Running head: INTEGRATIVE REVIEW 1

Integrative Review

Erin Paige Ricca

Bon Secours Memorial College of Nursing

"I pledge"

April 22, 2016

Abstract

Postpartum depression (PPD) is a serious illness and, if left untreated, can adversely affect both

mother and infant. The purpose of this paper is to provide an integrative review of the literature

regarding social support and its effect on postpartum depression. The design for this study is a

meta-analysis of the literature on social support and postpartum depression. Research was

conducted over a 12-week period and involved collecting research articles pertaining to the

researchers PICO question: What is the impact of social support during the postpartum period for

new mothers at risk for or diagnosed with postpartum depression? The results, based on review

of all five research articles, suggest that social support is important in order to reduce the risk for

or symptoms of PPD in postpartum mothers

 Integrative Review

Introduction

The purpose of this paper is to provide an integrative review of the literature regarding

social support and its effect on postpartum depression. Postpartum depression (PPD) is a serious

illness and, if left untreated, can adversely affect both mother and infant. For a mother, PPD can

result in mental and physical symptoms that greatly impact her general quality of life, overall

performance, and daily productivity. Infants of mothers with PPD can suffer from disruption in

mother-infant bonding, feeding, and sleeping. Studies have shown that PPD can be treated with

antidepressants and therapy. Although medication and therapy are good treatments for PPD,

many new mothers do not have the time, energy, money, or resources to receive these treatments.

Adequate social support has been shown to have a positive impact on new mothers mental

health state and risk for PPD. For this research study, the proposed PICO question is: What is the
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impact of social support during the postpartum period for new mothers at risk for or diagnosed

with postpartum depression?

Design/Search Methods

The design for this study is a meta-analysis of the literature on social support and

postpartum depression. Research was conducted over a 12-week period and involved collecting

research articles pertaining to the researchers PICO question. The researcher used computer

based search engines such as Google Scholar, PubMed, and EBSCO. Search terms used to gather

articles included postpartum depression, postnatal depression, postpartum doula, support,

social support, and postpartum support. Initially the search yielded 1,359 hits, until the

researcher limited the search criteria. The search was limited to peer reviewed quantitative and

qualitative articles written in English. In an effort to obtain current information on the topic, only

articles written between 2011 and 2016 were used. Five articles were selected based on their

relevance to the PICO question.

Findings and Results

The first research article selected was written by Judith Fry McComish, Carla J. Groh,

and Judith A. Moldenhauer and titled Development of a Doula intervention for Postpartum

Depressive Symptoms: Participants Recommendations (McComish, Groh, & Moldenhauer,

2013, p. 3). This was a qualitative study done in order to develop an intervention protocol for

enhanced doula care focused on helping women identify signs of PPD and seek treatment

(McComish et al., 2013, p. 4). More specifically the aim of this research was to develop

educational content for doulas to use with mothers after the birth of their baby. Focus groups

were conducted and they were comprised of postpartum mothers and postpartum doulas. The

focus groups were audio recorded and the tapes were transcribed verbatim. Data from the
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transcripts was subjected to content analysis, done independently by all three researches and

graduate nursing students that helped in the study. Each person identified themes separately, and

then collectively they were agreed upon. The common themes that emerged in this study were:

someone to talk to, flexibility, and interactivity (McComish et al., 2013). Materials; such as, a

brochure and a concept for a smartphone application, were then developed based on the findings

and suggestions found from the data. In conclusion, the data gathered from this research

provided researchers with information on creating an interactive way for doulas to provide

support to postpartum mothers at risk for postpartum depression.

The second research article selected was written by Kay Gjerdingen, Patricia McGovern,

Rebekah Pratt, Linda Johnson, and Scott Crow, and titled, Postpartum Doula and Peer

Telephone Support for Postpartum Depression: A Pilot Randomized Controlled Trial

(Gjerdingen, McGovern, Pratt, Johnson, & Crow, 2013, p. 36). This was a quantitative study

done to evaluate postpartum doula and peer telephone support and their impact on PPD when

used as adjunctive treatment. Postpartum doulas and mothers were recruited for this study from 3

hospitals in St. Paul Minnesota (Gjerdingen et al., 2013) . Tools used in this study to evaluate a

mothers depressive symptoms were a 2-question depression screen and the 9-item Patient

Health Questionnaire (PHQ-9). Thirty-nine postpartum mothers with depressive symptoms

participated. Three groups of participants were created: postpartum doula care group, telephone

support group, and a control group. Surveys were conducted at zero, three, and six months

postpartum to evaluate depressive symptoms (Gjerdingen et al., 2013). The results of this study

showed that there was greater satisfaction and reduction of depressive symptoms in the doula

care group. The doula care group provided in person social support to mothers, as well as support

with breastfeeding and integrating the baby into the home.

