Akshaya college of nursing tumkur karnataka



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SYNOPSIS / PROTOCOL OUTLINE


Submitted by:

Ms. Amanpreet Kaur

I Year M. Sc. Nursing



PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION


1.


NAME OF CANDIDATE AND ADDRESS

Ms. AMANPREET KAUR

FIRST YEAR M Sc. NURSING

AKSHAYA COLLEGE OF NURSING

TUMKUR - KARNATAKA



2.


NAME OF THE INSTITUTION

AKSHAYA COLLEGE OF NURSING

TUMKUR - KARNATAKA



3.


COURSE OF STUDY AND SUBJECT

MASTERS DEGREE IN NURSING

MENTAL HEALTH NURSING



4.


DATE OF ADMISSION TO COURSE





5.


TITLE OF THE TOPIC

A STUDY TO DETERMINE THE PREVALENCE OF POSTNATAL DEPRESSION AMONG PRIMIGRAVIDA MOTHERS IN SELECTED MATERNITY CENTERS IN TUMKUR DISTT. KARNATAKA.




BRIEF RESUME OF THE INTENDED WORK.

Introduction

Little is known about the prevalence of clinically significant postpartum depression in women of varying social status. The purpose of the present study was to examine the prevalence of postpartum depression among primigravida mothers. Postpartum depression (PPD), a major health concern, produces insidious effects on new mothers, their infant, and family. Depression affects 5-22% of women after childbirth. Some women with postnatal depression will experience a prolonged or relapsing illness that may last until their children enter school. It has adverse effects upon the coping abilities of women, their relationships with their infants, partners and social networks and may adversely affect the educational attainment and behaviour of their children. Since many more women are now active in the workforce, the effects of postnatal depression have obvious economic consequences both for their families and their employers. (Richards J.P. 1990)



NEED FOR THE STUDY

The birth of a baby can trigger a jumble of powerful emotions, from excitement and joy to fear and anxiety. But it can also result in something you might not expect — depression.

Many new moms experience the "baby blues" after childbirth, which commonly include mood swings and crying spells that fade quickly. But some new moms experience a more severe, long-lasting form of depression known as postpartum depression. Rarely, an extreme form of postpartum depression known as postpartum psychosis develops after childbirth.

Postpartum depression isn't a character flaw or a weakness. Sometimes it's simply a complication of giving birth. If you have postpartum depression, prompt treatment can help you manage your symptoms — and enjoy your baby.

Signs and symptoms of depression after childbirth vary, depending on the type of depression.

Postpartum depression symptoms


Postpartum depression may appear to be the baby blues at first — but the signs and symptoms are more intense and longer lasting, eventually interfering with your ability to care for your baby and handle other daily tasks. Postpartum depression symptoms may include:

  • Loss of appetite

  • Insomnia

  • Intense irritability and anger

  • Overwhelming fatigue

  • Loss of interest in sex

  • Lack of joy in life

  • Feelings of shame, guilt or inadequacy

  • Severe mood swings

  • Difficulty bonding with your baby

  • Withdrawal from family and friends

  • Thoughts of harming yourself or your baby

Untreated, postpartum depression may last for many months or longer.

Clinical Classification of Postpartum Illnesses
There has long been controversy as to whether puerperal illnesses are separate, distinct illnesses (Hamilton, 1982; Hays & Douglass, 1984; Hays, 1978) or episodes of a known psychiatric disorder such as affective disorders or schizophrenic psychoses, which occur coincidentally in the puerperium or are precipitated by it (Platz & Kendell, 1988; Robling et al., 2000).
Brockington (1988) argues that childbirth should be seen as a general stressor, like any other ‘life event’ which can trigger an attack of illness across the whole spectrum of psychiatric disorders. This view is now generally accepted and is supported by the wide variety of clinical disorders which follow childbirth, and the variety of symptoms which are found in illnesses which start after delivery.

Postpartum Affective Disorders
Postpartum affective disorders are typically divided into three categories: postpartum blues, nonpsychotic postpartum depression and puerperal psychosis.

