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Katie: Welcome back to the "7 Domains of Women's ÑÇÖÞ×ÔοÊÓƵ." I'm Katie Ward. I'm a women's health nurse practitioner, and I'm co-host for the "7 Domains of Women's ÑÇÖÞ×ÔοÊÓƵ" podcast. Today, we're continuing our series on the fourth trimester, or the postpartum period, focusing today specifically on the social domain.

In our previous episodes on the emotional domain, we talked about the prevalence and the treatment options for postpartum depression. One significant barrier to treatment might be that if you live far away from healthcare providers or you're in a rural area. Today, we're exploring how geographic isolation, as well as other social factors, impact new mothers during those crucial first few months after birth.

I always think of rural communities as being made up of tight-knit families and friends and people who know and support each other. And while, if you're like me, you might assume that rural mothers maybe have more family support than women who live in bustling urban settings, the research shows that rural women actually experience postpartum depression at rates that are significantly higher than many urban areas. The isolation is real, and the barriers to care are substantial for women.

So Kirtly Parker Jones is out today, but with me is . Gwen is a nurse midwife and a PhD researcher who I've worked with for many years. Gwen is a tenured professor at the ÑÇÖÞ×ÔοÊÓƵ of Utah College of Nursing, and she's been a certified nurse midwife for over 35 years and a researcher for 20.

She's the Principal Investigator of a currently funded NIH project called the Prevention of Perinatal Depression Among At-Risk Individuals through the Integration of Multimedia Web-Based Intervention within the ÑÇÖÞ×ÔοÊÓƵcare System. This project evaluates the implementation of an online perinatal depression prevention program in a large academic healthcare system and in several rural public health districts.

Her team uses electronic health records systems to automate perinatal depression screening and direct patients to resources and facilitate healthcare provider decision-making. Wow, that's a mouthful.

And then she's a fellow at the American College of Nurse Midwives and the American Academy of Nursing.

So welcome, Gwen. Thank you so much for joining us today.

Dr. Latendresse: Oh, wonderful to be here.

Katie: That was a complex title for your research, but I want you to just maybe start by telling us how you got involved in this particular line of research.

Dr. Latendresse: Well, as a nurse midwife, I haven't been practicing clinically for a few years, but when I did, one thing I really noticed is the lack of resources for women who are experiencing depression and anxiety in pregnancy and postpartum, and found myself really searching for resources and trying to get women connected.

I also like to call it the screeching halt experience. In the clinic when you had someone that you really wanted to make sure that they got connected to mental health resources, everything in the clinic seemed to come to a screeching halt. When you were trying to find something, you'd get on the phone, or you would call your mental health professional person, and you didn't want the person to leave. And those were cases that had progressed far enough that they were in need of resources right away.

So I began to think about the kinds of things we could do earlier as an earlier intervention before we get to that screeching halt moment in the clinic. And also, that it would make it easier for everyone involved, clinic staff, the providers, and the patients, to quickly and easily get access to mental health resources, including prevention care for those who are at risk.

So, clinically, that was where I started out long ago, and since then became a researcher and began to investigate and ask these questions and put together projects to explore.

Katie: Did you identify a specific gap between the universal screening we're doing and actually access to care? You were doing video conferencing before the pandemic. You identified an important need there.

Dr. Latendresse: Yeah. So I've been developing and piloting and refining both the screening and the intervention since probably about 2011, and all along really actively seeking input from the individuals that are impacted, so those experiencing depression and anxiety during pregnancy and after the birth of the baby.

There were several gaps that we identified, including in the healthcare system, when it comes to addressing perinatal depression. But the three major gaps that we've been looking at mostly . . . The first one was really tackling implementation of a universal screening, looking at a more automated way to screen that ensured that everyone got screened. It used to be that we only screened if we thought someone had depression. But now we found out that everyone needs to be screened, because a lot of women will experience this and there are no outward signs, for example.

The universal screening really didn't address what the healthcare providers did with the screening results, nor did it ensure that access to the resources that might be available once someone is screened positive for perinatal depression.

