Postpartum Depression and the Affordable Care Act : Recommendations for Social Work Educators

The Patient Protection and Affordable Care Act (ACA) mandates ongoing research on postpartum depression; however, very little research has been published in social work journals and in advanced-level textbooks on this topic. This article describes the problem of postpartum depression and argues that social work educators and researchers must pay greater attention to this issue in light of the ACA mandates, so that social workers can provide effective services to postpartum mothers and their children. The Council on Social Work Education’s recently published Educational Policy and Accreditation Standards are considered while making curriculum recommendations on postpartum depression for social work educators.

Approximately six million pregnancies occur in the United States each year, and up to 25% of the mothers develop postpartum depression (Gaynes et al., 2005;Schaar, 2012).Mothers with postpartum depression typically experience sadness; loss of interest in activities; noticeable changes in eating and sleeping patterns; problems in thinking, concentrating, and making decisions; feelings of worthlessness, shame, or guilt; thoughts of harming themselves (Centers for Disease Control [CDC], 2013); and increased need for psychiatric hospitalizations for depression and suicidality (Georgiopoulos, Bryan, Wollan, & Yawn, 2001;Kennedy, Beck, & Driscoll, 2002;Lucero, Beckstrand, Callister, & Sanchez Birkhead, 2012).The symptoms are persistent, eventually affecting not only the mother but her infant, spouse/partner, and extended family as well (Letoruneau, Tramonte, & Willms, 2013;Ngai & Ngu, 2015).
Unlike symptoms of major depressive disorder, which manifest within two weeks of the precipitating stressors (American Psychiatric Association, 2013), symptoms of postpartum depression may not become evident until several months after the mother has given birth (Chaudron et al., 2010;Parade, Blankson, Leerkes, Crockenberg, & Faldowski, 2014).Consequently, practitioners may avoid giving a diagnosis of postpartum depression due to what they perceive as the late onset of symptoms.
Moreover, social work journals provide practitioners with limited guidance on postpartum depression.We searched various social work databases for articles published in social work journals focusing on perinatal mood disorders published between the years 1980 to 2015.The search resulted in 101 published articles of which 80 used the term "postpartum depression" in the title.Of the existing articles, only 26 were published in social work journals.Consequently, although the literature on postpartum depression has grown substantially over the past 35 years, only a limited body of the literature has been published in social work journals.The majority of the research has been published in the fields of nursing, psychology, psychiatry, and medicine.As a result, much of this research has focused on individual-level approaches to treatment such as antidepressant medication, interpersonal and cognitive-behavioral therapy, and relapse-prevention strategies.There is very little research on community-level factors to help social workers address the problem of postpartum depression at all levels of intervention and even less on how social work educators can infuse content on postpartum depression into their courses.
The adoption of the Patient Protection and Affordable Care Act (ACA), Section 2952: Support, Education, and Research for Postpartum Depression mandates ongoing research to better understand the frequency and course of postpartum depression, address differences in treatment needs among racial and ethnic groups, and develop culturally competent evidence-based treatment approaches (U.S.Department of Labor, 2012).Given their direct practice, policy development, and research skills, we argue that social workers are among the most skilled professionals providing services to postpartum mothers and should take the lead in addressing the problem of postpartum depression.The purpose of this article is to bring attention to this problem and offer recommendations to social work educators to better prepare students to meet the needs of new mothers affected by postpartum depression.