The prevalence, onset and duration of the three types of postpartum affective disorders are shown in



Table 1 Postpartum Affective Disorders: Summary of Onset, Duration & Treatment


Disorder

Prevalence

Onset

Duration

Treatment

Blues

30 – 75%

Day 3 or 4

Hours to days

No treatment required other than

reassurance



Postpartum

Depression



10 – 15%

Within 12 months

Weeks – months

Treatment usually required

Puerperal Psychosis

0.1 – 0.2 %

Within 2 weeks

Weeks - months

Hospitalization usually required


Postpartum Blues
Postpartum blues is the most common observed puerperal mood disturbance, with estimates of prevalence ranging from 30-75% (O'Hara et al., 1984). The symptoms begin within a few days of delivery, usually on day 3 or 4, and persist for hours up to several days. The symptoms include mood lability, irritability, tearfulness, generalized anxiety, and sleep and appetite disturbance. Postnatal blues are by definition time-limited and mild and do not require treatment other than reassurance, the symptoms remit within days (Kennerly & Gath, 1989; Pitt, 1973).

The propensity to develop blues is unrelated to psychiatric history, environmental stressors, cultural context, breastfeeding, or parity (Hapgood et al.,1988), however, those factors may influence whether the blues lead to major depression (Miller, 2002). Up to 20% of women with blues will go on to develop major depression in the first year postpartum (Campbell et al., 1992; O'Hara et al., 1991b).


As the focus of this chapter is postpartum depression, only a brief overview shall be provided here. Data from a huge population based study showed that nonpsychotic postpartum depression is the most common complication of childbearing, occurring in 10-15% of women after delivery (O'Hara & Swain, 1996). It usually begins within the first six weeks postpartum and most cases require treatment by a health professional.

The signs and symptoms of postpartum depression are generally the same as those associated with major depression occurring at other times, including depressed mood, anhedonia and low energy. Reports of suicidal ideation are also common.

Screening for postnatal mood disturbance can be difficult given the number of somatic symptoms typically associated with having a new baby that are also symptoms of major depression, for example, sleep and appetite disturbance, diminished libido, and low energy (Nonacs & Cohen, 1998). Whilst very severe postnatal depressions are easily detected, less severe presentations of depressive illness can be easily dismissed as normal or natural consequences of childbirth.


Very severe depressive episodes which are characterized by the presence of psychotic features are classed as postpartum psychotic affective illness or puerperal psychosis. These are different from postpartum depression in etiology, severity, symptoms, treatment and outcome.
Research evidence has shown that risk factors for puerperal psychosis are biological and genetic in nature (see Jones et al., 2001). Psychosocial and demographic factors are probably not major factors in the development of puerperal psychosis (Brockington et al., 1990; Dowlatshahi & Paykel, 1990).

Due to the nature of psychotic or depressive symptoms, new mothers are at risk of injuring their children through neglect, practical incompetence or command hallucinations or delusions (Attia et al.,1999). Infanticide is rare, occurring in 1-3 / 50,000 births (Brockington & Cox-Roper, 1988; Jason et al.,1983), however, mothers with postpartum psychotic disorders commit a significant percentage of these, and estimates suggest that 62% of mothers who commit infanticide also go on to commit suicide (Gibson, 1982). Because of these serious consequences, early diagnosis and treatment interventions of postnatal illnesses are imperative for the health and well being of the mother and child (Attia et al., 1999).


Postpartum Depression: Clinical & Diagnostic Issues
Postpartum depression is the most common complication of childbearing and as such represents a considerable public health problem affecting women and their families (Warner et al., 1996). The effects of postnatal depression on the mother, her marital relationship, and her children make it an important condition to diagnose, treat and prevent (Robinson & Stewart, 2001).

Untreated postpartum depression can have adverse long term effects. For the mother, the episode can be the precursor of chronic or recurrent depression. For her children, a mother’s ongoing depression can contribute to emotional, behavioral, cognitive and interpersonal problems in later life (Jacobsen, 1999).

If postpartum depression is to be prevented by clinical or public health intervention, its risk factors need to be reliably identified, however, numerous studies have produced incomplete consensus on these (Warner et al., 1996; Cooper et al., 1988; Hannah et al., 1992). The remainder of this chapter will provide a synthesis of the recent literature pertaining to risk factors associated with developing the illness.
Prevalence
OHara & Swain (1996) in a meta analysis of 59 studies from North America, Europe, Australasia and Japan (n=12,810 subjects), found an overall prevalence rate of postpartum depression of 13%. This was based on studies that assessed symptoms after at least two weeks postpartum (to avoid confounding of postpartum blues) and used a validated or standardized measure to assess depression.
Postpartum depression (PPD) affects 10%--15% of mothers within the first year after giving birth, Younger mothers and those experiencing partner-related stress or physical abuse might be more likely to develop PPD. The postnatal period is well established as an increased time of risk for the development of serious mood disorders. There are three common forms of postpartum affective illness: the blues (baby blues, maternity blues), postpartum (or postnatal) depression and puerperal (postpartum or postnatal) psychosis each of which differs in its prevalence, clinical presentation, and management.

