Postpartum depression: Proposal for prevention through an integrated care and support network (originally published in Applied and Preventive Psychology (1997)

                 Postpartum depression poses significant challenges to families and the community at large.  Considerable research and clinical attention has been paid to this complex phenomenon (Campbell, Cohn, Flanagan, Popper, & Meyers, 1992; Collins, Dunkel-Schetter, Lobel, & Scrimshaw, 1993; Comport, 1990; Hamilton & Harberger, 1992; Harkness, 1987; Kendall-Tackett & Kantor, 1993; Kitzinger, 1994; Kruckman, 1992; Lim, 1993; LoCicero, 1993; Masden, 1994; O'Hara, 1995; Romito, 1989; Sheppard, 1994; Trotter, Wolman, Hofmeyr, Nikodem, & Turton, 1992).  This attention is justified, as it is estimated that between 10% and 20% of new mothers suffer from postpartum depression within the first several months after birth¹ (O'Hara & Engeldinger, 1989; Weissman & Olfson, 1995).

                Despite burgeoning research and clinical literature on this subject, there is no university accepted definition of postpartum depression.  The American Psychiatric Association's DSM-IV (1994) does not have a specific diagnosis for any postpartum- or pregnancy-related disorders.  We have found various descriptions and lists of symptoms for postpartum disorders and distress to be useful (Dunnewold & Sanford, 1994; Harberger, Berchtold & Honikman, 1994; Kendall-Tackett & Kantor, 1993; Kleiman & Raskin, 1994).  The wide range of symptoms described by various authors include many types of physical and emotional difficulties that can be mild or severe.  Some examples are mild depression, irritability, inconsolable sadness, suicidal ideation, over sensitivity, sleep and/or appetite disturbance, physical symptoms, loss of interest in activities usually enjoyed, excessive worry, feelings of inadequacy and anxiety (Dunnewold & Sanford, 1994; Harberger et al., 1992; Kendall-Tackett & Kantor, 1993).

                Recent literature on postpartum depression has identified numerous etiological factors at the cultural, social, psychological, and biological levels.  These factors include social isolation or lack of social support (Collins et al., 1993; Cutrona, 1984; Enkin, Keirse, Renfrew, & Neilson, 1995; Kitzinger, 1994; Oakley, 1980); disharmony in the primary relationship (O'Hara, 1995; Sheppard, 1994); recent life stresses (Casoni, David, & Berthiaume, 1993; Grossman, Eichler, & Winickoff, 1980); lack of culturally determined rituals, support, and recognition to the new mother (Harkness, 1987; Kruckmanm 1992; Stern & Kruckman, 1983); adverse economic conditions (Ballard, Davis, Cullen, Mohan, & Dean, 1994; Grossman et al., 1980); the mother's perceptions of the birth experience as problematic, or one in which she was helpless and disempowered (Edwards, Porter, & Stein, 1994; Greene, 1995; Oakley, 1980); vulnerability to depression (Campbell et al., 1992; O'Hara, 1995); difficult infant temperament (Casoni et al., 1993; Gelfand & Teti, 1990; Hopkins, 1984); and adverse reactions to biochemical and hormonal shifts (Hamilton & Harberger, 1992; Parry, 1992).

Interaction of Causal Factors

                Our experiences as providers of psychoeducational and clinical services to childbearing and adoptive families are consistent with the findings reported in recent literature: a multitude of factors contribute to the development of postpartum depression and early family distress.  It is clear from our experience, as well as from the case studies explored in the clinical literature (Dunnewold & Sanford, 1994; Kendall-Tackett & Kantor, 1993; Kleiman & Raskin, 1994) that the factors contributing to postpartum depression are likely to interact thereby increasing the risk of postpartum depression.²  For example, financial problems may contribute to marital disharmony; life events, such as a job change necessitating a move, may contribute to social isolation.  We have observed, however, that despite literature by both researchers and clinicians suggesting multiple, interacting factors in the evolution of postpartum depression, many practitioners continue to base their work on older models that identify a single etiological factor as ãprimaryä and provide treatments which address only that factor.³  The variety of causes thought to be ãprimaryä fall readily into five categories of experience: biological, psychodynamic, cognitive, developmental and life events.  As Figure 1 illustrates, each model identifies one area as primary and thus prescribes a course of action designed to address that area.  There is little likelihood of attending simultaneously to several etiological factors, or to the interactions among factors.  The following situation is illustrative of the results of these older models.

