Background Theory

All mothers of a first baby experience uncertainty as they learn how to care for the baby and to adjust to this permanent life change. Most seek information and assistance from primary health care professionals.

Prevalence

In the life phase of caring for infants and young children, women experience the common mood disorders of depression and anxiety at two to three times the rate reported for men (World Health Organization 2001) with a threefold increase in onset of depression in the first five postpartum weeks (Cox, Murray et al. 1993; O'Hara and Swain 1996), although this is often not apparent in the very early days after giving birth (Rowe-Murray and Fisher 2001). Up to 20% will experience clinically significant symptoms of depression and anxiety or adjustment difficulties with depressed or anxious mood at some point in the first year of the baby's life, most in the first six months.

Risk Factors

As yet no hormonal or other neurochemical mechanism has been found to cause postnatal mood disorders (Hendrick, Altshuler et al. 1998). The evidence for social factors far outweighs that for biological or psychological factors in causation (Scottish Intercollegiate Guidelines Network 2002; Chen, Subramanian et al. 2005).

Systematic reviews report a consistent association between depression after childbirth and quality of relationship with the intimate partner (Scottish Intercollegiate Guidelines Network 2002). If an intimate partner becomes actively involved in infant care and household work; is prepared to suspend his needs in service of those of the baby and the baby's mother; and provides reassurance, praise and encouragement, this appears to be psychologically protective for women. Low levels of practical support, lack of sensitivity, lack of invitations to confide, poor provision of emotional containment and, at worst, criticism, intimidation or hostility in the intimate relationship are more commonly reported by women who are depressed than those who are not (Boyce, Hickie et al. 1991; Fisher, Feekery et al. 2002).

There is increasing evidence that infant behavior also contributes to maternal mood. Unsettled infant behavior, in particular inconsolable crying and frequent overnight waking, has a marked detrimental effect on the development of a confident maternal identity instead contributing to a sense of ineffectiveness, powerlessness, isolation and ultimately exhaustion (Beebe, Casey et al. 1993; Murray, Stanley et al. 1996; Fisher, Feekery et al. 2002; Fisher, Rowe et al. 2004; Rowe and Fisher, 2010). Currently the predominant focus of early education for mothers is on the establishment of feeding, but there is much less about how to soothe and settle a baby and many parents feel under-skilled in managing infant crying and dysregulated sleep patterns. We postulate that this, coupled with the contemporary emphasis on early infant stimulation, may lead infants to have insufficient sleep and become exhausted and irritable (Hiscock and Wake 2001; Lam, Hiscock et al. 2003; Fisher, Rowe et al. 2004).

Severe fatigue is widespread, under-recognized and often normalized in mothers of newborns (Gunn, Lumley et al. 1998; Fisher, Feekery et al. 2002). Anxiety and fatigue are worsened if a woman is providing exclusive infant care because of insufficient support from her partner.

Prevention

The prevention of postnatal depression is an emergent field that has as yet quite a limited research base (Lumley and Austin 2001; Buist, Barnett et al. 2002; Scottish Intercollegiate Guidelines Network 2002). It is known that antenatal screening tests to identify women at risk of becoming depressed postpartum have low predictive values (Austin and Lumley 2003). Most trials of interventions to prevent postpartum depression have been conducted antenatally with groups of women and these have all been ineffective (Lumley and Austin 2001). Reviews of these conclude that they may have been unsuccessful because events after the birth of the baby are more salient (Hayes, Muller et al. 2001; Lumley and Austin 2001; Scottish Intercollegiate Guidelines Network 2002). Antenatal preparation-for-parenthood group interventions that included fathers in at least one session had some beneficial effect (Gordon and Gordon 1960; Elliott, Leverton et al. 2000).

Current Treatment

Although the quality of a woman's relationship with her partner is of central significance to her emotional wellbeing in the postpartum period, very few interventions have attempted to enhance fathers' understanding and skills directly. Similarly, although it is known that caring for an unsettled baby increases the likelihood that a woman will become anxious and depressed, to our knowledge no prevention trials have focused on the infant's behaviour and manageability. Counselling by maternal and child health nurses (Holden 1989; Appleby, Warner et al. 1997), psycho educational groups (Honey, Bennett et al. 2002) and training in infant sleep and settling strategies (Hiscock and Wake 2002) have been shown to be beneficial in treating postnatal depression or distress, but have not been applied in preventive interventions.

Innovation

What Were We Thinking (WWWT) is an innovative psycho-educational intervention, using specifically developed resources, for small groups of mothers and fathers and their first babies. WWWT aims to address two significant gaps in current parenting education: adjustment to changes in the relationship between partners after the birth of a baby and effective management of infant crying, resistance to soothing and dysregulated sleeping and feeding behaviour. The content of the program is derived from research evidence and clinical experience. The Australian Government, through the Department of Family and Community Services and Indigenous Affairs' Invest to Grow scheme, funded a controlled trial of WWWT in Victoria.

Benefits

This brief, targeted intervention is designed to be applied routinely in primary care settings to prevent the development of depression, anxiety and adjustment difficulties in mothers of newborns. In conducting the intervention, clinically relevant information becomes available for primary health care professionals about the need for referral to secondary level health care providers.

For Further Information

For further information please see:

WWWT development
https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/1471-2458-10-499

WWWT evaluation
https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/1471-2458-10-432