Postpartum non-psychotic depression is the most common complication of childbearing affecting approximately 10-15% of women and as such represents a considerable public health problem affecting women and their families (Warner et al., 1996). The effects of postnatal depression on the mother, her marital relationship, and her children make it an important condition to diagnose, treat and prevent (Robinson & Stewart, 2001).

Untreated postpartum depression can have adverse long-term effects. For the mother, the episode can be the precursor of chronic recurrent depression. For her children, a mother’s ongoing depression can contribute to emotional, behavioral, cognitive and interpersonal problems in later life (Jacobsen, 1999).

If postpartum depression is to be prevented by clinical or public health intervention, its risk factors need to be reliably identified, however, numerous studies have produced inconsistent results (Appleby et al.,1994; Cooper et al., 1988; Hannah et al.,1992; Warner et al., 1996).

Because of the following reasons I have selected this problem for my research study.

Earlier depression diagnostic &severity assessment were not conducted during pregnancy and after delivery, Untreated, Post partum depression can have especially severe long-term consequences, not only for the mother but also for the child and whole family. Post-partum depression had a small but significant effect on children’s cognitive & emotional development. Most of the nurses working in maternity centers failed to diagnose the post -partum depression in earlier stages among the post natal mother’s. This study will help to develop a base line data regarding information on prevalence of post-partum depression in Tumkur district, hence I selected this study as my research project.


REVIEW OF LITERATURE

Reviewing literature is important in broadening the understanding and gaining an insight necessary for development of broad conceptual context into which a problem fix. Review of literature helps in selecting methodology, developing a tool and also analyzing the data.



Incidence of Postpartum Depression

Gavin NI, et al,. (2005) systematically reviewed evidence on the prevalence and incidence of perinatal depression and compare these rates with those of depression in women at non-childbearing times. DATA SOURCES: We searched MEDLINE, CINAHL, PsycINFO, and Sociofile for English-language articles published from 1980 through March 2004, conducted hand searches of bibliographies, and consulted with experts. METHODS OF STUDY SELECTION: We included cross-sectional, cohort, and case-control studies from developed countries that assessed women for depression during pregnancy or the first year postpartum with a structured clinical interview. TABULATION, INTEGRATION, AND RESULTS: Of the 109 articles reviewed, 28 met our inclusion criteria. For major and minor depression (major depression alone), the combined point prevalence estimates from meta-analyses ranged from 6.5% to 12.9% (1.0-5.6%) at different trimesters of pregnancy and months in the first postpartum year. The combined period prevalence shows that as many as 19.2% (7.1%) of women have a depressive episode (major depressive episode) during the first 3 months postpartum; most of these episodes have onset following delivery. All estimates have wide 95% confidence intervals, showing significant uncertainty in their true levels. No conclusions could be made regarding the relative incidence of depression among pregnant and postpartum women compared with women at non-childbearing times. CONCLUSION: To better delineate periods of peak prevalence and incidence for perinatal depression and identify high risk subpopulations, we need studies with larger and more representative samples.




Mann R, Gilbody S, Adamson J. (2010) BACKGROUND: Postnatal depression (PND) has a significant impact on maternal mental health. Systematic reviews provide a useful tool to summarise research, however little is known about the quantity and quality of existing systematic reviews of prevalence and incidence of PND. OBJECTIVE: The objective of this paper is to provide a systematic overview of existing systematic reviews of prevalence and incidence of PND in the first 12 postnatal months. METHOD: Medline, Embase, Cinahl, PsychInfo and the Cochrane Library were searched for systematic reviews of prevalence and incidence of PND which met the Database of Abstracts of Reviews of Effects (DARE) criteria. Characteristics of selected reviews, completeness of reporting results and methodological quality were evaluated. RESULTS: Five reviews were selected for appraisal. Only one systematic review was identified; four reviews were non-systematic. Only two reviews provided a quantitative summary estimate of prevalence of PND. Completeness of reporting results using published guidelines was not undertaken by any review. The methodological quality of four reviews revealed limitations. CONCLUSIONS: Limited generalisable evidence exists in the form of high-quality systematic reviews to inform current knowledge of the prevalence and incidence of PND. The implication of this represents an important limitation for health services planning and service delivery.

