134
Appendix C

northern health
RESEARCH PARTICIPANT INFORMATION SHEET
Researcher:

Meridy Black,
Master of Science Student in Community Health, UNBC
Phone: (250) 565-7429
E-mail: Meridy.Blaek @northemhealth.ea

Supervisor:

Dr. Karen Kelly
Associate Professor, Chair, Health Services/Health Policy
(250) 960-6450
E-mail: kellyk@unbc.ca

Project Type: Community Health Masters Thesis, UNBC
Project Title: KEEP ASKING ME HOW I AM FEELING
Purpose:

This study will find out if it is possible to screen moms during the 2 and 4
month child health clinics and help identify those who may be in the early
stages of depression.

Risks:

There are no known risks associated with being part of this study.

Benefits:

It will benefit women who are experiencing depression, as they will be
given immediate help in connecting with support services.

Participants

Moms who delivered infants during the months of November 2004 to
February 2005 will be invited to participate in the study.
Participation is completely voluntary.
The information you provide will be kept private.
As a participant you have the right to leave the study at any time and your
information destroyed.
Your decision to participate or not will in no way influence services
received now or access to any services in the future.

135
What are you being asked to do?
At both the 2 and 4 month Child Health Clinie you will be asked to complete a
short survey about yourself, your pregnancy, and your baby, and fill out the
Edinburgh screening scale. This will take 10 minutes.
The public health nurse you see will ask you 2 short questions; this will take 2
minutes.
If you score 12 or more on the Edinburgh screening scale you will be invited to
take part in a one time 2 hour focus group to talk about how best to screen new
mothers.
This will occur early summer of 2005. If you attend you will be paid $25.00 to
help cover travel and ehildcare costs.
How will vou keep mv information private?
A code number, not your name, will be used on the forms. Personal information
will not be used.
If you participate in the focus group what you and others say will be recorded
without the use of names. You will also be asked to respect the privacy and
confidentiality o f others and what they share.
Who will be able to see mv information?
Only the research student and the members of her research committee will see the
information on the forms. Your name will not be used, only a code number.
How will the information be stored and for how long?
The information will be kept secure in a locked filing cabinet for 5 years. After
this time, forms will be shredded and the record of the focus group destroyed.
How do 1 get a copv of the results of the research?
If you are interested just ask Meridy Black. She will provide you a summary of
the results of the study. You could also check out a copy of her completed thesis
at the UNBC library.
Please contact Meridy Black or her supervisor, Dr. Karen Kelly at the above numbers if
you have any questions. I f you have any complaints or would like to report any violation
o f professional or ethical conduct during this study please call the Vice-President
Research, UNBC at 960-5820.

136
Appendix D
Informed Consent Form
Do you understand that you have been asked to be in a research
study?

Yes 0

No □

Have you read and received a copy of the attached information
sheet?

Yes □

No □

Do you understand that the focus group will be recorded?

Yes □

No □

Do you understand the benefits and risks involved in
participating in this study?

Yes □

No 0

Have you had an opportunity to ask questions and discuss this
study?

Yes □

No 0

Do you understand that you are free to refuse to participate or to
withdraw from the study at any time? You do not have to give a
reason and it will not affect any medical or other kind of care
you are receiving.

Yes □

No 0

Has the issue of confidentiality been explained to you?

Yes □

No 0

Do you understand who will have access to the information you
provide?

Yes □

No 0

This study was explained to me by: _______________________________
Print Name
1 agree to take part in this study:
Date:
Signature of Research Participant

Printed Name of Research Participant
I believe that the person signing this form understands what is involved in the study and
voluntarily agrees to participate.
__________________________________ Date:_____________________
Signature of Investigator
Date:
Signature of Investigator

.

137
Appendix E
Definition of Terms
“ pop-up alerts” ; This term is used to signify a special alert to healthcare professionals
accessing this infants file. In this study, it was applied to the infants electronic database
file to inform nurses of the study code # associated with this infant for the four month
follow-up screening.
“ iphis data base” : This term is used to signify the computer program which houses the
health information on an infant and family members.
“check-in” : This term was used to signify the point of entry to the child health clinic, it is
the first point of contact with the health aide who acknowledge mothers and infants
attendance on the scheduled appointment list. Once this was completed, she initiated her
admin work.
“study envelope box” : This term was used to signify the study box which was used to
house the study forms, study envelopes and guidelines for the research process. It kept
the paperwork organized and orderly. It was easily portable to the worksite each day and
returned to the researchers office at the completion of each day.
“ study envelope storage container” : This term was used to signify the designated
container in the researchers office into which the public health nurses deposited the
sealed study envelopes following each child health clinic. At the completion of each day,
the researcher removed the sealed envelopes and locked them in the designated filing
cabinet for safe storage.

