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Analysis Promoting women’s health in China

Empowering new mothers in China: role of paediatric care in screening and management of postpartum depression

BMJ 2024; 386 doi: https://doi.org/10.1136/bmj-2023-078636 (Published 30 August 2024) Cite this as: BMJ 2024;386:e078636

Read the collection: Promoting women's health in China
  1. Yunting Zhang, researcher13,
  2. Haiwa Wang, PhD student12,
  3. Saishuang Wu, PhD student12,
  4. Yuyin Xiao, postdoctoral researcher3,
  5. Fan Jiang, professor24
  1. 1Child Health Advocacy Institute, National Children’s Medical Center, Shanghai Children’s Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
  2. 2Department of Developmental and Behavioral Pediatrics, National Children’s Medical Center, Shanghai Children’s Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
  3. 3School of Public Health, School of Medicine Shanghai Jiao Tong University Shanghai, China
  4. 4MOE-Shanghai Key Laboratory of Children’s Environmental Health, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
  1. Correspondence to: F Jiang fanjiang{at}shsmu.edu.cn

Though general paediatricians have traditionally been the gatekeepers of children’s health, they can also work as part of a multidisciplinary team to tackle postpartum depression, argue Fan Jiang and colleagues

The Global Burden of Disease study showed that mental disorders were still one of the top 10 leading causes to disease globally in 2019, with no discernible reduction since 1990.1 The highest rates of depression in women occur during the first few weeks, months, or year after giving birth compared with at other times in a women’s life.2 Postpartum depression has an estimated point prevalence of 13% in high income countries and 20% in low and middle income countries, affecting a large proportion of women in their most productive and active years.3 In China, the prevalence of postpartum depression is about 18% (fig 1).4 Evidence from many studies indicates that postpartum depression has a negative effect on the health and wellbeing of women, and their families and offspring.5 As such, it is a serious public health concern.

Fig 1
Fig 1

Prevalence of postpartum depression and number of births by country. Prevalence data from Wang et al4; number of births from the United Nations World Population Prospects, 2022; Gross domestic product (GDP) per capita from World Bank, 2022

In clinical settings, it is common practice for obstetricians to screen women during pregnancy and within one month of delivery for postpartum depression. However, postpartum depression can manifest at any point during the first postpartum year and symptoms may persist for an extended period. This paper aims to review the current screening and management practice for postpartum depression, and advocates for the ongoing provision of these services beyond the initial one month period. We argue that combined with maternal care, paediatric care provides a good opportunity to conduct repeated assessments for postpartum depression and implement follow-up strategies. Moreover, we propose actionable steps for integrating such services into paediatric care and creating a continuum of care that ensures consistent and comprehensive services for women with postpartum depression in China.

Consequences of postpartum depression

Postpartum depression is a psychological disorder with multiple cascading negative effects. It is one of the most common complications of childbearing,6 Because it occurs within the physiological processes of pregnancy and childbirth and is widely perceived as transient, the public may mistakenly view it as a temporary condition that will naturally improve with time. This may lead to women not seeking medical help. However, if left untreated, postpartum depression can develop into severe clinical mental disorders, and even suicide.3 About 20% of women affected by postpartum depression still experience depression beyond the first year of giving birth, and 13% continue to be affected after two years. Furthermore, about 40% experience a recurrence during subsequent pregnancies or in other situations.6 In addition, untreated postpartum depression is associated with long term adverse events and poor quality of life. Postpartum depression occurs at a time when the infant is fully dependent on parental care and highly sensitive to the quality of the interaction. Evidence shows that even mild maternal depression can adversely affect the emotional, social, and cognitive development of a child,7 often in ways that are not fully recognised (box 1).5

Box 1

Effects of postpartum depression on maternal and child health5

Diminishing maternal wellbeing

  • Short term. Postpartum depression results in a deterioration of maternal mental health, an increase of anxiety and depressive symptoms, and a decline in overall quality of life. For example, women with postpartum depression have lower self esteem, decreased happiness, heightened irritability, increased sadness, lower anger control ability, and poorer responses to negative stimuli compared with mothers without postpartum depression. In severe cases, the condition may even lead to suicide.3

