It has long been known that postpartum depression affects a significant proportion of women. These individuals suffer from both major and minor depressive episodes, which can arise any time in the 12 months following delivery. Experts contend that, if left untreated, postpartum depression has the potential to impair mother-child bonding and infant development. It has also been shown to cause marital discord and even maternal suicide.

The risk of depression for women during and after pregnancy is the topic recent graduate Charlon Orr (DNP ’20) chose to address for her research project as part of The University of Tulsa’s family nurse practitioner (FNP) program. “A major focus of one’s work as an FNP is to advocate for early screening and intervention by preventive services in order to improve individual and community health,” noted Orr. “My research fell right in line with this objective, and the FNP project courses I took increased my knowledge of evidence-based health care practices and how to apply them.”

A nurse practitioner with a passion for women’s health

Ever since she received her BSN in 2002 from Langston University in Tulsa, Orr had envisioned becoming a nurse practitioner. Finally, after marriage and three children, the time was right. “I looked at several different programs,” she said, “but TU’s FNP route was clearly the best choice for me. The hybrid combo of rigorous online and in-person classes enabled me to gain the level of expertise I sought.”

Orr’s decision to focus her FNP project on postpartum depression came naturally to someone with a longstanding interest in women’s health. “My goal when I applied to the program was eventually to work in a family practice, focusing on women’s health issues and health promotion. The FNP program challenged me to think of ways to impact the health of other women so I could improve their health outcomes across various health care settings, including in hospitals and community clinics.”

The knowledge and skills Orr acquired are now put to the test every day in her work on a women’s antepartum, postpartum and medical surgical unit at Tulsa’s Saint Francis Hospital.

Research aims

It is at Saint Francis, where she has worked for nearly 10 years, that Orr implemented her FNP quality improvement project, beginning on January 13 and wrapping up the data gathering on March 2. The purpose of her study was to determine whether using a standardized tool – the Edinburgh Postnatal Depression Scale (EPDS) – on a postpartum hospital unit would enable the detection of women who are at high risk for postpartum depression prior to discharge.

“I really enjoyed working with Charlon on her research project,” said Jennifer Ryan, the clinical manager at Saint Francis who served as Orr’s site mentor. “I can’t underscore enough the importance of her work in identifying at-risk patients. The approach Charlon took enables early communication with patients’ physicians, which is essential if we’re to improve our ability to meet new mothers’ needs. I also want to note that Charlon is so professional and well organized, as well as being the most genuinely kind person I have ever met.”

Carried out under the supervision of FNP Program Director Sheryl Stansifer, Orr’s project encompassed three critical aims:

1. To assess the prevalence of depressive symptoms experienced by postpartum women
2. To identify relationships among postpartum depression scale scores and patient demographics
3. To establish a protocol for patient education and referral for women identified as “high risk”

“The research literature clearly shows that increasing opportunities to screen mothers for postpartum depression enhances health care practitioners’ ability to prevent adverse outcomes for the mothers, their babies and their families,” Orr commented. “I was excited to get involved in this vital work of early detection. The sooner we know who is at risk, the earlier we can put into action appropriate mental health interventions.”

Methodology

Orr’s quasi-experimental study design entailed developing a quality improvement patient packet and giving it to each patient upon admission to the postpartum unit. The packets, which were available in English and Spanish, contained the following:

• Introductory letter explaining the project’s purpose
• EPDS survey instrument
• Demographic survey instrument: age, ethnicity, week of gestation at delivery, vaginal or c-section birth, live birth or fetal death, number of children

In addition, the admitting nurse introduced the project to each patient and went over the instructions by reading a standardized script. During their hospital stays the patients completed the surveys, which were then placed in a locked box in the nursing breakroom. A Collaborative Institutional Training Initiative (CITI)-trained nurse assessed the packets daily for EPDS scores to determine whether a patient was at risk for postpartum depression. If a patient scored 10 or greater, a standard protocol for patient education and referral was implemented.

Findings and conclusions

Thirty-six patient packets were returned. Four of those did not meet the study’s inclusion criteria. Of the 32 that did, four (12.5%) were found to be at high risk for mild to severe postpartum depression. “The 12.5% result is similar to both national (12.5%) and Oklahoma (15%) rates,” Orr noted.

The study did not find significant differences in mean scores across age group, race/ethnicity, number of children, weeks of gestation or birth type. Orr explained this result as likely being due to the small sample size and lack of variation within the sample. In addition to increasing and diversifying the sample size, Orr also recommends that future studies include socioeconomic variables.

Despite those limitations, Orr is confident that her research supports early universal postpartum depression screening. “As an FNP working in women’s health, I know how important it is to have the means necessary to distinguish between the so-called baby blues and genuine postpartum depression. In-hospital screening before a woman gives birth shows significant promise in being able to identify her level of risk and, thereby, triggering the resources to help in a timely manner.”

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