138
Appendix F

Northern Health / The University of Northern British
Columbia
have given approval for this study.

YOU ARE INVITED TO BE PART OF THIS STUDY
If you are a new mother o f 19yrs and older and are attending an
immunization appointment with your baby o f 2 months, between January
and April of 2005, then this study might interest you.
As new mothers we are often faced with a yariety o f challenges,
which can make the role o f being a mother, at times, a hard thing to do. No
two mothers experiences are the same when it comes to mothering a new
baby as we all experience pregnancy and birth somewhat uniquely. As well,
we all haye different life eyents that play a big part in how we cope with this
new role. What might appear to be just perfect one week may suddenly
change because o f a life eyent the next week, leaying us with feelings o f
uncertainty.
The purpose o f this study is to ask new mothers some questions about
their emotional health while they come for their infant’s immunization
appointments at 2 and 4 month’s o f age. Some mothers are being challenged
with their emotional feelings and may not haye a chance to really tell the
nurse how they are feeling. So, this study hopes to make that change so that
mothers will haye the chance to yoice their real feelings with their public
health nurse.
You will be asked to fill out a simple screening scale and to complete
a simple questionnaire; this will take about 10 minutes. Your public health
nurse will ask you 2 simple questions.
All this information is kept priyate between the researcher and her research
co m m ittee. I f h o w ev er, w e fin d that any mother is experiencing thoughts o f
harming herself or those in her household, we haye the duty to report this to
her family doctor.
-Thank you for your consideration ~

139
Appendix G
PHN Guidelines
When PHN’s discover mothers with EPDS scores within the following numerical range:
(0 to 8), (9 to 11), (12 to 30), they will take the action as outlined upon this sheet:
Scenarios
1. When a mother scores between 0 to 8 on the EPDS, the score will be recorded on
the designated line of the PHN survey. PHN’s will discuss with mothers that
should they feel any changes with their emotions before their next clinic
appointment that they should connect with the children & families on-call line for
consultation of available resources or connect with their family doctor.
2. When a mother scores between 9 to 11 on the EPDS, this score will be recorded
on the designated line of the PHN survey. The PHN will encourage this mother to
connect with her family doctor or other primary healthcare provider. The PHN
will provide the mother with a list of current resources.
3. When a mother scores between 12 to 30 on the EPDS, this score will be recorded
on the designated line of the PHN survey. The PHN will, with the mother’s
agreement, call upon the on-call nurse or the back-up immunization nurse to assist
the mother in connecting with the:
a) Community Response Unit
b) Family Doctor
c) Emergency Department
* The PHN will then record the action taken upon the PHN survey form.
* In the event that the mother refuses to seek referral, as advised by the clinic PHN and
departs on her own accord, it will be the responsibility of the attending nurse to call this
women’s family doctor and notify him or her of the situation and score. PHN’S have a
duty to report when the well being of a person or persons within their care may be
threatened.
* If a mother is believed to be psychotic and the mother disagrees to receive assistance,
the PHN will seek assistance to refer this mother to the PGRH emergency department.
* PHN’S are cognisant about the sensitivity of this issue and further understand that this
clinic setting is limited in its provision of an environment, which is private for
discussions of a sensitive nature. Therefore, they will assert their best practice effort in
having this conversation and will not take action, which could result in the creation
o f a scene for either this mother her or that o f other attending fam ilies.

140
Appendix H
RESEARCH PARTICIPANT INFORMATION SHEET AND CONSENT
Researcher;

Meridy Black,
Master of Science Student in Community Health, UNBC
E-mail: Meridy.Blaek @northemhealth.ca

Supervisor:

Dr. Karen Kelly
Associate Professor, Chair, Health Services/Health Policy
E-mail: kellyk@unbc.ca

Project Type: Community Health Masters Thesis, UNBC
Project Title: KEEP ASKING ME HOW I AM FEELING
Focus Group Participants
Purpose:

This study will investigate if screening moms during the 2 and 4 months
child health clinics will help to identify those moms who may be in the
early stages of depression.

Risks:

There are no known risks associated with being part of this study.

Benefits:

It will benefit women who are experiencing depression in that they will be
given immediate help in connecting with support services.

Participants:

PHN participants were chosen based on years of experience and full time
employment or connection with PPD in their nursing role. Participation is
completely voluntary.

What are vou being asked to do?
You are being asked to participate in a 1Vi hr focus group to discuss your experiences in
the PPD screening study.
How will the confidentialitv of the information be maintained?
The focus group will be taped-recorded and transcribed. All personal identifying
information will be omitted from the transcription. Information will not be linked to
participants. No names will be recorded on the audiotape and the identity o f participants
will be held confidential. Participants of the focus group will also be asked to respect the
privacy and confidentiality of others and what they share.