                Rosalie was 4 weeks' postpartum when she began to experience insomnia, loneliness, uncontrollable weeping, and anxiety about her baby's health and her own adequacy as a mother.  She and her husband had been having marital difficulties prior to conceiving the child, but had believed these to be normal adjustment issues.  Rosalie first consulted Psychiatrist A, who suggested regular psychotherapy sessions to explore her relationship with her mother and her feelings about being a woman.  Although she felt comfortable talking with Psychiatrist A, Rosalie's symptoms did not abet and she sought a second consultation.  Psychiatrist B told Rosalie that although he had no objection to her seeking psychotherapy, she would not recover from postpartum depression without medication, which he prescribed.  Rosalie's symptoms decreased, but she continued to be lonely, and to experience marital distress, concerns about her ability to mother, and worries about her baby's health.

                The new mother who has symptoms of depression is often treated in ways that do not take into account the complex factors that are a part of her life.  The mother is either seen as a depressed women who also has a young baby, or as a woman with a chronic depressive illness whose current episode was precipitated by giving birth.  This diagnostic approach is reflected in the DSM-IV, which does not provide a diagnosis for postpartum depression, though it does allow the addition of a specifer for ãpostpartum onsetä if an episode of a mood disorder occurs within 4 weeks' postpartum (American Psychiatric Association, 1994).  Though each of Rosalie's psychiatrists defined the problem differently, and prescribed a different course of treatment based on this definition, neither course of treatment included attention to issues specific to her situation as a new mother.  Context was not explored in the evaluation process and was therefore absent from diagnosis and treatments.  Attention to contextual factors did not play a part in the recommendations or treatments provided by these care providers because they assumed that the primary cause of Rosalie's difficulties was either biological (Psychiatrist B) or psychodynamic (Psychiatrist A).  Each of the psychiatrists Rosalie consulted identified one etiological factor-within Rosalie-as primary and prescribed treatment to address that factor alone.

                Another common, limited approach to postpartum depression is to attribute the difficulty, even when severe, to the normal stress associated with the transition to parenthood.  This is illustrated by Martha's case.

                At 8 weeks' postpartum, Martha attended a new mothers' support group at a community-based family resource center.  When Martha shared some of her concerns about her ability to care for her baby, about marital problems, and about her increasing impatience with her colicky baby, the other mothers, as well as the group leader, validated her concerns and reassured her that such concerns were a normal aspect of the transition to motherhood.  These reassurances continued despite Martha's complaints of ongoing anxiety and growing detachment from her baby.

                In Martha's case, those who provided support also used a one-dimensional model to explain and respond to postpartum distress-a model that normalizes mothers' concerns, attributing even serious concerns to developmental and transitional processes.  This model ignores both internal and contextual factors specific to Martha's situation.

                The group members and leader with whom Martha had contact saw only her status as a new mother when considering what contributed to her difficulties.  In contract, the psychiatrists who saw Rosalie focused on one aspect of her life history, (either biological or psychodynamic) and her current depression, and barely acknowledged the importance of her ongoing experience as a new mother.  Our work as service providers indicates that effective assistance for a new mother who has symptoms of depression must include both attention to her status as a new mother and to her depression.

Attention to Context: An Ecological Framework

                Attending to the new mother both as a new mother and as a person who is depressed is not even sufficient.  In order to provide adequate care for women with postpartum depression, providers must also recognize that postpartum depression evolves within a complex life context.⁴  Bronfenbrenner's (1979, 1995) perspective on human development offers a broad-based, multidimensional framework in which to conceptualize postpartum depression.  He suggests that individuals must be seen within the context of the systems in which they are active participants-for example, within the family, community, workplace, society, and culture.  All of these systems interact with one another, while the individual plays an active role in shaping his or her experience.