So these last two gaps are the ones that we've especially been keen to tackle in the last few years. The video conference and online interventions that we developed increased access to support and mainly reduced some of the barriers that we learned from individuals that they were encountering, and that has to do with transportation.

You can imagine out in rural areas that people who needed healthcare services had to travel. Sometimes they're traveling hours, three, four, five hours to get into a location.

Or ÑÇÖÞ×ÔοÊÓƵcare. They needed somebody to take care of their ÑÇÖÞ×ÔοÊÓƵ, or they tried to take them with them, which is very difficult to have a mental health visit and have ÑÇÖÞ×ÔοÊÓƵren with you.

High costs. It's really expensive for a one-on-one visit with a mental health professional. Even if your insurance covers it, there's still a cost associated typically.

And then time constraints. So the time away from work, the time away you’re your home, from your obligations, whether it's on the ranch or the farm or whatever you're doing in rural areas.

The videoconferencing and online interventions really became a way to access, and this is not just for rural individuals. We also saw that a lot of our urban individuals found that they had an equally difficult time getting across the city, for example, or if they didn't have a car, or they had to borrow a car. If they had to get on the bus, they might have to take two or three different buses. From ÑÇÖÞ×ÔοÊÓƵcare, again, high costs, time constraints, it was all very similar between rural and urban.

Katie: Yeah, so you were just way ahead of the curve with that pre-COVID. I remember these groups going on and thinking how exciting and refreshing and kind of . . . it seems so very new. So you must have been ready. Now we're all experts.

Dr. Latendresse: We've got everything set up, right? We've got our video conference project. We've got online resources. So we won't be really impacted, and even more people will be willing to participate or want to participate because given COVID and they wanted to avoid exposure.

But what we found is a really big reduction in willingness to participate. And I'll tell you what we found. We started asking every woman we talked to or offered this resource to . . . We learned that, during a crisis, women actually drastically reduce their time that they take for them to take care of themselves, for example. Instead, they took care of everybody else.

So these women were stressed, they were anxious, they were having increasing symptoms of depression, but their priority was not to take care of themselves and participate in something that during this time period, early COVID, seemed to be a luxury.

They were busy taking care of their kids that were now at home, taking care of their partners, worrying about not being able to work or their partners losing their work, fear of COVID infection itself and pregnancy, worrying about their pregnancy or their newborns. They were trying to protect their newborns or their unborn baby.

And so participation in an online intervention to take care of themselves, what we found was people said, "I don't have the time." So we found that really interesting.

It was sad, but I think that probably it'd be interesting to look across different types of crises for pregnant and moms of newborns and what kinds of things they did to take care of themselves versus taking care of the crisis and the people in the same crisis with them. I think that they're probably taking care of everybody else and not themselves.

Katie: That's true. But that's so interesting that you have this kind of pre-during and now post-COVID. So are things improving now?

Dr. Latendresse: They are improving, but as you know, we all know the world is a different place now. And so people have accommodated things in different ways. But I don't think it's returned to what we saw pre-pandemic. I don't know. That'd be interesting to learn more about that. 

Katie: Tell me a little bit about your intervention. I'm a little bit familiar, but just for everybody that's listening. Are you connecting people with therapists? It's not individual therapy. This is something different.

Dr. Latendresse: Yeah, it is something different. We've really tried to take it from an angle of empowering women to be well. These are not therapy sessions or therapy groups. The design of the intervention is based on mindfulness-based cognitive behavioral therapy. And these are practices that anyone can learn. You don't need a mental health professional to learn these practices.

We did have mental health professionals for some of our groups, facilitating some of our groups. These are all group-oriented. They're on synchronous video conferences like Zoom. And it's a very structured, manualized program where the facilitator is introducing women to these practices.

These are practices that are evidence-based. They're known to prevent depression and anxiety and reduce symptoms of depression and anxiety for those who are experiencing those. And these are practices, like I said, anybody can learn.