The Varying Rates of Postpartum Depression
Prevalence estimates for postpartum depression vary widely across studies.The discrepancy is due in part to varying definitions of the disorder, different conceptualizations of the postpartum time period, and varying assessment and diagnostic approaches (Banti et al., 2011).Although the rates vary, much of the existing research indicates that up to 25% of new mothers experience postpartum depression (Gaynes et al., 2005;Schaar, 2012).Additionally, rates of postpartum depression may be higher in diverse or vulnerable groups.While some researchers have found the rates of postpartum depression to be higher in rural areas (Villegas, McKay, Dennis, & Ross, 2011), others have reported the prevalence to be higher in urban areas (Clare & Yeh, 2012).Likewise, various researchers have found differences among racial and ethnic groups (Gress-Smith, Luecken, Lemery-Chalfant, & Howe, 2012;Savitz, Stein, Ye, Kellerman, & Silverman, 2011) and the likelihood that the rates for low-income mothers and for mothers of color are higher than estimated (CDC, 2008;Dolbier, et al., 2013;Gress-Smith et al., 2012;Lara et al., 2015).Some researchers have suggested that mothers of color face more elevated rates of postpartum depression than White mothers because of greater life stressors, including economic factors known to affect postpartum depression.To date, research has concluded that compared to White mothers and mothers from privileged backgrounds, mothers of color have lower incomes (Dagher, McGovern, Dowd, & Gjerdingen, 2012;Feder et al., 2009;Kozinsky et al., 2012;Lara et al., 2015), lower levels of education (Dagher et al., 2012;Lanes, Kuk, & Tamim, 2011), higher rates of unemployment (Boyce & Hickey, 2005;Dagher et al., 2012;Janssen, Heaman, Urquia, O'Campo, & Thiessen, 2012), greater likelihood of single parenting (Boyce & Hickey, 2005;Lewin, Mitchell, & Ronzio, 2013), and worse housing conditions (Cutrona et al., 2005;Jacobs, 2011;Redshaw & Henderson, 2013).Moreover, mothers of color generally have higher rates of chronic diseases such as diabetes mellitus and hypertension (Kim et al., 2014), are more likely to have inadequate health insurance (Blumenthal & Collins, 2014), and have poorer access to adequate healthcare (Orr, Reiter, James, & Orr, 2012) than other mothers.Coupled with higher exposure to community violence (Miller et al., 2012), it is understandable that mothers of color are at increased risk of clinical depression.
A further problem is the preponderance of research has considered primarily White women who are married, well-insured, from middle-class backgrounds, and have access to healthcare.The few studies that have focused on mothers of color concluded their rates of postpartum depression to be higher than among White mothers (CDC, 2008;Surkan, Peterson, Hughes, & Gottlieb, 2006).Yet, social workers employed in maternal and child health settings looking to advance their skills in working with mothers with postpartum depression from non-White backgrounds have a limited body of social work literature to draw upon.

Working with Mothers who have Postpartum Depression
Social workers employed in health and mental healthcare settings often face various difficulties in working with mothers living with postpartum depression.Many mothers are reluctant to seek treatment, and those who do are often reticent to disclose their symptoms to health care providers (Abrams & Curran, 2009;CDC, 2008;Ko, Farr, Dietz, & Robbins, 2012), particularly women from diverse cultures (Dennis & Chung-Lee, 2006;Kozhimannil, Trinacty, Busch, Huskamp, & Adams, 2011).Because many of the symptoms of postpartum depression mimic signs of pregnancy including fatigue, anxiety, and irritability, many providers are hesitant to screen for depression (Seehusen, Baldwin, Runkle, & Clark, 2005).Due to inconsistent screening procedures, depressed pregnant and postpartum women may go without effective treatment until the depression has advanced, which can result in further health risks including poor adherence to prenatal and postnatal care plans, preterm delivery, and low infant birth weight (Littleton, Bye, Buck, & Amacker, 2010).
The American College of Obstetricians and Gynecologists (ACOG, 2006) argues that psychosocial screening and feedback performed at an initial visit and every three months thereafter may reduce the risk for persistent depression and improve birth outcomes.Screenings should include an assessment of obstacles to care, unstable housing, unintended pregnancy, barriers to communication among family members, problems with nutrition, ongoing tobacco and other substance abuse, depression, safety, intimate partner violence, and stress (ACOG, 2006;Dobson & Dozois, 2008).
The National Association of Perinatal Social Workers (NAPSW, 2009) the largest social work organization that most directly addresses the gap in social work education and practice on postpartum depression, consists of roughly 275 members (L.R. Baker, personal communication, July 8, 2015).The NAPSW provides 10 standards for Perinatal Social Workers Working with Patients Experiencing Post Partum Depression.Each standard includes specific roles for social workers.Most important among the standards are for MSW-prepared social workers to conduct full psychosocial assessments of women during the perinatal period for depression (Standard 2); use standardized screening tools to screen for depressive symptoms (Standard 7); provide resources and referrals for all women in the perinatal period, including culturally and linguistically appropriate support groups and evidence-based counseling services (Standard 5); and provide information on postpartum depression to the woman's partner/spouse and family members (Standard 6).In addition, NAPSW ( 2009) advocates for social workers to be an integral part of the interdisciplinary health teams providing support and education to medical and support staff and to assist in developing and formulating hospital policies and decisions related to the assessment and treatment of postpartum depression (Standards 9 and 10).
Although there are no federal policies that require screening of new mothers for postpartum depression (Rhodes & Segre, 2013), 12 states have adopted either state legislation, developed awareness campaigns, or convened tasks forces.States that require screening include New Jersey (Findings, Declarations Relative to Postpartum Depression, 2006), Illinois (Perinatal Mental Health Disorders Prevention and Treatment Act, 2008) 2011).Washington has passed statewide awareness campaigns, and California, Michigan, and Oregon have postpartum depression awareness months (Rhodes & Segre, 2013).Finally, Maine, Massachusetts, and Oregon have appointed perinatal depression task forces (Rhodes & Segre, 2013).The remaining 38 states have yet to pass any type of legislation or develop any campaigns to bring the problem of postpartum depression to the public's awareness.