                Each of the factors known to contribute to postpartum depression can be located within one of the levels identified by ecological theory.  For example, relationship disharmony takes place within the level of the family; lack of ritualized support and recognition reflects a failure on the cultural level.  Furthermore, every one of the levels identified by the theory contains one or more of the factors known to contribute to postpartum depression.  For example, there are factors within the mother, such as prior history of depression, as well as outside factors involving the family (e.g.. lack of support), the community (e.g., social isolation), and society (e.g., socioeconomic conditions).

                Ecological theory has been applied to both individual and family development (Moen, Elder, & Luscher, 1995).  We highlight the applicability of this theory to the understanding and prevention of postpartum depression: the interconnections among factors at various levels affect the mother's well-being.

                Ecological theory addresses the real-life context of the person studied.  The realities of life in any one community or society shift over time, however.  In the next section we describe some factors specific to contemporary American life. Which, as we conclude from research and clinical experience, are likely to increase new mothers' vulnerability to postpartum depression.

Contemporary American Families at Risk

                Comparing our own case studies with literature on childbirth and family development we found considerable agreement on several factors in contemporary American society that have a potentially adverse effect on maternal well-being and healthy family development (Belsky & Kelly, 1994; Cohen & Estner, 1983; David-Floyd, 1992; Elkind, 1994; Gaskin, 1990; Grossman et al., 1980; Harkness, 1987; Kruckman, 1992; LoCicero, 1995; Mutryn, 1993; Panuthos, 1984; Peterson, 1991).  These factors include the lack of universally accepted traditional or rituals around childbearing, the American ethic of individualism, contemporary economic conditions, the expectation or need faced by most families to have both parents work full time before and after bearing or adopting children, the mobility of families, the medicalization and technologizing of childbirth practices, and the advent of managed medical care.

                The lack of universally accepted traditions or rituals regarding childbearing results in multiple, often conflicting, cultural practices and expectations regarding the ways pregnant women and new parents should be treated and should treat themselves and their babies.  For example, parents receive conflicting advise regarding whether to pick up a baby who is crying during the night, whether the baby should sleep in the same room with the parents, and wither to breast-feed exclusively.  In the absence of expected and even ritualized practices, many American mothers and families find themselves uncertain as to what to expect, and are on their own to invent ways to meet challenges of parenthood.  Those women and families who do come from backgrounds which rich traditions and rituals regarding childbearing seldom find medical care providers who are willing to integrate these practices into standard prenatal care.

                The American ethic of individualism causes many women to be unwilling to admit to a need for support or to accept prescribed or ritualized kinds of support.  Anthropologists have suggested that in cultures where there is a more collective ethics that supports a prescribed structuring of the postpartum period, there is less postpartum depression (Harkness, 1987; Stern & Kruckman, 1983).

                When motherhood is viewed as only one of several important life roles for women, there tends to be a decrease in the extent to which young women are expected to have contact with babies and children.  This leaves many new mothers with little experience, few internalized role models, and little sense of self-efficacy in the mothering role.  The high proportion of women who are working also means that fewer experienced mothers are available in neighborhoods or communities to give informal support, advise, and guidance to new mothers.  In addition, a dual commitment to career and motherhood tends to increase the amount of stress experienced by some new mothers, who will try to ãso it allä well, only to learn that this is not possible for most women.

                The mobility of families has led to women giving birth in communities in which they have no relatives or old friends.  Thus, fewer women benefit from naturally occurring, longstanding, informal social-support networks.  In addition, family mobility eliminates some possible buffers for economically stressed new parents, such as the availability of grandparents as babysitters.

                The medicalization and technologizing of childbirth practices leads many women to feel disempowered during childbirth and increases the likelihood that many will need to grieve actively the loss of the anticipated birth experience.  One in four births takes place by cesarean section and the vast majority of vaginal births include invasive interventions, such as epidurals and episiotomies.  These procedures, particularly when unplanned, lead many women to feel both physical and psychological distress (Greene, 1995; Mutryn, 1993).