And so through the course of . . . it used to be we had eight or nine sessions for one hour. So once a week for eight or nine weeks. We have reduced that to what we're currently offering: one hour every two weeks.

That was based on input we received from women who had been participating who'd said, "Once a week is a little too much for eight weeks. But you know what? If it was four sessions every other . . . one session for an hour every other week, I can deal with that. I could do that."

And we found that there was better participation if we offered fewer, but in conjunction with that, we also offered self-guided or self-directed online modules that women can go in any time and learn those same practices in an online format on their own and practice them.

That in conjunction with the video conferencing synchronous community has been . . . we think we've kind of arrived at the sweet spot of what people can commit to and what they will be willing to engage in and that they get the most out of.

Obviously, you're going to have enough exposure to learning these practices on a community of people who are supporting one another through it that you get some effectiveness from it.

So mostly that's what we've been offering, is the video conference sessions, and they're based on a set of practices that women learn. We've had them facilitated by a mental health professional. The last couple of years it's been peer facilitated. These are laypeople who have gone through the sessions themselves, so they've learned and used the practices themselves. They're mothers, and they can help facilitate the groups so that it's truly a peer-supported experience.

Not therapy but learning these practices and learning from one another what life is like and how they have been applying these practices in their own lives to their own benefit.

Katie: That is so cool. So are you comparing the peer-facilitated groups to the past use of health professionals? I mean, maybe you don't need to do that comparison, but I love that it's kind of organically grown into a peer . . .

Dr. Latendresse: We haven't done the comparison within our own groups, but that literature is published out there. There have been other studies that have looked at the effectiveness of a mental health professional versus peer facilitation. Same outcomes with improvements.

Katie: Because this is not therapy. This is learning, and then . . . But it seems like the magic ingredient here might be community.

Dr. Latendresse: Yeah, the interesting thing . . . So we had a study that was what we call a randomized controlled study. And what that is, is that you have one group that gets the intervention, which in our case is the video conference mindfulness-based cognitive behavioral therapy. They receive the intervention. And then we have another group that's called a control group.

In our case, we wanted what we call an attention control group, which means that every aspect of the experience for both groups, the control group and the intervention group, is the same as much as possible. And the only difference is the actual intervention.

For us, that intervention was the MBCT, the mindfulness-based cognitive behavioral therapy. And the other group, because we wanted them to have equal attention, went through a ÑÇÖÞ×ÔοÊÓƵbirth education or new parenting education series. So the same number of sessions, same length of time. The only difference was the content.

And interestingly, what we found is that both groups improved the same, meaning they had fewer symptoms of depression or, to a less degree, depression and anxiety in both groups. And that was surprising because we thought, "Oh . . ."

Katie: The mindfulness.

Dr. Latendresse: Yeah, the content would be the thing that would work. But we did a mixed-method study, which means that we did both quantitative measures and qualitative measures, and our qualitative measures included focus groups.

So we invited women who had participated in both groups, whether it was the intervention group or the attention control group, and we asked them about their experiences. It was a very what we call a semi-structured interview where we asked open-ended questions, and they would provide information.

When we analyzed all that data, what we found for both groups was that they developed a sense of community that was really valuable to them and of benefit to them. Our speculation, of course, was that sense of community was really having a beneficial effect.

And we looked at other studies that have been published, and indeed there is a beneficial effect of community, removing that sense of isolation, and having others that are situated similarly. So they're experiencing symptoms, they're pregnant or postpartum, they're a new mom, and they're having symptoms of depression and anxiety. Having a community of trusted individuals that they can share those experiences with and learn together was probably the most important thing. That was the secret sauce, so to speak.

Katie: I mean, it's super cool, and it's such a great use of the technology that we have to connect now, even if you can't find it. Did you find groups wanting to connect outside of the video conference? Were they able to do that?

Dr. Latendresse: Because of our study protocol, we could not facilitate or allow that to happen because we were trying to measure the intervention and not what they did outside.