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The third research article selected was written by Hourieh Milani, Eznollah Azargashb,

Narges Beyraghi, Sara Defaie, and Taha Ashabhi and titled, Effect of Telephone-Based Support

on Postpartum Depression: A Randomized Controlled Trial (Milani, Azargashb, Beyraghi,

Defaie, & Asbaghi, 2015, p. 247). This research was done in order to study the effect of

telephone based postpartum support on decreasing PPD. The tool used to evaluate PPD in this

study was the Edinburgh Postnatal Depression Scale (EPDS). The EPDS was given ten to fifteen

days after giving birth and scores used as pre-trial markers (Milani et al., 2015). Fifty-four

women were found eligible and assigned to two groups, each consisting of twenty-seven women.

An intervention group and control group were created. Both groups received routine postpartum

care, but the intervention group received telephone support from health volunteers.

Questionnaires were used to collect demographic and health information from all participants

(Milani et al., 2015). At the end of six weeks the mothers retook the EPDS in order to be

reassessed for depression after intervention. Data for this study was analyzed using the chi-

square, Fishers exact, t- and paired t tests (Milani et al., 2015). The results of this study were as

follows; depression scores at six weeks were lower in the intervention group than in the control

group. This information supports the notion that support during the postpartum period reduces

the symptoms of PPD.

The fourth article selected was written by Dr. Fiona Cust and titled, Peer support for

mothers with postnatal depression: A pilot study (Cust, 2016, p. 38). The aim of this study as to

determine whether or not one-to-one support from a peer support worker (PSW) would aid in the

reduction of PPD in new mothers (Cust, 2016). For this study eight PSWs and thirty new

mothers were recruited. Mothers were recruited based on their scores on the EPDS. Two groups

were created, both consisting of fifteen mothers, a control group and an intervention group. Both
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groups received routine visits from their family health visitors. In addition to their family health

visitor, intervention group mothers were assigned a PSW. PSWs provided in home, one on one

visits with their assigned mothers over a course of six weeks. Control group mothers relied on

support from a family health visitor. Both quantitative and qualitative data was collected in this

study. Quantitative data consisted of EPDS scores from all mothers at six weeks, twelve weeks,

and six months postpartum. Qualitative data was gathered from logbooks all mothers kept and

recorded information about after each visit from either their health visitor or PSW. Results of this

study showed that mothers who received support from a PSW had a better mental health outlook

and bonded better with their baby.

The fifth, and last article selected was written by Rennie Negron, Anika Martin, Meital

Almog, Amy Balbierz, and Elizabeth A. Howell and titled, Social Support During the

Postpartum Period: Mothers Views on Needs, Expectations, and Mobilization of Support

(Negron, Martin, Almog, Balbierz, & Howell, 2013, p. 616). The goal of this research was to

examine postpartum mothers views on social support and experiences during the postpartum

period. The sample for this study was comprised of thirty-three ethnically diverse postpartum

women who had prior participation in a randomized trial about postpartum depression (Negron et

al., 2013). All participants were between six and twelve moths postpartum. Four focus groups

were conducted in a New York City teaching hospital. The focus groups were audio recorded and

then professionally transcribed. Main themes were identified from the transcripts, and were as

follows: mothers major needs and challenges postpartum, social support expectations and

providers of support, how mothers mobilize support, and barriers to mobilizing support (Negron

et al., 2013). In all four groups, women reported that receiving adequate support was essential to

their both their physical and emotional recovery. The results of this study yielded that it is
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important to identify support needs and expectations of new mothers in order to facilitate their

recovery in the postpartum period and decrease their risk of PPD.

Discussion/Implications

The findings of the integrative review suggest that social support is essential in reducing

PPD in new mothers; therefore, it can be said that the findings both relate to and support the

researchers PICO question.

The results, based on review of all five research articles, suggest that social support is

important in order to reduce the risk for or symptoms of PPD in postpartum mothers. All five

research studies were done on the premise that social support is important in reducing PPD. Two

of the five articles examined the use of a postpartum doula for PPD symptoms, and both

concluded that the additional support provided by a postpartum doula is beneficial for mothers

with PPD. The use of the EPDS to screen participants in the studies was a commonality in two of

the research studies as well. In one study, telephone support was provided by a women who had

suffered from PPD, and in another study telephone support was provided by a trained health

volunteer; but bother studies involved telephone support for PPD. Some differences noted in the

research were the different methods of support; for example: doula support, peer support, or peer

support worker support were all different support methods examined in the different studies.