                The advent of managed medical care has led, in many cases, to restrictions on choice of care providers and place of birth and to restrictions on direct referral from one prenatal care resource to another.  Managed-care policies rarely have provisions for doulas for labor support, despite the fact that research has shown that the presence of doulas has many beneficial effects, such as decreased likelihood of cesarean sections and other interventions, and increased success in breast-feeding and postpartum adjustment (Klaus, Kennell, & Klaus, 1993).  Furthermore, most managed-care policies also restrict coverage of postpartum home-care services.

                Recently there has been tension between managed-care organizations and consumer advocates regarding the number of hours a women stays in the hospital following birth.  There has also been disagreement over who makes this decision in each individual care.  It seems to us that the discussion should also include how to best use the time spent in the hospital, rather than focusing exclusively on the number of hours spent.  During the hospital stay, families and providers should collaborate to determine the specific needs of the family, both in the immediate hours postpartum and after discharge.  Services available should include, at minimum, screening for risk of postpartum depression, lactation support, basic education in infant care and postpartum care for the mother, identification of community resources, and discharge planning and referral.

                Our society has, unfortunately, never instituted the practice of universal provision of professional home-care services for new families.  Such home care is routine in countries such as the Netherlands, Britain, Ireland, Costa Rica, and Belgium.  Hewlett (1991) regarded home-visiting services and other community-based supports as both humane and highly cost-effective, especially in relation to the public costs of treatment and remediation for babies and families whose postpartum needs have been neglected.

                New parents in the United States too often are left essentially on their own with their infants.  Our experience suggests that this contributes to the incidence and severity of postpartum depression and other serious disruptions in the functioning of new families, as shown in the following case example.

                Barbara's circumstances reflect some previously discussed contemporary issues.  A 35-year old corporate attorney, Barbara reluctantly discontinues unsuccessful treatment for infertility, due to growing evidence that the treatments might post health risks.  A year later, she was surprised and delighted to discover that she was pregnant.  The birth was by cesarean section; it was followed by a 24-hour separation of Barbara and her baby.  During the separation, Barbara's baby was bottle-fed, and this led to later difficulties in breast-feeding.

                Barbara had resigned from her job in order to be at home with her baby; however, Barbara became overwhelmed when her husband returned to work.  Barbara had few friends in the community, having recently moved across the country.  When Barbara's baby was 2 weeks' old, the pediatrician noted that her baby was not gaining weight at an adequate rate.  Barbara's mother came to help, and, although the baby did better, Barbara's sense of adequacy as a mother plummeted.  Soon she began to have difficulties sleeping and was anxious and uneasy caring for her baby.  She was troubled about the birth; she felt that she had been cheated of a normal birth experience.  She alternated between feelings that her body had failed and feeling that her doctor had performed a cesarean unnecessarily.

Integrated Care and Support Network: A Model for Prevention

                We have seen that the complexities of women's postpartum emotional experience, including depression, are such that no simple model of causality or treatment can be considered adequate.  As noted above, a variety of factors have been shown to contribute to postpartum depression: social isolation or lack of social support; recent life stresses; lack of culturally determined rituals, support, and recognition of the mother; disharmony in the primary relationship; adverse economic conditions; difficult birth experiences; vulnerability to depression; difficult infant temperament; and adverse reactions to biochemical and hormonal shifts.

                Despite an existing, rich body of knowledge about the evolution of postpartum depression, prevention efforts have not become widespread.  In the remainder of this article, we propose a model for prevention of postpartum depression, which we call an 'Integrated Care and Support Network.'

