Introduction

Pregnancy and parenthood require multiple changes and adjustments which are obtained through, physical, social and psychological alteration. The prospect of becoming parents can impact on women and their partners in different ways and expectations are influenced by cultural norms and societal expectations that a frequently romanticised – particularly by the media. It is essential the needs of the parents are addressed during this transition. The postnatal period represents the period signifies a life change which affects the woman and her life is disrupted since she is now faced with the task of adjusting to taking care of a new-born baby. PHNs can assist the parents to navigate through this challenging period with the application of interventions from evidence-based research.

Circular 41/2000 sets out the PHN services to be to provide support, education and preventative services (including screening, disease control, immunisation and breastfeeding).

The perinatal maternal health promotion model provides a rationale for a health promotion approach to maternal postpartum care (Fahey and Shenassa 2013). While the biomedical definition describes the postpartum period as the six to eight-week time period after the birth, it often takes the mother up to one year after the birth to fully adapt back to a nonpregnant state, physically, socially, and psychologically. The structure is based mainly on the three core concepts of health promotion. The first aspect is the perspective of health as a state of wellbeing (Fahey and Shenassa 2013). The next key aspect of health promotion is universal application. Every individual can benefit from health promotion, and so, the risk of diagnostic errors is diminished. If the PHN understands that all people need health promotion means that all women achieve the correct coping skills. Finally, the last tenant of health promotion is the importance of contextual influences. Family misunderstanding of any issues the mother is facing, be it psychologically, socially, or physically, can often be a deterrent to treatment. It is the role of the PHN to encourage a positive attitude across the family, and ensuring social barriers are reduced. (Fahey and Shenassa 2013) The application of this model will be discussed further in the essay.

In 1.1 of this essay, the author will discuss the physiological needs of parents with regards to health teaching and the promotion of breastfeeding.

In 1.2 of this essay the author will discuss the psychological needs of parents with regards to screening for mental health difficulties such as postnatal depression.

In 1.3 of this essay, the author will discuss the sociological needs of parents with regards to support networks for post-natal depression and home visiting.

Physiological Needs

Health Promotion

The postpartum period is a time of significant change for a new mother. Physical and hormonal changes, shifting family dynamics and sleep deprivation are some of the many challenges facing new parents, all while attempting to provide the best care possible to their new-born. (Spelke and Werner 2013) Physical symptoms are very common in this period. In a study done by (Cooklin 2015), evaluating maternal physical health symptoms in the first eight weeks in Australian primiparous women the authors found that women experienced physical morbidity in the earlier weeks of post-partum as compared to 8 weeks after delivery. The study therefore reiterated support for earlier identification and screening for mothers. While this may not be completely feasible due to the staff shortcomings, nevertheless the family can be given information on the postnatal expectations and what they should consider severe. Since it is common knowledge that most of the symptoms go away with time majority of the mothers do not consult a health in effect might lead to deteriorating symptoms or prolonged recovery periods that would have been otherwise mitigated (Cooklin 2015).  The postnatal period is a critical phase in the lives of mothers and new-born babies and cannot be underestimated


. and according to the WHO it is most neglected period for the provision of quality care. The Confidential Enquiry into Maternal Deaths in the UK (2006–08) published in 2011 showed that mothers deaths. resulting from complications of the post-natal including haemorrhage or infection.

The HSE and Public Health Nurses in Ireland are mandated to provide the first postnatal visit 48 hours postpartum this gives the opportunity to assess the physical and physiological condition of the mother and the baby (Phelan 2018). This visit is often to address any potentially serious symptoms, such as infection, yet some mothers have reported a desire to address issues that limit their ability to function daily, such as incontinence. (Martin et al. 2014)

In the National Institute of Clinical Excellence postnatal guidelines provide a comprehensive framework to assess the mother at the PHN’s first visit. It is essential that the needs of the mother’s physical condition is assessed. A poorly contracted uterus is a danger sign and could indicate post-partum haemorrhage on examination the uterus cannot be felt easily because it is soft in consistency often described as (boggy) The PHN needs to educate the mother about vaginal bleeding and explain thatsome bloody discharge is normal, in the immediate postnatal period, but advise her to attend the GP as this bleeding is profuse as this  is a life threating condition .in the post-natal period and warrants urgent medical attention Advice should be given about pelvic floor exercises especially as many pelvic floor complications are related to childbirth. (McClurg.2015). Urinary and faecal incontinence and organ prolapse. Can occur All Healthcare professionals have a responsibility to support the woman in learning the techniques of pelvic floor exercises. (McClurg et al. 2015)