How social work educators can take the lead in working with mothers with postpartum depression
Given that postpartum depression affects mothers from all backgrounds, incorporating course content on postpartum depression into each curriculum area would be a significant step forward in helping social workers take the lead in addressing this growing problem.The Council on Social Work Education (CSWE, 2015), Competency 2 mandates social workers to engage in diversity and difference in practice.With this in mind, social work educators must include research studies and evidence-based treatment approaches aimed at eliminating health and mental health disparities across all areas of health care.Students need to understand various barriers to care that members from oppressed groups face, as well as the limitations of traditional health and mental health treatment and community services (Ley, Copeland, Flint, White, & Wexler, 2009).Students need to understand how social location (i.e., the groups to which individuals claim membership based on their sex, socioeconomic class, religion, and sexual orientation) may inhibit people from traditionally oppressed backgrounds from seeking care, particularly when the research on approaches to care is based on mothers from privileged backgrounds.Bringing the focus to postpartum depression specifically, social work students should be prepared to address barriers to services and facilitate mothers' access to child care, transportation, and prenatal appointments that accommodate inflexible work schedules.Social work students should also be prepared to advocate for mothers who will likely experience delays in appointments, particularly for mothers who receive public insurance (U.S.Department of Health and Human Services, Office of the Surgeon General, Substance Abuse and Mental Health Services Administration 1999).
Social work research courses.Competency 4 states, social workers are expected to engage in research-informed practice and practice-informed research (CSWE, 2015).Instructors can help students develop and test interventions with individuals, families, groups, and communities and later evaluate those interventions by using various assessment tools.Program evaluation courses should evaluate services postpartum mothers use including Women, Infants, and Children (WIC) clinics, prenatal care agencies, and pediatric clinics.Additionally, students can be taught how to work with cultural brokers to access communities where they can facilitate focus groups and conduct community-based participatory research to help community agencies evaluate the cultural appropriateness of their services.Finally, students can learn to employ qualitative and quantitative methods to obtain client feedback about the experience of postpartum depression and services received.
Human behavior and the social environment courses.Competency 6 states social workers are to engage with individuals, families, groups, organizations, and communities by applying knowledge of human behavior and the social environment (CSWE, 2015).Among the ways educators can help students develop these skills is by including course content on risk and protective factors of postpartum depression in course units focused on the developmental stages of pregnancy, childbirth, and infancy.Students should study theories of societal oppression and how oppression affects women and children.Students can then investigate which theories best explain the lived experiences of new mothers affected by postpartum depression.Instructors can also include content on family systems theory to gain greater understanding of the effects of postpartum depression on the family.
Social work practice courses.Competency 8 requires social workers to intervene with individuals, families, groups, organizations, and communities (CSWE, 2015).Instructors can develop various case scenarios and encourage students to evaluate practice approaches and interventions for working mothers living with postpartum depression.The modules can emphasize relationship-building, engagement, contracting, validation, and resource acquisition.Interventions that highlight supportive counseling and problem-solving, and use strengths-based and women's empowerment approaches applicable across settings are needed.Given the impact of postpartum depression on external systems, curriculum modules on family therapy that address the needs of spouses/partners, children, and extended family members as well as group therapy/counseling course modules that address both psychotherapeutic and mutual-aid group strategies for working with mothers who have postpartum depression are needed.Finally, course modules are needed to teach students how to form coalitions with service providers caring for new mothers.These coalitions will help communities to advocate for new, culturally relevant services that enhance formal and informal support systems.Working with agencies to develop brochures that are easy to read and help mothers and families access appropriate services are also needed.