                The network that we are proposing includes a wide range of services ad resources available to meet the needs of childbearing families, such as sensitive prenatal and pediatric health care, prenatal and postpartum exercise classes, home-visiting services, parenting education and family support programs, and breast-feeding support.  Additional services for families with special childbearing needs include mother-baby psychiatric units, Depression after Delivery (a mutual support group), pregnancy loss groups, and post-cesarean support.  All of the elements of the network we are proposing already exist in many communities⁵; however, they currently exist as separate, free-standing entities, rather than as an integrated network.  The network would emphasize collaboration among the providers of those resources and services, many possible points of entry into the network, and freedom of movement within the network from any one service to any other, as needed⁶.  Figure 2 illustrates such a network.  We will describe the network and discuss changes among professionals and the community at large, which we believe necessary in order for such a network to be established.

Description of an Integrated Care and Support Network

                Each resource of the care network we are proposing addresses an area known to put women at increased risk for postpartum depression.  For example, postpartum mother-baby groups, the La Leche League, and self-help groups address isolation and lack of social support; childbirth education and sensitive perinatal care address the disempowerment, helplessness, and overmedicalization that lead to dissatisfaction with the birth experience; perinatal psychotherapy that affect childbearing.  Although this network can serve many purposes, we are focusing on the preventive benefits of such a network.

Use of the Network

                The many services available to childbearing families have not evolved naturally into a network.  Nor has the existence of various services led to a diminution in the incidence of postpartum depression.  Unless the network is a visible and ordinary part of everyday community life, it will be underused, particularly as a form of prevention.

                It is surprising that support for a common life events such as childbearing is not part of the fabric of normal everyday living.  Rather, each family has to create its own system of support.

                Figure 2 illustrates a network of prenatal care and its entry points.  The content and entry points alone do not define the network, however.  Below are some functional aspects of the network that allow it to serve as a means of prevention.

1.        The set of services available should be commonly known among members of the community, both professional and nonprofessional.  This would increase the likelihood that a childbearing family would reach appropriate services as needed, and before a crisis evolved.

2.        Prospective parents should be encouraged to explore the network prior to conception.  This, too, would increase the likelihood of crisis prevention by allowing early use of services.

3.        Childbearing families should be welcome to enter the network at any point in time and through any of a variety of referrals, including self-referral.  This would allow both preventive efforts and early intervention by reducing red tape.

4.        The network should be an open system: movement from one service to another should be easy with or without formal referral.  This would allow families to receive services that address more than one casual factor simultaneously.

5.        Providers should communicate readily with other providers about services offered.  This would facilitate cross-referrals.

6.        Network providers should include professionals and volunteers, in both forma and informal caregiving contexts.  This would expend the consumer base, including those who are more comfortable with professionals, as well as those more comfortable with volunteers.

7.        The network should include services and resources appropriate from preconception through early family development.

8.        A continuum of care should be available, ranging from universal access to childbirth preparation, parenting education, community resources, and social support, to more intensive mental health services and preventive interventions for women who need them

Transition to Integrated Care

                Although all of the elements of the network we are proposing already exist, we find it distressing to note how few providers of conventional prenatal care are aware of the existence of services other than their own.  It is our observation that even when some awareness exists, providers make referrals infrequently, and that when referrals are made, they are more likely to come following a crisis, rather than as a means of prevention.  Although integration of existing services may appear to be a straightforward task, it would, in fact, require radical changes in our society's approach to, and understanding of, family formation and development.  In the United States, pregnancy and childbirth are currently defined as momentous, medical/technological events (Davis-Floyd, 1992; Martin, 1987), with minimal attention to psychological, social, or cultural perspectives on pregnancy or birth, and almost no attention at all to the postpartum period and its challenges.

Recommendations for Change

                In order for care-and-support networks to be established and to serve a preventive function in the area of postpartum depression, the following changes in professional practice and philosophy must occur:

1.        Care providers must recognize that the factors contributing to postpartum depression are complex, interactive, and may be manifest at nay point in time, from preconception through early family development.  In order for this recognition to occur, there must be a change from seeing birth as a unitary, isolated medical event to seeing it as an important point along the continuum of personal and family development.  In addition, this continuum must be recognized as an organic, ever-changing system. Wherein a change in one part will reverberate through the entire system.

2.        Professionals and community members must be educated regarding the range of available choices in prevention and treatment of postpartum depression-including mainstream care, such as medication and psychotherapy, and alternatives such as acupuncture and self-help groups.