The perinatal maternal health promotion model describes a health promotion approach to physical symptoms in the postpartum period. While the traditional focus is to ensure normal reproductive system involution, population-based surveys of mothers shows that many mother express concerns directly related to childbirth up to twelve months postpartum. (Fahey and Shenassa 2013) The main concerns are fatigue, lack of self-care, and pain in the back, breast, perineal, and head. The PHN should be educated on these concerns and be able to correctly identify any issues the mother may be facing. Self-efficacy is a key health promotion strategy for the PHN. (Fahey and Shenassa 2013) Therefore the PHN should strive to empower the mother in her new role and offer support with tasks she might seem too difficult. When the mother feels capable of taking on her new role, she may be able to overcome lacking self-care, fatigue and other physical problems associated with lacking self-efficacy. In relation to breastfeeding, self-efficacy plays an important role in promoting breastfeeding. In Ireland, mothers still feel shame and embarrassment when the breastfeed. While some can overcome this, when mothers begin to have trouble or pain it can become easy to give up. It is important that the PHN can establish belief within the mother and communicate that it is not always easy to begin. A therapeutic relationship between the PHN and the mother can positively influence

Ireland and Norway have many similarities from a geographic and demographic perspective, and both have a strong focus on primary care and health. Ireland’s two-tier health care system has failed in many respects however in delivering services to meet people’s needs (Tussen and Wren. 2006). In contrast to Ireland, Norway has universal health care for its entire population and free health care at the point of delivery. Despite this, guidelines for resolving PND are lacking in both Ireland and Norway (A Vision for Change 2006; Norwegian Directorate of Health, 2004), with no resources increased either in Norway or in Ireland to help (Clancy and Leahy-Warren 2013).

The role of the Public Health Nurse (PHN) in screening and treating PND is paramount. Morrell et al. (2000) and MacArthur et al. (2002) illustrated the role of nurses in providing support with PND, providing a service that was flexible to the individual needs of the postnatal women. The PHN used symptom checklists and EPDS to identify health needs and guidelines for the management of these needs. The Edinburgh Postnatal Depression Scale (EPDS) created by Cox et al. in 1987. However, the EPDS has been criticised for ignoring psychosocial factors that contribute to PND symptoms such as lack of social support and significant life events (Beck et al. 2000; Appleby et al. 1994; Beck & Gable 2001).  Circular 41/2000 sets out the PHN services to be provided, which includes provide support, education and preventive services (including screening, disease control, immunisation, breastfeeding support).

The PHNs screening duties help prevent PND. One tool used to measure PND is the Edinburgh Postnatal Depression Scale (EPDS) created by Cox et al. in 1987. It’s important to note that the EPDS was designed as a screening tool, not a diagnostic tool to detect PND (Cox et al., 1987). This self-reporting screening tool has been proven as an effective means of measuring PND (Cox and Holden 2003; Milgram et al. 2011; Boyce et al. 1993). However, the EPDS has been criticised for ignoring psychosocial factors that contribute to PND symptoms such as lack of social support and significant life events (Beck et al. 2000; Appleby et al. 1994; Beck & Gable, 2001). One tool that is currently used to measure depression (not necessarily PND) is the Whooley Questionnaire. A positive test identifies patients who may benefit from further screening. A negative test essentially rules out depression. One problem with self-reporting tests are that ‘’they are only as good as the person taking them’’ and people may not be entirely truthful when filling it out. (Leahy Warren 2012)

The PHN must have the confidence and skill to engage in a discussion with the parents about their mental health require referral to a councillor or specialist. She needs to be able differentiate between what mental health concerns can be resolved with support and those that require specialist mental health service intervention. Being able to discuss mental health concerns with women and their partners is extremely important to midwifery and nursing. However, some studies have shown that PHNs lack knowledge on mental health problems and did not always prioritise women’s mental health needs. According to Leahy-Warren (2007), the husbands/partners of first-time mothers need to be more involved also in antenatal and postnatal care and the study showed the need for public health nurses and midwives to work together to facilitate social support for first-time mothers on an evidence-based basis. (Leahy-Warren 2007).