The implications of the findings suggest that social support has a positive impact on PPD.

Ensuring new mothers have adequate social support before sending them home from the hospital

could potentially decrease the incidence of PPD. If mothers indicate they do not have proper

social support, resources such as telephone support personnel or the option for a postpartum

doula should be discussed with the new mother

Limitations
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There were several limitations for the researcher that impacted this integrative review.

One such limitation was the inexperience of the researcher in conducting research. This

integrative review was the first attempt by the researcher to conduct such research and perform a

meta-analysis of the information collected. Another limitation to this study was the lack of time

the researcher had to conduct the study due to outside conflicts; such as family and ill children.

The last limitation to this study was the difficulty in finding information pertinent to the PICO

question at hand. The researcher had a difficult time finding relevant research articles for her

study that were written within the last five years.

Conclusion

Postpartum depression is a serious mental condition that affects mothers shortly after

giving birth. PPD can affect both the mother and the infant, and should be detected early and

treated. Research was done to determine the relationship between social support and PPD. In

conclusion, the findings of this research support the notion that adequate support is important

during the postpartum period. Social support has a positive impact on PPD and has been shown

to reduce PPD in mothers. The results from this study could aid in supporting a change in

practice screening procedures in postpartum women. Postpartum women could be screened more

thoroughly to determine how much support they have at home and if they think their

expectations and needs will be met by their support person after they are discharged.
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References

Cust, F. (2016, January). Peer support for mothers with postnatal depression: A pilot study.

Community Practitioner, 89(1), 38-41. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/26911102

Gjerdingen, D. K., McGovern, P., Pratt, R., Johnson, L., & Crow, S. (2013). Postpartum doula

and peer telephone support for postpartum depression: A pilot randomized controlled

trial. Journal of Primary Care & Community Health, 4(1), 36-43.

http://dx.doi.org/10.1177/2150131912451598

McComish, J. F., Groh, C. J., & Moldenhauer, J. A. (2013). Development of a doula intervention

for postpartum depressive symptoms: Participants recommendations. Journal of Child

and Adolescent Psychiatric Nursing, 26, 3-15. http://dx.doi.org/10.1111/jcap.12019

INTEGRATIVE REVIEW 10

Milani, H. S., Azargashb, E., Beyraghi, N., Defaie, S., & Asbaghi, T. (2015). Effect of telephone-

based support on postpartum depression: A randomized controlled trial. International

Journal of Fertility and Sterility, 9(2), 247-253. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518494/

Negron, R., Martin, A., Almog, M., Balbierz, A., & Howell, E. (2013). Social support during the

postpartum period: Mothers views on needs, expectations, and mobilization of support.

Maternal and Child Health Journal, 17(4), 616-623. http://dx.doi.org/10.1007/s10995-

012-1037-4

Appendix

First Author Fiona Cust (2016)/PhD, senior lecturer on children and

(Year)/Qualifications mental health nursing
Background/Problem Psychosocial support has been shown to be of great
Statement importance to decrease the risk of postpartum depression.

Purpose: A pilot study to determine if one-on-one support

from a peer support worker would aid in the reduction of
postpartum depression in new mothers.

Conceptual/theoretical The basis for this study was the idea that peer telephone
Framework support has previously been proven to be effective in the
prevention of postpartum depression. This study used both
telephone support and face-to-face support methods.
Design/ This design for this study was both qualitative and
Method/Philosophical quantitative. The philosophical underpinning for this study
Underpinnings was symbolic interaction.

Sample/ Setting/Ethical For this study, 8 peer support workers and 30 new mothers
Considerations were recruited. 15 mothers wee put in a control group and
15 mothers were put in an intervention group. The setting
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for this study was in each new mothers home.

Full informed consent was obtained and participant

information sheets were given. Training regarding
confidentiality was conducted for peer support workers.
Ethical approval for this study was granted by De Montfort
University Faculty of health and Life Sciences Research
Ethics Committee.
Major Variables Studied The independent variable in this study is the support from a
(and their definition), if peer support worker. The dependent variable in this study is
appropriate the development of postnatal depression in new mothers.

Measurement Tool/Data Qualitative data:

Collection Method Peer support workers visited the 15 intervention group
mothers in their homes or at a location of their choice on a
weekly basis for 6 weeks. Support for the intervention
group mothers was provided by both their peer support
worker. Control group mothers received support from their
family health visitor only. Both groups of mothers were
asked to keep a log book about their feelings and emotions
after each visit from either their peer support worker or
health visitor.