3.        Interdisciplinary communication, referral, and coordination of services should be improved.  Practitioners in fields such as mental health, childbirth and parenting education, pediatrics, family support, self-help, alternative health care, and informal support services must develop both formal linkages and informal collaborative relationships with providers of obstetrical care⁷.  These alliances can be strengthened through joint planning activities, collaborative partnerships among private practitioners, multidisciplinary conferences, and professional development organizations (Knitzer, 1993).⁸

4.        Screening for risk of postpartum depression (including adequacy of social support) should become a standard part of prenatal and postpartum health care, childbirth education classes, hospital discharge routines, home-visiting services, and pediatric practice (Placksin, 1994).  Dunnewold and Sanford (1994) and Kleiman and Raskin (1994) have constructed self-assessment tools for use by women who are in distress during the postpartum period.  Though now meant for prenatal or for professional use, they might provide starting points for construction and evaluation of multiple factors, a systematic approach to assessment is needed, Krauss and Jacobs (1990) describe such an approach to assessment of families.9

5.        Providers must acknowledge the rights of women and families to choose the interventions that are most consistent with their own values and preferences, and to have access to information that will assist them in making comfortable and wise choices.

6.        Finally, the transition to an effective system of preventive care must be accompanied by significant improvements in women's basic access to perinatal health care, including mental health services and follow-up care.

Partial Integration of Services: A Transitional Step

                Integrated perinatal care has not yet become commonplace.  However, we have case studies illustrating the benefits of partial integration of care.  Presently, such integration occurs only when individual providers or families are persistent in seeking to collaborate and integrate care.  One such care is Eve, whose primary care provider, a midwife, initiated and coordinated varied services.

                Even had several risk factors for postpartum depression.  The most dramatic was Eve's sister's sudden death when Eve was in the first trimester of his first pregnancy.  Concerned that the resulting anxiety and depression would place Eve at risk for postpartum depression, her midwife referred her for psychotherapy.  The midwife chose to refer Eve to a prenatal specialist who frequently collaborates with, and consults to, the midwifery practice.  The midwife also provided Eve with names and numbers of other postpartum support services such as the local La Leche League, support programs for new mothers, drop-in groups, and home-care services.

                Eve was seen for short-term therapy.  Sessions included grief work, as well as psycho education and support around mothering, breastfeeding, and infant development.  The therapist reinforced the midwife's suggestion that Eve attend La Leche League meetings and postpartum groups.  She also referred Even to a home-visiting program run by a colleague of the therapist, so that Eve could have a veteran mom visit her weekly to adjust to motherhood.

                Eve followed the recommendations of the midwife and the prenatal psychologist.  She made supportive connections with other mothers.  Her depression and anxiety lifted and her grief became manageable.  Even benefited greatly from integration of care.  The services she received were complementary in nature.  Despite risk factors including her sister's death, Eve did not develop postpartum depression.  We cannot know, of course, whether Eve's use of partially integrated care was the crucial factor in her avoidance of postpartum depression.  We do, however, believe that widespread availability of adequate, varied services and the encouragement to choose services consistent with personal value is likely to reduce the incidence and severity of postpartum depression.

                Eve was referred to various resources by her midwife.  In our integrated care-and-support model, however, the direction could easily have been reversed: friends, neighbors, or others in a prenatal support group might have referred Eve to a particular midwife or prenatal therapist.  In fact, Eve could have referred herself to any of the resources in the network, or moved from one resource to any other, based on her own perception of need.

Support for Fully Integrated Care

                It has long been recognized that women such as Eve could benefit from integration of care and support services.  An integrated care-and-support network such as the one we propose parallels service integration models in the fields of health, mental health, child welfare, and education.  Early in the community mental health movement in Massachusetts, in fact, a similar model was proposed by Bibring and Caplan (Bibring, Dwyer, Huntington, & Valenstein, 1961; Caplan, 1954/1974).