Sociological Support

Social Support

Sociological support is very important in the postnatal period. It is challenging time for parents, especially new mothers. Support can come from partners, family friends or the PHN. In previous studies, mothers reported that help from their partners with household duties and infant care was greatly important to them in the postnatal period and ultimately helps with their transition to parenthood (Haggman-Laitila 2003). Research also has shown that there is a positive relation with social support and self-efficacy (Jones and Prinz 2005) Support from the maternal mother is especially important for first time mothers and studies have shown that maternal support is key to increasing self-efficacy (Haslam et al. 2006). However, a lack of social support has been found to be a contributing factor to PND. Coupled with this, is the “considerable shortage of postnatal support services available in many countries”. Barak et al. (2008) also found that online support groups offer people a sense of control, self-confidence, feelings of more independence, social interactions, and improved feelings, all of which help in the screening and support of those with PND. These Peer support telephone calls have been widely used for a variety of health-related concerns, including PND (Dale et al. 2009). (Dennis 2012) evaluated the voluntary mother’s experience of providing telephone peer support finding that phone peer support is an effective preventative intervention

In Ireland, support can be seen from PND Ireland, founded in 1992 by Madge Fogarty. following her personal experience of the condition. This support group utilizes the telephone support mentioned above and it continues to operate monthly in Cork, providing the only known support group in Ireland for mothers suffering from PND. They also provide support via e-mail support, website, online discussion forum, and a drop-in service by appointment.

The current goal of the organization is to establish support groups in other areas of Ireland and to draw awareness to senior figures in the HSE about the importance of support for mothers suffering from PND. In 2011, Nurture Post Natal Depression Support Service was also established and it currently links women with PND to low cost counselling in Dublin and this service hopes to provide a wider range of services in the future. Communicating and Relating Effectively (CARE) is another support, a relationship-focused behavioral nursing intervention, designed to promote responsive interaction over time between depressed mothers and their infants. By teaching the mother how to interpret her infant’s communication cues and by coaching her to try alternate behaviors, the nurses attempted to promote new maternal responses and skills.

Conclusion

In conclusion, the author has outlined the significance of the physiological, psychological and sociological needs of parents in the postnatal period, with reference to PHN interventions and evidence-based practice.

Regarding physiological needs, PHN interventions such as health teaching and the promotion of breastfeeding and its health benefits are essential to the parents in the postnatal period. Health teaching includes educating the woman about the changes in her body such as the involution of her uterus and lactation. The PHN should also inform the woman of early warning signs of complications such as mastitis or bleeding. The PHN should also promote breastfeeding and its health benefits to the mother. If the mother is having trouble, it is the job of PHN to educate the mother on correct positioning to ensure proper latching.

In relation to psychological needs of parents, the PHN should be able to screen for symptoms of postnatal depression using symptom checklists and tools such as EPDS or the Whooley Questionnaire. The PHN must have a enough knowledge of mental health and the confidence to engage with parents in conversation about their wellbeing and refer onto a counsellor or specialist accordingly.

With regards to sociological needs, the PHN should make sure that the parents are supported by family and have good support networks throughout the postnatal period. According to numerous studies, these networks are key to self-efficacy and parental confidence. The PHN should also make sure the parents have adequate access to support groups and support organizations.

The postpartum period is a time of great change for any family. At such a time, the needs of the parents should be of utmost importance to the PHN. While traditionally there has been a lack of parental support during this period, the modern approach considers all the family across physiological, societal, and physiological needs. By using the interventions mentioned above, the PHN can ensure proper care of both the parents and the baby in the postnatal period