Quantitative data:
The Edinburgh Postnatal Depression Scale was at 6 weeks,
at 12 weeks, and 6 months postpartum.
Data Analysis Quantitative data:
Edinburgh Postnatal Depression Scale scores were analyzed
and summarized using charts and graphs. Non-parametric
analysis was done using Friedmans Anova and several
other tests were run to validate the analysis.

Qualitative data:
Log book data and interview transcripts were analyzed
using a constant comparative method. The lead researcher
read and re-read text data, compared new codes and
categories when they came about and also compared new
codes and categories against old ones. Similarities and
differences in the data were highlighted. All participants
were contacted at the end of data analysis in order to
confirm the validity of the findings and ensure that the
researchers data interpretation was agreeable.
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Findings/Discussion Results indicate that peer support workers can have a

positive impact on postpartum mothers mental health,
outlook, and relationship with their newborn.

Appraisal/Worth to practice This study is supportive of the idea that social support is
crucial during a mothers postpartum period, and decreases
risks associated with postpartum depression.

First Author Rennie Negron (2012)/MPH

(Year)/Qualifications
Background/Problem Social support has been proven to be effective in aiding women
Statement during the postpartum period. Limited social support has been
found to be a predictor of postpartum depression.

Purpose: Explore postpartum womens views and experiences

with social support after childbirth.

Conceptual/theoretical The theoretical framework for this study was based on the idea
Framework that social support is imperative to lower maternal postpartum
risk for postpartum depression.
Design/ This is a qualitative study in which focus groups were conducted
Method/Philosophical to gain insight into postpartum mothers needs and expectations
Underpinnings during the recovery period. The philosophical underpinning for
this study was phenomenology, because it revolves around the
lived experience of mothers.
Sample/ Setting/Ethical The sample for this study was comprised of 33 mothers: 11
Considerations Hispanic, English speaking women; 3 Hispanic, Spanish
speaking women; 9 African American women; and 10 white and
other non-black, non Hispanic women. Focus groups were
conducted and participants sat in a circular pattern to facilitate
open discussion.
All participants gave written informed consent prior to
participating in the focus groups.
Major Variables n/a
Studied (and their
definition), if
appropriate

Measurement Tool/Data Postpartum depressive symptoms were assessed using the 10-
Collection Method tem Edinburgh Postnatal Depression Scale and the Patient
Health Questionnaire-9.

Focus groups were conducted and recorded.

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Data Analysis
Focus group sessions were audio-recorded and
professionally transcribed. Transcripts were
reviewed multiple times and four themes were
identified.

Findings/Discussion Social support is essential for the overall well being of mothers
following childbirth. Partner support was found to be important
and closeness with partner had an inverse relationship with
mothers risk for postpartum depression. The results of this
study imply that it is important to mothers postpartum recovery
for support needs and expectations of new mothers need to be
identified.

Appraisal/Worth to This article has strong information and supports the idea that
practice social support is essential in lowering the risk for postpartum
depression.

First Author Dwenda Kay Gjerdingen (2013)/MD, MS, Professor at the

(Year)/Qualifications University of Minnesota in the Department of Family Medicine
& Community Health. Gjerdingen has studied womens
postpartum health for over twenty years, with a focus on
interventions for postpartum depression
Background/Problem The researchers of this article studied whether in person doula
Statement visits versus peer telephone support helped mothers at risk for
postpartum depression better cope with the postpartum period.
Conceptual/theoretical Not readily identified
Framework

Design/ This was a randomize control trial.

Method/Philosophical
Underpinnings

Sample/ Setting/Ethical The sample for this study was comprised of thirty-nine
Considerations postpartum mothers from the St. Paul, Minnesota area
considered to be at risk for postpartum depression. The sampling
method for this study was randomized. In order to achieve
randomization, the thirty-nine mothers were randomly assigned
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to three groups: postpartum doula group, peer telephone support

group, and a control group. The support coordinator performed
unblinded random assignment for this study by using random
number tables
Major Variables The major variables in this study are doula support, peer
Studied (and their telephone support, and postpartum depressive symptoms. There
definition), if are two independent variables in this study, doula support and
appropriate peer telephone support. The dependent variable in this study is
postpartum depressive symptoms experienced by postpartum
mothers.
Measurement Tool/Data Subjects were mailed surveys at the beginning of the study, at
Collection Method three months, and again at six months. The surveys measured
demographic and work characteristics, social support, mental
health, illness days, and current health state of the subjects. All
surveys were based on different item scales adapted for this
study.
Data Analysis Descriptive analyses assessed the subjects demographic
characteristics. Intent-to-treat analysis was used with one-way
analyses of variance to compare the survey data at baseline and
at six months in the general health, mental health, and social
support areas of the study.