The incidence of depression in women postpartum is similar to depression in women generally. However, the incidence of depression in the first month after childbirth is three times the average monthly incidence in nonchildbearing women. Studies across different cultures have shown consistent incidence of postnatal depression (10 to 15 percent), with higher rates in teenage mothers. A meta-analysis of studies, mainly based in developed countries, found the incidence of postnatal depression to be 12 to 13 percent. (Howard. L, 2010)

The incidence of the problem has been reported from as low as 8% to as high as 23% nationally. Most epidemiologic studies have not used the strict criteria of onset within 4 weeks, as stipulated by the DSM-IV. The inconsistencies in the time frame used for diagnosing PPD make the literature, at least epidemiologically, difficult to interpret. In fact, there have been several published reports that suggest the highest risk time frame for onset of PPD is within the first 3 months postpartum. (Andrews C. 1999)

(Joy. S. 2012) Patients and their caregivers frequently overlook postpartum depression, despite the fact that effective nonpharmacologic and pharmacologic treatments are available for this condition.Untreated postpartum affective illness places the mother and infant at risk and is associated with significant long-term effects on child development and behavior. Therefore, appropriate screening for and prompt recognition and treatment of depression are essential for maternal and infant well-being and can improve outcomes. The American Academy of Pediatrics (AAP) has encouraged pediatric practices to create a system to better identify postpartum depression to ensure a healthier parent-child relationship. Postpartum psychiatric illness was initially conceptualized as a group of disorders specifically linked to pregnancy and childbirth and thus was considered diagnostically distinct from other types of psychiatric illness. Evidence now suggests, however, that postpartum psychiatric illness is virtually indistinguishable from psychiatric disorders that occur at other times during a woman's life During the postpartum period, up to 85% of women experience some type of mood disturbance; the AAP estimates that more than 400,000 infants are born each year to mothers who are depressed. Although for most women, symptoms of mood disturbance are transient and relatively mild (ie, postpartum blues), 10-15% of women experience a more disabling and persistent form of depression, and 0.1-0.2% of women experience postpartum psychosis.
Statement of the Problem

A study to determine the prevalence of postnatal depression among primigravida mothers in selected maternity centers in Tumkur Distt. Karnataka.


Objectives of the study

1. To determine the prevalence of postnatal depression among primigravida mothers in selected maternity centers in Tumkur Distt. Karnataka.

2. To determine the level of association between prevelance of postnatal depression and selected demographic variables of primigravida mothers (Age, Religion, Educational status, Occupational status, Place of domicile, Type of delivery, Past history of psychiatry illness, Dietary pattern, Type of marriage, Type of support)


  • Conceptual/theoretical framework

Fish Bone Model Kaoru Ishikawa (1986)


  • Operational definitions

    • Prevalence: refers to the total number Primigravida mothers affected by postpartum depression in selected maternity centers in Tumkur district during the period of data collection.

  • Postpartum Depression: Postpartum depression is a mood disorder that begins after childbirth and usually lasts beyond six weeks as measured by Edinburgh Postpartum depression Scale.

  • Primigravida Mothers: Refers to the mothers who delivered a baby for first time in selected maternity centers in Tumkur District.

  • Maternity Centers: A medical facility in Tumlur District often associated with a hospital, that is designed to provide a comfortable, homelike setting during childbirth and that is generally less restrictive than a hospital in its regulations, as in permitting midwifery or allowing family members or friends to attend the delivery




  • Hypothesis

H1: There will be a significant association between level of postpartum depression and selected demographic variables (Age, Religion, Educational status, Occupational status, Place of domicile, Type of delivery, Past history of psychiatry illness, Dietary pattern, Type of marriage, Type of support) among primigravida mothers in selected maternity centers in Tumkur District.


  • Assumptions

  • Mothers after delivery are at risk of developing postpartum depression.

  • Determining the prevalence of postpartum depression will help nurses to plan psychological care.

  • Assessing the prevalence of postpartum depression among primigravida mothers will help the nurse to prevent further psychiatric morbidity.