References

• A Vision for Change (2006) Report on the Expert Group on Mental health Policy. Dublin, Ireland, Stationery Office.
• Abell, S. (2007) ‘Postpartum depression’, Clinical Pediatrics, 46, pp. 290–291.
• American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (4th ed. text rev.). Washington, DC:
• Appleby, L. (2003) ‘The treatment of postnatal depression by health visitors: Impact of brief training on skills and clinical practice’, Journal of Affective Disorders, 77(3), pp. 261–266.
• Barak, A., Nissim, M., and Suler, J. (2008) ‘Fostering empowerment in online support groups’, Computers in Human Behaviour, 25(5), pp. 1867-1883.
• Beck, C. T., & Gable, R. K. (2000) ‘Postpartum depression screening scale: Development and psychometric testing’, Nursing Research, 49(5), pp. 272–282.
• Beck, C. T. (2001) ‘Predictors of postpartum depression: An update’, Nursing Research, 50(5), pp. 275–285.
• Begley, C. Gallagher, L. Clarke, M. Carroll, M. Millar, S. (2008). National Infant Feeding Survey 2008 Prepared for the Health Service Executive: UCD & TCD.
• Boyce, P., Stubbs, J., and Todd, A. (1993) ‘The Edinburgh postnatal depression scale: Validation for an Australian sample’, Australian and New Zealand Journal of Psychiatry, 27, pp. 472-476.
• Clancy, A., P. Leahy-Warren, M. R. Day, and H. Mulcahy (2013) ‘Primary Health Care: comparing public health nursing models in Ireland and Norway’, Nursing Research and Practice.
• Cox J.L. & Holden J. (2003) Perinatal Mental Health: A Guide to The Edinburgh Postnatal Depression Scale. (EPDS) Gaskell, London.
• Cox, J. L., Holden, J. M., & Sagovsky, R. (1987) ‘Detection of postnatal depression: Development of the 10 item Edinburgh Postnatal Depression Scale’, British Journal of Psychiatry, 150, pp. 782–786.
• Cooklin, A., Amir, L., Jarman, J., Cullinane, M. and Donath, S. (2015). Maternal Physical Health Symptoms in the First 8 Weeks Postpartum Among Primiparous Australian Women.
  
  Birth
  
  , 42(3), pp.254-260.
• Dale H., Lee A. (2016) ‘Behavioural Health Consultants in Integrated Primary Care Teams: A Model for Future Care’, BMC Family Practice 17(97), pp 2-9.
• Department of Health (2016) Creating a Better Future Together National Maternity Strategy 2016-2026
• Fahey, J. and Shenassa, E. (2013). Understanding and Meeting the Needs of Women in the Postpartum Period: The Perinatal Maternal Health Promotion Model.
  