Qualitative data was also gathered and analyzed using NVivo9

software

Findings/Discussion The results of this study yielded that women at risk for, or
diagnosed with, postpartum depression were more satisfied with
the postpartum doula support when compared to women who
received peer telephone support. The qualitative data gathered in
the study suggested that telephone support was not as
convenient for postpartum mothers as having a postpartum
doula make occasional house visits.

Appraisal/Worth to The results of the research provide some good information on

practice the possible benefits of postpartum doula use for postpartum
depression; however, more research needs to be done in this
area.

First Author Judith Fry McComish (2013)/PhD, RN, works for Wayne State
(Year)/Qualifications University and is qualified in mental health, infant mental
health, and community and family health.
INTEGRATIVE REVIEW 15

Background/Problem The purpose of this research was to create an intervention

Statement protocol for better doula care focused on helping women
identify signs of postpartum depression and seek treatment
Conceptual/theoretical Not readily identified
Framework

Design/ This is a qualitative study in which mothers, doulas, and doula

Method/Philosophical trainers participated in focus groups in order to provide feedback
Underpinnings about creating a doula support program for postpartum
depression. The philosophical underpinnings of this study are
identified in the title and are that of phenomenology.
Phenomenology was chosen in order to get direct advice from
mothers, doulas, and doula trainers in order to capture the lived
experience of both motherhood and postpartum depression.
Sample/ Setting/Ethical The sample size consisted of twenty mothers, five postpartum
Considerations doula trainers, and five doulas. The participants were given a
full explanation of the study after meeting all inclusion criteria.
After being given detailed information about the purpose of the
research, the women were encouraged to ask questions and, if
they agreed to the study, informed consent was obtained. The
confidentiality of the participants was addressed at the
beginning of each session and ground rules regarding
maintaining confidentiality were set at each session.
Major Variables n/a
Studied (and their
definition), if
appropriate

Measurement Tool/Data Audiotapes were used to record each focus group session and
Collection Method then transcribed verbatim.

Data Analysis The transcripts of each session were then subjected to content
analysis by each researcher and also by graduate nursing
students that aided in the data collection. After independent
review, the researchers and graduate students collectively came
to an agreement on the common themes and ideas within the
transcripts.
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Findings/Discussion The three main themes were: someone to talk to, flexibility, and
interactivity. All participants, mothers, doulas, and doula
trainers, agreed that having someone to talk to was the best
option for new mothers for a variety of reasons. Participants all
agreed that it is important to have someone you can trust and
lean on for support in order to work through all the emotions
that come about during the postpartum period.

Appraisal/Worth to The findings of this research support the idea that mothers need
practice support and someone to talk to during the postpartum period.
Support is essential in recognizing and working through
postpartum depression.

First Author Hourieh Shamshiri Milani (2015)/ M.D., M.P.H, Infertility

(Year)/Qualifications
Background/Problem
Statement
and Reproductive Health Research Center at Shahid
Beheshti Universit of Medical Sciences, Tehran, Iran;
Department of Health and Social Medicine at Shahid
Beheshti Universit of Medical Sciences, Tehran, Iran
Baby blues, postpartum depression, and anxiety are all
common problems in new mothers. This study looks at the
effect of telephone based health volunteers support on the
reduction of postpartum depression.

Conceptual/theoretical This study was done based on the concept that support is
Framework key for women in the postpartum period in order to reduce
their risk of severe postpartum depression.

Design/ This study was a randomized controlled trial. 54 postpartum

Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
women with mild to moderate depression were broken up
into two groups of 27; one a control group and the other an
intervention group. The women in the intervention group
received routine postpartum care, as well as telephone
support from health volunteers. The control group only
received routine postpartum care.
203 women with uncomplicated deliveries were given the
Edinburgh Postnatal Depression scale. The sample for this
study was comprised of 54 of those women who scored >10
on the Edinburgh Postnatal Depression Scale 10 to 15 days
after giving birth.
The major variables in this study were telephone support
and postpartum depression. The independent variable for
this study was telephone support and the dependent variable
was postpartum depression symptoms.
INTEGRATIVE REVIEW 17

Measurement Tool/Data A questionnaire was used to collect both demographic and

Collection Method obstetric data from participants. At the end of 6 weeks, all
participants retook the Edinburgh Postnatal Depression
Scale.

Data Analysis Data was analyzed using the chi-square, Fishers exact, t-
tests, and paired t tests.

Findings/Discussion The depression scores in the intervention group at week six

were significantly less than those in the control group.

Appraisal/Worth to practice This research supports the notion that support is effective
and imperative to the reduction of postpartum depression.