  • Long term. Mothers diagnosed with postpartum depression score lower on emotional wellbeing at one year postpartum compared with mothers without postpartum depression. Even three and a half years after childbirth, mothers with postpartum depression still have considerably higher anxiety levels than mothers without postpartum depression, and they tend to face more negative life events and financial challenges in the subsequent years. The likelihood of homelessness for mothers who have experienced postpartum depression is twice that of mothers without postpartum depression. Postpartum depression is also associated with more interpersonal difficulties and lower social functioning. As regards quality of life, the classic core symptoms of a depressive disorder would be expected to decrease the subjective quality of both an individual’s inner life experiences—for example, with signs of anhedonia, sadness, hopelessness, and thoughts of death—as well as their functioning, including slowed thought, reduced physical movements or restlessness, and disturbed sleep.3

Impairment of offspring’s development

  • Short term. Children born to mothers with postpartum depression are more likely to experience excessive crying, sleep disturbances, and temperament problems. Additionally, postpartum depression leads to less favourable mother-infant interactions, which reduces the likelihood of mothers starting and sustaining breastfeeding and ultimately hinders the formation of a normal parent-child attachment.8 Presence of maternal depressive symptoms when infants are 5 months predicts increased overall health problems and a higher incidence of diseases in infants at 9 months. Furthermore, postpartum depression is linked to a threefold increase in the risk of death for infants younger than 6 months and about a twofold increase for infants younger than 12 months.9 In cases of severe postpartum depression, infanticide is a risk.10

  • Long term. In the long term, postpartum depression has been associated with stunting and reduced weight gain.11 It also affects the motor, cognitive, and language development of the offspring, thus increasing their emotional and behavioural problems, and greatly influences their long term achievements and overall wellbeing.

RETURN TO TEXT

Importance of screening and management of postpartum depression

Many studies have provided evidence that timely diagnosis and appropriate treatment of postpartum depression could mitigate its effect on mothers and their offspring. As awareness of this problem has increased, professional guidelines have begun to recommend screening for depressive symptoms during pregnancy and shortly after birth. For example, the American College of Obstetricians and Gynecologists recommends screening for perinatal depression at the first prenatal visit, later in pregnancy, and at postpartum visits within the first month of giving birth.12 In Australia, the National Perinatal Depression Plan, launched by the federal government in 2008-09 with a budget of more than $A80m (₤40m; €45m; $63m, in 2009) over five years, promoted routine screening once or twice antenatally and at least once in the early postnatal period in primary care settings. A year after implementation of this plan, hospital admissions with a psychiatric diagnosis in the first postnatal year had decreased by up to 50%.13 Similar practices have been adopted in China as well. The exploration of depression prevention and treatment work service plan issued by the National Health Commission in 2020 proposed to incorporate screening for depression during the pregnancy into routine prenatal care and postpartum follow-up care.14 Actions in line with these recommendations have already been implemented in projects such as one in Shenzhen where screenings are carried out during postnatal home visits or at the six week postnatal check-up, incorporated into routine maternal healthcare delivery.15

Nevertheless, screening for postpartum depression only up to four or six weeks after delivery is insufficient. A recent population based study found that 7.2% of women reported depressive symptoms at nine to 10 months postpartum, with 57.4% of them not reporting depressive symptoms in the early postpartum period (that is, two to six months).16 In addition, depression persisting beyond four to six weeks after delivery may still require treatment. Therefore, in clinical practice and clinical research, the definition of postpartum depression varies and refers to depression occurring within the first four weeks, three months, six months, or up to 12 months of childbirth.6

Based on current evidence, support is growing for the feasibility and importance of screening for postpartum depression beyond four weeks after delivery. The clinical practice guideline of the American College of Obstetricians and Gynecologists recommends the use of two well validated tools, the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire-9, to screen for postpartum depression.12 The usual screening tool currently is the Edinburgh Postnatal Depression Scale.17 However, it is only applicable up to eight weeks postpartum and is not suitable for longer term management in paediatrics. The Patient Health Questionnaire-9 seems to be a feasible alternative for screening perinatal depression, with operational characteristics similar to the Edinburgh Postnatal Depression Scale.18 Additionally, evidence has shown the effectiveness of interventions, including antidepressants and psychotherapy, after the diagnosis of postpartum depression. Furthermore, a simulation analysis found that screening and treating postpartum depression was a cost effective approach considering mothers’ quality adjusted life years in both the short and long term. The results suggested that screening and treating postpartum depression was cost effective.19 However, an effective method for public health services to identify and manage postpartum depression is still not available.