  Journal of Midwifery & Women’s Health
  
  , 58(6), pp.613-621.
• Fettling, L. (2002) Postnatal Depression; A practical guide for Australian families. Menbourne, ID Communications.
• Gaynes, B.N, Gavin N (2005) ‘Perinatal depression: prevalence, screening accuracy, and screening outcomes’, Evidence report/technology assessment119, pp.1-8.
• Haagman-Laitila A (2003) Early support needs of Finnish families with small children. Journal of Advanced Nursing 41, 595-606.
• Haslam D, Pakenham K & Smith A (2006) Social support and postpartum depressive symptomatology: the mediating role of maternal self-efficacy. Infant Mental Health Journal 27, 276-291.
• Hatsu, I., McDougland, D, and Anderson, A (2008) “Effect of infant feeding on maternal body composition”, International Breastfeeding Journal 3 (18).
• Higgins, A. (2017) Perinatal mental health: an exploration of practices, policies, processes and education needs of midvives and nurses within maternity and primary care services in Ireland. Dublin: HSE
• Hoddinott, P. Craig, LCA. Britten, J. McInnes, RM. (2012). ‘A serial qualitative interview study of infant feeding experiences: idealism meets realism’. BMJ Open 2:e00050
• Jones TL & Prinz RJ (2005) Potential roles of parental self-efficacy in parent and child adjustment: A review. Clinical Psychology Review 25, 341-363.
• Leahy-Warren, P., McCarthy, G. & Corcoran, P. (2012) First-time mothers: social support, maternal parental self-efficacy and postnatal depression. Journal of Clinical Nursing, 21(3/4), 388-397.
• Lee, D.T.S., Yip, A.S.K., and Chiu, H.F.K. (2000) ‘Screening for postnatal depression using the double test strategy’, Psychosomatic Medicine, 62, pp. 258–263.
• MacArthur, C., Winter, H., Bick, D., Knowles, H., Lilford, R., Henderson, C., Lancashire, R., Braunholtz, D., and Gee, H. (2002) ‘Effects of redesigned community postnatal care on women’s health 4 months after birth: A cluster randomised controlled trial’, The Lancet, 359(9304). pp.378-385.
• McClurg D., Gerrard J.,Hove TR. (2015) Reducing the incidence of incontinence. British journal of Midwifery 23 (1) pp 17-21.
• McGorrian, C., Shortt, E., Doyle, O., Kilroe, J. and Kelleher, C.C, (2010). An assessment of the barriers to breastfeeding and the service needs of families and communities in Ireland with low breastfeeding rates. UCD: Dublin.
• Martin, A., Horowitz, C., Balbierz, A. & Howell, E. (2014) Views of Women and Clinicians on Postpartum Preparation and Recovery. Maternal & Child Health Journal, 18(3), 707-713.
• McAndrew, F., Thompson, J., Fellows, L,. Large, A., Speed M. & Renfrew M.J. (2012) Infant Feeding Survey 2010. Health and Social Care Information Centre, Leeds.
• Milgrom, J., Mendelsohn, J., and Gemmill, A. (2011) ‘Does Postnatal Depression screening work? Throwing out the bathwater, keeping the baby’, Journal of Affective Disorders, 132, pp. 301-310.
• Molyneaux E., Poston L., Khondoker M., Howard LM. (2016) ‘Obesity, antenatal depression, diet and gestational weight gain in a population cohort study’, Arch Womens Mental Health 19(9), pp. 899-907.
• Morrell, C.J., Spiby, H., and Stewart, P. (2000) ‘Costs and effectiveness of community postnatal support workers: a randomised controlled trial’, British Medical Journal, 321, pp. 593–598.
• Mulcahy, H., Phelan, A., Corcoran, P. & Leahy-Warren, P. (2012) Examining the breastfeeding support resources of the public health nursing services in Ireland. Journal of Clinical Nursing, 21(7/8), 1097-1108.
• Navarro, P., Ascaso, C., Esteve, L.G., Aguado, A.T., and Santos, R.M. (2001) ‘Postnatal Psychiatric Morbidity: A validation study of the GHQ-12 and the EPDS as screening tools’, General Hospital Psychiatry, 29(1), pp. 463-475.
• National Institute for Health and Clinical Excellence (2006) Postnatal Care Guidelines. London
• Norwegian Directorate of Health (2004) Norwegian Directorate of Health, The municipalities’ work for health promotion and prevention in well baby clinics and school health services. Veileder til forskrift av 3. Norway.
• O’Hara, M.W., and Swain, A.M. (1996) ‘Rates and risk of postnatal depression – a meta-analysis’, International Review of Psychiatry, 8, pp. 37–54.
• Phelan, A. (2014). Examining the Synergy of Practice.
  
  Global Pediatric Health
  
  , 1.
• Ramsay, R. (1993) ‘Postnatal depression’, The Lancet, 341 (1358), pp.3213-3217
• Schwarz, E., McClure, C., Tepper, P., Thurston, R., Janssen, I., Mathews, K. and Sutton-Tyrrell, K. (2010) “Lactation and maternal measures of subclinical cardiovascular disease”, Obstetrical and Gynaecological Surveys 115(1), 41-48. 94
• Scottish Executive. (2001c) Scottish Executive: nursing for health: a review of the contribution of nurses, midwives and health visitors to improving the public’s health. Scotland, Edinburgh Scottish Executive.
• Spelke B, Werner E. The fourth trimester of pregnancy: committing to maternal health and well-being postpartum. R I Med J (2013). 2018;101(8):30 –3
• Tarrant, RC. Younger, KM. Sheridan Pereira, M. White, MJ. Kearney, JM. (2009). ‘The prevalence and determinants of breast-feeding initiation and duration in a sample of women in Ireland’. Public Health Nutrition 13(6):760-70.
• Tussing and Wren (2006) How Ireland Cares, the Case for Health Care Reform. New Island, Dublin, Ireland.
• Williams, J., Greene, S., McNally, S., Murray, A., and Quail, A (2010) Growing Up In Ireland: National Longitudinal Study of Children The Infants and Their Families. Office of the Minister for Children and Youth Affairs: Dublin.
• World Health Organization (2010). Women’s health.