141

How will the information be stored and for how long?
The information will be kept secure in a locked filing cabinet for 2 years. After this time
the audio-tape will be destroyed.
How do I get a copy of the results of the research?
If you are interested just ask Meridy Black. She will provide you a summary of the
results of the study. You could also check out a copy of her completed thesis at the
UNBC library.
Please contact Meridy Black or her supervisor, Dr. Karen Kelly at the above numbers if
you have any questions.
I f you have any complaints or would like to report any violation ofprofessional or ethical
conduct during this study please call the Vice-President Research, UNBC.
Informed Consent
Do you understand what you have been asked to be in a research study?
No

Yes_

Have you read and received a copy o f the attached information sheet?
No__

Yes_

Do you understand that the focus group will be recorded?
No__

Yes_

Do you understand the benefits and risks involved in participating in the focus group?
No__

Yes__

Have you had an opportunity to ask questions and discuss this study?
No__

Yes_

Do you understand that you are free to refuse to participate or to withdraw from the
study at any time?
N o_

Yes

Has the issue o f confidentiality been explained to you?
No__

Yes_

Do you understand who will have access to this information?
N o __

Yes_

This study was explained to me by:
1 agree to take part in this study:

_________________________________

142

Signature o f Research Participant

Date

Printed Name o f Research Participant
I believe that the person signing this form understands what is involved in the study and
voluntarily agrees to participate.

Principle Investigator

Date

143
Appendix I
SOCIO-DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS

Demographic variable
Age
19-24
25-30
31-36
37+
Education
< grade12
Grade 12,Trade or College
University
English
Language
Other
Single
Marital status
Married
Coupled <2yr
Coupled >2yrs
SES
< 20,000
21-42,000
43-64,000
65,000 +>
Employment
Full time
History
Part-time
Unemployed
Regular exercise
Yes
No
Time to self
Yes
No
Number of people
1-5
to talk to
6-10
11>
Parity
1
2
3+>
Planned Pregnancy
Yes
No
Mood in Pregnancy V. Happy
Happy
Neutral
Not Happy
Not at all Happy
History of Depression Never
0-2years
2-5 years
> 5years

Two Month (n=207)
Frequency
Percent
51
24.5
46.9
97
50
242
3.9
8
31
15.1
132
623
17.9
38
92
195
9
4.4
24
11.3
117
552
16
7.5
48
22.6
43
202
40
18.8
39
18.4
74
34.9
118
55.7
39
18.4
48
22.6
174
82.1
33
15.6
174
82.1
33
15.6
119
56.2
34
72
9
4.3
110
51.9
72
34.0
11.7
25
128
60.4
74
34.9
64
302
34.4
73
49
23.1
14
6.6
1.4
3
113
532
34
16
13.2
28
29
13.7

Four Month (n=l
Frequency
Pen

133
57
118
72
105
65
13

62.7
26.9
55.7
34.0
49.5
30.7
6.1

144
Yes
No

51
147

24.1
693

68
102

32.1
48.1

Yes
No
Uncertain

5
37
7

2.4
17.5
3.3

10
43
16

4.7
20.3
7.5

4
10
164
25
18
101
106
91
72
43
109
55
25
12
194

1.9
4.7
77.4
11.8
8.5
47.6
50.0
42.9
34.0
20.3
51.4
25.9

6
19

2.8
9.0

95
94
77
90
20
90
70

11.8

11

44.8
44.3
363
42.5
9.4
42.5
33.0
5.2

5.7
91.5

17
171

Resource booklet EPDSused
If completed EPDS was
score >12

Score >12 did you contact
resources
Yes
No
8 weeks
Age of Baby
9 weeks
10+11 weeks
Male
Gender of Baby
Female
Breast
Feeding type
Formula
Both
Alone
Participant Visit
With Partner
With another Adult
Clinic location
FRC
Health Unit
Return to work
Yes
No
Age of Baby
16 weeks
17 to 19weeks
20 to 22 weeks

12

174
163
25
3

8

80.7
5.7
82.1
76.9
11.7
1.4

145
Appendix J
PEARSON’S CHI-SQUARE RESULTS AT TWO MONTHS
Demographic
Variables:
P ositive
EPDS (> 12)

N egative
EPDS (< 12)

Chi-sq.
Value

Sig.