Paediatrician screening and management of postpartum depression

Globally, child health workers, such as paediatricians, general practitioners, or nurses, who have regular contact with new mothers during well baby visits, are often considered the best choice for screening and managing postpartum depression during the first year postpartum. The guidelines of professional associations, such as the American Academy of Pediatrics, call for the establishment of a postpartum depression screening and management system within paediatric healthcare.20 Apart from the easy accessibility of child health workers, they have other advantages. A systematic review showed that child health workers have a rapport with postpartum women and these women are more likely to talk to them about their depression.21 Child health workers offer child focused interventions with a family perspective, which are effective in reducing maternal depressive symptoms and motivating mothers to improve their wellbeing for the sake of their children.22

Drawing on the global experience, the Chinese maternal and child healthcare system would be the most suitable platform for the extension of postpartum depression screening and management. This system, which covers more than 90% of the country’s primary care institutions and operates under a hierarchical ranking system from the county level to the national level, is well structured and effective. In addition to maternal and child healthcare, child health workers, including paediatricians, general practitioners, and nurses in community centres or township hospitals, provide primary child healthcare services within this framework. This system has already been shown to be effective in reducing maternal and child mortality rates.23 In particular, child health workers in the maternal and child healthcare system offer six free well-child visits for each child during their first year, with continued check-ups every six months for children aged 1-2 years, and annual check-ups for children older than 2 years. Additionally, nearly half of the child health workers have a first degree or higher.24 Based on this system, a pilot project screening for postpartum depression in mothers at many postpartum time points has already been undertaken in Shanghai.25

However, evidence on real-world implementation is still limited.20 Globally, pilot studies have provided weak but promising evidence, while also revealing some barriers to implementation.26 First, time constraints and incomplete training were the barriers most often noted by the child health workers who were surveyed.27 Second, the lack of free and available community mental health services, a referral system between primary health care and mental health services, and continuity of care were also barriers to the detection and management of postpartum depression in women.28 Third, ethical and legal issues on the boundaries of paediatric care were also mentioned as a challenge, because the primary obligation of child health workers is to children rather than mothers.29 Fourth, the lack of reimbursement strategies impedes the implementation of postpartum depression screening and management systems, especially in paediatric practice settings where mothers are not the identified patients.30 Last but not least, even in paediatric settings, pervasive stigma surrounding psychosocial health in maternity is still a considerable obstacle that prevents mothers from accepting mental health screening and support.31

Integrating postpartum depression screening and management in paediatric care in China

For implementation in China, it is important to recognise that addressing the aforementioned concerns is essential to enhance the role of paediatric practice to effectively screen and manage women with postpartum depression. Based on the framework for analysing the integration of targeted health interventions in health systems,32 we propose four actions.

Intervention

Introducing postpartum depression screening and management into child healthcare is complex, as it is characterised by episodes of care (many screening time points), a comprehensive set of components within the system (screening, home visits, community based counselling, psychological support, referral, and follow-up management), and different levels of care (health professionals in both primary care and psychiatric hospitals). Given the complexity, efforts need to be made in three areas.

First, institutional arrangements should be based on existing evidence, which includes defining methods and time points for screening and counselling. Second, as child health workers are often not equipped with the necessary skills to provide psychological support for new mothers, training is crucial. The World Health Organization’s thinking healthy manual is designed to reduce postpartum depression in low socioeconomic settings and improve health outcomes in these children through the adaptation and integration of cognitive behaviour therapy into the routine work of community health workers.33 This approach has already been effective in reducing postpartum depression and improving long term child development outcomes, and it can be adapted and implemented in regions with limited psychiatric resources.34

Third, referral systems to psychiatric hospitals need to be further strengthened in primary health care. Recent policies, such as those released by the Shanghai municipal health bureau, offer opportunities in this regard. For instance, these policies promote a higher priority in primary health care for tertiary hospital appointments, including mental health institutions.35

Adoption of the intervention

The framework underscores the important role of key stakeholders such as health workers, patient groups, and communities, whose perceptions and positions greatly influence the adoption of new interventions. In the context of postpartum depression screening and management, community stigmatisation is an important problem that cannot be overlooked. Stigma about mental disorders is notably prevalent in east Asia and often acts as a barrier to healthcare utilisation. Choosing non-stigmatising language has proved effective in tackling this challenge.36

By drawing insights from initiatives such as “She Conquers,” a programme in South Africa that originally targeted HIV reduction and successfully evolved to empower young women and avoid stigma,37 we can initiate similar pathways in postpartum depression screening and management. Transitioning these services to paediatric care presents an opportunity to reshape young mothers’ perspectives on postpartum depression. This approach shifts the perception of postpartum depression as only an individual medical condition to recognising that it affects parenting skills and family function and that managing the condition enhances these aspects.

