Beyond the Surface: re-framing perinatal depression 

The global prevalence rates of ‘perinatal depression’ range from 10% to 20% in developed countries and up to 24% in underdeveloped nations influenced by terminology, research designs, screening tools, socioeconomic conditions, and cultural contexts. Limitations of screening tools and research designs lead to inaccurate identification of depression and underscore the need for culturally tailored interventions. Despite its developed status as a country, addressing perinatal depression remains challenging in New Zealand. The impact on the family unit is significant, particularly for Māori women who face unique challenges and heightened maternal suicide rates highlighting the need for culturally sensitive approaches, support systems, and interventions. The New Zealand Health Research Council funded research to view the concept of perinatal depression as emotional distress. The aim to reduce stigma associated with depression and provide better support for various psychological perinatal experiences. By focusing on distress-specific emotions interventions can be more targeted and helpful. 

A review of the main screening scales used for perinatal depression was undertaken followed by a comprehensive literature search focused on antenatal, postnatal, and perinatal depression research using Semantic Scholar, Scopus, and PubMed. A second search was undertaken, scanning seven domains that are associated with perinatal depression: sleep disturbances, eating disorders, anxiety, emotional lability, mental confusion, guilt and shame, and suicidal ideation2. A retrospective clinic records review (2022-2023) from two very low-cost access primary health services (VLCA) was then examined to identify patterns of distress reported supplemented by a cultural advisor’s interpretation of these domains in Te Reo Māori. Data were collected on age, delivery type, diagnosis, medications, and referrals. The study met the criteria outlined in the Health and Disability Ethics Guidelines as women at both clinics signed research permission on registration with the clinics.  

Results 

Current screening scales for antenatal/postnatal depression being used have major validity flaws. 

The Edinburgh Postnatal Depression Scale (EPDS) shows high certainty for major depression, recommended for scores >13 with further assessment. The K10 Kessler Psychological Distress Scale lacks validation for perinatal women and is not recommended due to low certainty. The PHQ-9 Patient Health Questionnaire has low sensitivity and specificity for perinatal depression but can be used cautiously alongside clinical judgment. Evidence for GAD-2/GAD-7 anxiety scales in pregnancy remains insufficient. The Beck Depression Inventory (BDI-II) and Postnatal Depression Inventory (PDI-14) are widely used but lack specific validation for perinatal depression. The Postnatal Depression Screening Scale (PDSS), based on extensive research, has a copyright and has to be purchased. 

A literature search identified over a million articles on perinatal depression.  For currency years 2018 – 2024 that specified antenatal, postnatal, and perinatal depression and any specific emotional distress domains indicated as consequential, were reviewed.  

1. Sleep Disturbance: 982 articles. Recent studies linked poor prenatal sleep quality to postpartum depressive symptoms, underscoring the need for attention during prenatal care. Eating Disorders: 121 articles (20 in the last 6 years). Concerned eating disorders, body image, and pregnancy.  
2. Anxiety and Insecurity:  Pregnancy anxiety and insecurity significantly affect both maternal and infant well-being, with a high prevalence of anxiety reported. Pregnancy anxiety (4480), antenatal stress (5703), and postnatal anxiety/stress (1922) articles. Perinatal insecurity correlates with anxiety and emphasizes the importance of addressing these concerns especially social 
3. Emotional Lability: 3,260 articles highlighted that perinatal emotional symptoms including depressive and anxiety disorders, are prevalent and require attention. Low mood is associated with depressive disorders, and bipolar disorder by severe alternating mood swings. Anxiety disorders are also common.   
4. Mental Confusion: (5,460 articles) indicated its impact on maternal cognition and mental health during the perinatal period. Two typologies were mood instability/constant change and low mood/parenting anxiety shedding light on the nuanced experiences of women during this critical period.  
5. Loss of Self: Pregnancy can trigger an identity crisis (368 articles). Loss of self occurs when individuals feel disconnected from their sense of self impacting aspects like cultural identity, relationships, careers, and hobbies necessitating support. The challenge intensifies when confronted with new responsibilities, such as caring for a newborn.  
6. Guilt and Shame: Publications ranged from 248-2429. Feelings of guilt and shame are common among pregnant individuals and new parents, stemming from societal and personal pressures, and exacerbated by mental health challenges.  
7. Suicide Ideation: Perinatal suicidal ideation, particularly among vulnerable populations like Māori women, is a significant concern, necessitating increased research and support. Despite a review of 17,338 records only 59 relevant studies were identified, emphasizing the scarcity of research. Over the past 16 years, more than half of pregnant or new mothers who died by suicide in New Zealand were Māori revealing high rates of depressive symptoms (22%), anxiety symptoms (25%), significant life stress (55%), and poor mood during pregnancy (18%). 

The concepts of the domains explored in this study specific to perinatal care and submitted to Te Reo Interpreters are not readily interpreted in Te Reo and some of the perinatal conditions referred to are not familiar Māoritanga. 

Clinical Implications 

The clinic records revealed that a significant proportion of women experienced emotional distress with anxiety, suicidal ideation, and sleep disturbances being the most common issues. Various screening tools and medications were used,  however there was a lack of consistent follow-up and referrals. The prevalence of Māori women facing higher rates of distress was noted, particularly in socially deprived areas. The study highlighted the need for improved and culturally sensitive screening and interventions. 

In New Zealand, it is getting harder to find a midwife and women are also missing early pregnancy assessment in their primary health clinics. Coordination between health practitioners, maternity carers, and social agencies is lacking yet crucial to address the complex emotional needs of perinatal women effectively. The current screening tools used are not validated for screening perinatal women for depression. Only the Edinburgh Postnatal Depression Scale has any credibility but it does not identify pregnancy-related anxiety. The lack of suitable Te Reo Māori interpretations highlighted the need for culturally appropriate frameworks in primary care.  

Conclusion 

Perinatal emotional distress presents with a range of physical, mental, and social symptoms. Addressing these issues requires a comprehensive understanding of the health system and the individual needs of pregnant women. Current screening tools are not diagnostic, have limitations, and should be complemented by thorough clinical assessments. The high rates of suicidal ideation and self-harm among perinatal women highlight the urgent need for improved mental health services and culturally sensitive interventions. Further research into emotional distress domains and their impact on maternal health is essential for developing effective, person-centered care strategies. Midwives are central to re-framing depression as emotional distress and seeking to manage the root causes leaving a definitive diagnosis of perinatal depression to specialists.