Social policy courses.
Competency 5 requires students to engage in policy practice that advances human rights and social justice (CSWE, 2015).Instructors can provide course content on the ACA with specific focus on Section 2952.Students can trace the development of the ACA while considering other legislation focused on bringing to light the needs of mothers and children including the Sheppard-Towner and Melanie Blocker-Stokes Acts.Students can also write policy statements in their field agencies on how to better provide services to new mothers with postpartum depression in light of the ACA.
Fieldwork.Educational Policy 2.2 requires field educators to provide students with opportunities to integrate classroom content with practical experience.Field educators can assign students in maternal and child healthcare placements to work with first-time mothers, provide education to the mother's partner/spouse and other family members about the signs and symptoms of postpartum depression, explore the use of informal supports, and make referrals to appropriate community resources.Students' cultural competence can be enhanced by field education experiences and service-learning opportunities that involve working with diverse populations across the lifespan (Ley et al., 2009).Finally, better screening methods should be incorporated into agency practice to include not only use of postpartum depression scales (e.g., Edinburgh Postnatal Depression Scale; Cox, Holden, & Sagovsky, 1987), but also predictors of postpartum depression that would help prepare students for working with new mothers who may develop postpartum depression.Students should also be instructed in the use of standardized screening instruments and on how to advocate with hospitals for developing written plans that provide specialized social work services related to postpartum depression (NAPSW, 2009).Students can be assigned tasks that investigate strategies for how best to remove barriers to care that postpartum mothers of color face including the lack of culturally appropriate and relevant brochures on postpartum depression.Students can develop in-service discussions on the predictors of postpartum depression and assess the agency's readiness to provide services that are affordable, adequate, and accessible to all mothers.

Summary and Conclusion
Despite being an ongoing problem for many years, postpartum depression has only begun to receive public attention within the past two decades.Accounts of new mothers harming their newborn babies have brought additional focus to the rationale for developing new services.Many services, however, are being developed without the input of social workers who, given their training in cultural competence, advocacy, and policy development as well as multi-system interventions, can bring a much-needed perspective to address this problem.
Although the social work profession has contributed to the development of services and policies on maternal and child health, it needs to take a more decisive step forward in addressing postpartum depression.The adoption of the ACA affords an excellent opportunity for social work educators to provide learning opportunities for students to address this significant problem so that new mothers and their children can live healthy and productive lives.
, and West Virginia (Uniform Maternal Screening Act, 2009).Other states require education about postpartum depression including Texas (Relating to Information Provided to Parents of Newborn Children, 2005), Virginia (Certain Information Required for Maternity Patients, 2003), Minnesota (Postpartum Depression Education and Information, 2015), and Oregon (Relating to Perinatal Mental Health Disorders and Declaring an Emergency,