19-30
31 +

14
3

134
55

1.011b

0.315

Total

17

189

< High School

3

28

High School,
Trade School
or College
University

11
3

121
35

0.078a

0.962

Total

17

184

Single
Married
Partner <2yrs
Partner >2yrs

3
10
1
2

21
107
15
46

1.762a

0.623

Total

16

189

<20,000
21,00042,000
43,00064,000
65,000 +

3

40

4

36

2
6

37
68

0.713a

0.87

Total

15

181

Full-Time
Part-Time
Unemployed

11
2
4

107
37
43

0.677a

0.713

Total

17

187

Yes
No

11
6

161
27

5.058b

0.025

Total

17

188

Yes
No

11
6

162
26

5.453b

0.02

Total

17

188

Yes
No

7
10

121
64

3.937b

0.047

Total

17

185

V. Happy
Happy
Neutral
Not & Not
at all Happy

3
3
8
3

61
70
41
14
8.807a

0.032

Total

17

186

Grouping

Age
(N=206)

Education
(N=201)

Marital Status
(N=205)

SES.
(N=196)

Employment
(N=204)

Regular
Exercise
(N=205)
Time to
Self
(N=205)
Planned
Pregnancy
(N=202)
Mood in
Pregnancy
(N=203)

146

History of
Depression
(N=204)

Resource
booklet
EPDS
(N=196)
Gender
Of Infant
(N=207)
Feeding
(N=206)

Ft. Visit
(N=189)

never
0-2yrs ago
2-5 yrs ago
>5 yrs ago

4
6
6
1

109
28
22
28

Total

17

187

Yes
No

6
10

45
135

Total

16

180

Girl
Boy
Breast
Formula
Both

11
6
17
4
7
6

95
95
190
87
65
37

Total

17

189

Alone
Partner
other Adult

10
4
1
15

99
51
24
174

Total

Total

14.452a

0.002

1.193b

0.275

1.351b

0.245

3.839a

0.147

0.792a

0.697

147
PEARSON’S CHI-SQUARE RESULTS AT FOUR MONTHS
Demographic
Variables:
Positive
EPDS (> 12)

N egative
EPDS (< 12)

19-24
25-30
31-36
37+

2
6
1
0

42
84
47
7

Total

9

180

Single
Married
Partner
(<2yrs
Partner
(>2yrs)

2
3

24
103

2

12

2

41

Total

9

180

< 20,000
21,00042,000
43,00064,000
65,000+

3

34

4

37

1
1

33
65

Total

9

169

Yes
No

0
9

12
165

Total

9

177

Yes
No

7
2

165
15

Total

9

172

Yes
NO

9
0

151
30

Total

9

181

Yes
No

4
4

64
98

Total

8

162

Girl
Boy

7
2

87
93

Total

9

181

Breast
Formula
Mixed

3
5
1

74
85
19

Total

9

178

Alone
Partner
other
Adult

7
2

83
68

0

11

Total

9

162

Grouping

Age
(N=189)

Marital Status
(N=189)

SES
(N=178)

Return to
work
(N=186)
Regular
Exercise
(N=189)
Time to
Self
(N=190)
Resource
EPDS
(N=170)
Gender
of Infant
(N=190)
Feeding
type
(N=187)
Pt. Visit
(N=171)

Chl-sq.
Value

SIg.

1.834a

0.608

4.166a

0.244

4.645a

0.2

0.652b

0.419

2.020b

0.155

1.771b

0.183

0.35b

0.554

3.037a

0.219

0.251a

0.882

2.565a

0.277

148
Appendix K
T-TEST RESULTS AT TWO MONTHS
Demographic
Variables;

Exercise
Frequency
per week
(N=126)
Number
Minutes
(N=122)

Total

Total

P ositive
EPDS (> 1 2 )

N egative
EPDS (< 12)

8

118

8

118

8

114

8

114

10

138
138

Frequency
of time to self
in week
(N=148)

Total

10

Number
of minutes
(N=144)

9

135

Total

9

135

People to
talk to
(N=192)

14

178

Total

14

178

Parity
(N=207)

17

190

Total

17

190

17

190

190

Number of
weeks when
completed
resource
EPDS
(N=207)

Total

17

Age of Infant
(N=207)

17

190

Total

17

190

T-Test

S ig. (2tailed)

-0.317

0.752

0.392

0.696

-0.749

0.455

-2.385

0.018

2.041

0.043

-2.952

0.004

-1.052

0.294

0.412

0.681

149
T-TEST RESULTS AT FOUR MONTHS
Demographic
Variables:
G rouping

Exercise
Frequency
per week
(n=131)

P ositive
EPDS (2 12)

N egative
EPDS (< 12)

5

126

5

122

Total

5

122

Time to self
frequency
(n=130)

Total

6
6

124

Time to self
minutes
(n=40)

Total

People to
talk to
(n=182)

Total

Age of
Infant
(n=190)

124

39

Total

Total

S ig. 2tailed

1.417

0.159

-0.228

0.82

-0.494

0.622

0.304

0.763

1.912

0.057

0.006

0.995

-0.702

0.483

126

Total

Exercise
minutes
(n=127)

Resource
EPDS-wks
completion
(n=39)

T-Test

39

174

8
8

174

2

37

2

37

9

181

9

181