DELIMITATIONS

Assessment of prevalence of postpartum depression among primigravida mothers is limited to obtaining first hand information on prevalence rate of postpartum depression.
METHODOLOGY

Research design

Non – Experimental, Descriptive research design will be used in the present study.


Variables

  • Research Variable – Prevalence of Postpartum depression

  • Other variables – (Age, Religion, Educational status, Occupational status, Place of domicile, Type of delivery, Past history of psychiatry illness, Dietary pattern, Type of marriage, Type of support)

Source of data

  • Settings

Selected maternity centers in Tumkur District.


  • Population – Primigravida Mothers


Methods of data collection (including sampling procedure; if any)

- Sample and sampling criteria

  • Sample: Primigravida mothers in selected maternity centers in Tumkur Districr.

  • Inclusion criteria

  • Primigravida mothers in age between 21 to 30 years.

  • Primigravida mothers who could speak and write kannada.

  • Primigravida mothers who will be admitted for delivery in the selected maternity center.




  • Exclusion criteria

  • Primigravida mothers who delivered baby through lower cesarean section.

  • Primigravida mothers who will not participate in research.




  • Sampling technique

Purposive sampling technique


  • Sample size

Total: 100 Primigravida mothers



  • Data collection technique

Interview method by using Edinburgh Postpartum depression questionnaire.


Data will be collected from primigravida mothers in selected maternity centers in Tumkur District by means of Interview method. Data Collection period will be for 20 days. Each day will be collected from 5 postnatal mothers.


  • Plan of data analysis

Descriptive and inferential statistics

Descriptive statistics will be used to describe the characteristics of study sample in terms of frequency and percentage.

Chi – square will be used to find the association between the level of postpartum depression among primigravida mothers with their selected demographic variables.
Protection of Human Rights

Before conducting this study the researcher will obtain permission from ethical committee from college of nursing and research will be conducted. Before collecting data from samples written consent will be obtained from them after explaining the needs of research.



LIST OF REFERENCES


  1. Amankwaa,L.C.(2003).postpartum depression among African-american women.issues in Mental Health Nursing,24,297-316.

  2. American college of obstetricians and Gynecologists.(2010).Screening for depression during and after pregnancy 115,394-395.

  3. American Psychological Association.(2000).Diagnostic and statistical manual of mental disorders-Text revision (DSM-4-TR).Washington,DC:Author.

  4. Association for Women’s Health ,Obstetric and Neonata l Nurses.(2008) The role of nurse in post partum depression and anxiety disorders.Position statement.Washington,DC:Author.

  5. Beck, C.T.(1993).Teetering on the edge :A substantive theory of postpartum depression. Nursing Resrarch,42,42-48.

  6. Beck,C.T.(1998).The effects of post partum depression on child development: A meta analysis .Archives of Psychiatric Nursing12, 12-20.

  7. Beck.C.T.(2004).Birth trauma:in the eye of beholder.NursingResarch,53, 28-35

  8. Dennis,C.L.,Hodnett,E.,Kenton,L.,Weston,J Effect of peer support on prevention of postnatal depression among high risk women:Multisite randomized controlled trail. British Medical Journal,338.

  9. Edge,D.,Baker,D,&Rogers,A(2004).Perinatal depression among black Caribbean women.

  10. Pankaj Desai Duru shsh, principles&practice of obstetrics&Gynecology 3rd edition 2005,Jay pee publisher page no-381

  11. Joan C.Engerbetson Lynnay.Littlecton, Maternity Nursing 2nd edition 2007,Thomson Delmer pp-674-675

  12. Elizabeth Steppgilbert , Manual of High Risk Pregnancy Delivery,4th edition2007,Elsevier,pp-1344-1346

  13. Shirish N Daftary, Manual of obstetrics.2nd edition 2005,Elsevier, pp-133-140

  14. Registard Nurses’ Association of Ontario.(2005).Interventions for post partum depression.Toronto,Canada :Author.

  15. Shakespeare,J.Blake,F,&GarciaJ (2003)A qualitative study of the acceptability of routine screening of postnatal women using the Edinburgh Postnatal Depression Scale. British Journal of General Practice,53 (493),614-619

9. Signature of the Candidate


10. Remarks of the guide

11. Name and designation of guide (In block letters)


11.1 Co-Guide (if any) Not Applicable
11.2 Signature
11.3 Head of Department

11.4 Signature





    1. Remarks of Chairman and Principal

12.2 Signature






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