                Our recommendations are fully consistent with those of the Carnegie Task Force on Meeting the Needs of Young Children (1994) and other initiatives that emphasize collaboration and coordination of community resources for families (Bruner, 1994; Dunst, Trovette, & Deal, 1994; Harberger et al., 1992).  We agree with those family-policy advocates who believe that widespread social change in the way new mothers and families are supported by the community is necessary (Hewlett, 1991; Kagan & Weissbourd, 1994).  We see prevention of postpartum depression as one of the objectives of such a change.

Summary

                A review of research and clinical literature, combined with our experience as providers of psycho educational and clinical services, strongly supports the position that postpartum depression results from the interplay of a multitude of factors on various levels.  This is consistent with an ecological model of human development, with attention to the levels of the individual, the family, the community, and the society.  Given the knowledge currently available, it is surprising that the focus of care providers continues to be on diagnosis and treatment, rather than prevention of postpartum depression.  Furthermore, the care commonly provided for postpartum depression fails to take into account all of the individual and contextual factors known to contribute to its development.

                Both individual and contextual factors very for each women and her family.  Several factors in contemporary American society have frequently been cited as having an adverse affect on maternal well-being and early family development.  These factors include contemporary economic conditions, expectation or need for both parents to work fulltime, mobility of families, and the medicalization and technologizing and childbirth practices.  Such contextual factors must be taken into account in designing strategies for prevention.

                We propose a model for prevention that we call an ãIntegrated Care and Support Network.ä  The proposed network includes a wide range of formal and informal services and resources available to meet the needs of childbearing families.  Collaboration among all providers, easy access to the network, and ease of movement among the various resources in the network are crucial elements of its functioning.  Our integrated care- and support-network for childbearing families, with an emphasis on prevention of postpartum depression, parallels service integration models used in related fields that focus on comprehensive prevention, such as community mental health and family support.

                Despite the fact that a wide range of resources and services for the care and support of childbearing families already exist, and despite the fact that our integrated care-and-support network model is similar to comprehensive prevention models proposed by advocates of service integration in related fields, the transition to an integrated care-and-support network serving childbearing families would require major changes in care provision and in popular perceptions of the process of childbearing and family development.

                We propose some steps toward the establishment of an integrated care-and-support network, such as the development of local, multidisciplinary planning councils on meeting the needs of childbearing and adopting families; integrated referral systems; joint training and professional development programs; public education and empowerment; and the coordination of prenatal services and supports though both formal linkages and informal collaboration among professionals, agencies, and community groups.

         Alice K. Locicero and Dianne M. Weiss, Tufts University
Deborah Issokson, Private Practice in Belmont, MA

Footnotes

1. Estimates vary among studies, but the ranges suggested by Weissman and Olfson (10%-15%) and O'Hara and Engeldinger (10%-20%) are representative.

2. Earlier work on depression (not necessarily in the postpartum period) by Brown and Harris (1978) also suggests that factors interact to cause depression. 

3. In fact, we have noted that practitioners are often at pains to argue that the casual factor they favor is more primary than the casual factor favored by some other practitioner.

4. This point is made strongly by Kendall-Tackett and Kantor (1993.) particularly in describing the experience of the new mother they call "Jenny."

5. A recent directory of resources available to childbearing families in Massachusetts (Massachusetts Friends and Midwives . 1996) lists approximately 280 individuals and institutions offering many types of care. 

6. It has been reported that in some communities there are is movement toward integrated perinatal care (L. Butterfield. personal communication. Nvember 1996; Placksin, 1994). 

7. Kagan, Gofin, Gollub, and Pritchard (1995) have developed a comprehensive analysis of strategies that facilitate movement from fragmented services to integrated systems of care. 

8. Postpartum Support International (PSI), founded by Jane Honikman, is an example of a group that supports multidisciplinary conferences and professional collaboration, and publishes an extensive bibliography of research on postpartum mood and anxiety disorders (Kruckman, 1994). 

9. Krauss and Jacobs (1990) recommended a risk-management model that includes multiple strategies to assess the balance between stressors and supports, such as structured interviews, observations, and standardized instruments. 

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