In line with this approach, we propose framing the goal of the initiative as “empowering new mothers for happy and healthy children,” rather than only emphasising the aim of reducing mental disorders. This reframing not only fosters greater acceptance of psychosocial support among depressed mothers and their families but also helps child health workers embrace this new responsibility. It is grounded in the understanding that detecting and supporting mothers with postpartum depression ultimately contributes to the wellbeing of young children.

Health system characteristics

In the broader context of integrating new interventions, it is important to recognise that this process goes beyond simply changing service content. It necessitates revisions in regulations, financing mechanisms, and governance within the health system. For postpartum depression screening and management, ensuring child health workers have the appropriate qualifications to work effectively with young women is paramount. Equally important are confidentiality, medical documentation standards, and liability matters, all of which should be prioritised.

Evidence exists that supports the use of child health workers to provide mental health care for mothers. A WHO guideline highlights the importance of supporting maternal mental health as one of the four recommendations to improve early childhood development.38 In China, emphasis on continuity of care is growing. Recently, paediatricians, traditionally responsible for patients younger than 18 years, have been authorised to see patients up to 35 years of age.39 Additionally, other factors, such as financing for new services and establishing relevant regulations and supervision policies, need to be considered.

Context

In the context of China’s declining birth rate, strengthening the identification and management of postpartum depression is particularly important because of its profound effect on women’s long term health and the development of future generations. This initiative is crucial for China to effectively adapt to the evolving changes in population dynamics and promote optimal development of its people. The importance of this initiative should be widely recognised beyond the health sector, and cross sector collaboration with departments such as finance and medical insurance should be fostered. This collaboration would ensure better support for the implementation and advancement of projects related to postpartum depression screening and management.

Summary

Integrating the screening and management of postpartum depression into primary paediatric care, combined with maternal care and through multidisciplinary collaboration, represents key pathways for China to effectively manage this condition. We see this as a good opportunity in China to reshape maternal and child healthcare services at a time when the birth rate is declining substantially and the workload of child health workers is tending to decrease. On the other hand, grandmothers also serve as caregivers for infants in China, so the incorporation of this new component into paediatric care not only benefits young mothers but also extends to a larger population of women, including elderly women.

Key messages

  • Postpartum depression greatly affects women’s health, child wellbeing and long term development, and family wellbeing

  • The current practice of screening for postpartum depression during pregnancy and one month after delivery is insufficient for detection and management

  • Integrating diagnosis and management of postpartum depression into primary paediatric care is a promising approach to effectively manage this condition

  • Implementing this approach requires reshaping maternal and child healthcare services, strengthening referral systems, training health workers, reducing stigma, and fostering cross sectoral collaboration

Footnotes

  • We thank Hao Pan for her work on the figure. The authors are supported by grant 82073568 and U23A20170 from the National Natural Science Foundation of China, grant GWVI-11.2-XD16 from Shanghai Municipal Health Commission and by the Innovative Research Team of High-level Local Universities in Shanghai (SHSMU-ZDCX20211900). The funders had no role in the collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

  • Contributors and sources: FJ is a developmental behavioural paediatrician and has long research expertise in child health in primary health care. YZ is an epidemiologist and has expertise in early childhood development. FJ and YZ conceptualised the manuscript. SW and HW are PhD candidates in paediatrics and have experience in risk factors on early child development. YX is a postdoctoral researcher in health policy and has onsite experience in screening interventions for postpartum depression. YZ, SW, YX, and HW retrieved data and evidence from the literature and all authors contributed in drafting the manuscript. FJ revised the manuscript critically for important intellectual content. All authors approved the manuscript for submission. FJ is the guarantor.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • This article is part of a collection proposed by the Peking University, led by Jie Qiao. Open access fees were funded by individual institutions. The BMJ commissioned, peer reviewed, edited, and made the decision to publish. Jin-Ling Tang and Jocalyn Clark were the lead editors for The BMJ.

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