But we had that more than once, in fact several times, where people said, "Hey, can we share our emails, our phone numbers?" It was like, "I'm so sorry, we can't do that. But you know what? We'll take that feedback, and for the next thing that we develop and offer is the ability to contact one another outside of these more structured groups." So how much did they do it? What did they do when they got together? Did they get together in person? Did they call each other on the phone or get on Zoom?

They just wanted the ability to continue the conversations they were having in the groups and to have somebody that, if they were having a tough moment, they could reach out to and say, "You know what? That practice that we learned, those skills we learned aren't working for this situation. I need somebody to talk to."

So, yeah, we did have people who asked for that because they had established a community of people, and they wanted to have that ongoing interaction.

Katie: This is your research, obviously, but is this something that healthcare systems are picking up? Is there a way that we can hardwire this into healthcare? What would it take to do that?

Dr. Latendresse: I have to tell you that the current project that we have is we've been trying to integrate a prevention program in both a large academic health setting and in these rural health districts we've been working with.

There are a lot of barriers to implementing anything and making change in a healthcare system, as you can imagine. Some of those barriers are . . . Let me say one of the biggest barriers is, "We've always done it this way and we're going to continue to do it this way."

What we're doing right now . . . We'll just take The U ÑÇÖÞ×ÔοÊÓƵ System, for example. It's a large academic health system. We worked with the Women and Children's Service Line. So this is across the entire U ÑÇÖÞ×ÔοÊÓƵ System that we have implemented online modules that are available through . . . They have an online education portal system that they actually put in place the first year that COVID happened because they wanted to make sure that women had access to education anywhere from breastfeeding to what happens in the first trimester, how to prepare for labor and delivery, and a variety of things.

But we helped them put together . . . it's called a mental wellness tile. It's just a place they can click on when they go to the portal, and they can learn all about maternal mental health. They can learn about symptoms of depression, symptoms of anxiety, things they can do to prevent, hotlines, warmlines, connected mental health professionals that are accessible through the university system, that sort of thing.

They get really well vetted, so no dis- or misinformation in this system. They get well-vetted, correct, accurate information about mental health, in addition to all the other things that platform offers.

And so every single individual who comes in pregnant for their first OB visit gets free access to this platform. And on that platform, again, they can learn more about mental wellness.

But when they first come in, they get screened for perinatal depression symptoms, and they get screened for risk for depression. And some of those risk factors, for example, are if you've ever had a history of depression or anxiety, then you're at higher risk of getting postpartum depression. If you've had some significant stressful situations in the past year, like divorce or death of a loved one, those kinds of things put you at higher risk. So they get screened for those things automatically. It's part of the electronic health record system.

So the examples that I wanted to get to have to do with electronic health records, and they have the capacity to do a lot of automated work. For example, as soon as a woman registers for her first OB visit in the system, she'll get these screening tools that they complete before they come in for their first visit. Then those are in the system and available for review by the healthcare provider when they come in for their visit.

Getting that implemented in an automated way in the EHR system takes several different approvals: the IT folks who are specialists in programming in the system, and then the owner who has proprietary interest to make sure that these things are put in place, and then the capacity of that system to be able to take those results and deliver it to the individual who took the screening, to send it to the providers, whether it's the midwife, the nurse practitioner, the physician, and then for that provider to do something with it.

That was one of the gaps that I mentioned. You can screen someone, but if the providers or the clinical staff aren't aware that the screening was done or they have to go search for it and find the results, that may sound ridiculous, but even something that takes half a minute or a minute disrupts the clinical flow.

It's a non-starter for a lot of clinics because of clinic flow and the number of patients who come in. It's very hard to disrupt that. Nobody likes to get disrupted in their work.

So we're trying to look at how to automate this, and that's been the key for us, is how much of this can we automate, where, for example, nobody has to remember to administer the screening tool, nobody has to remember to go look for the results, and nobody has to remember to think about what options there are. It's all presented to you within the electronic health record.

And that's what we've been working on for nearly the past three years right now. We've got it to a point where the screening happens, the screening results get communicated to the patient through MyChart automatically, it directs them to register for this online education platform, and automatically the screening tool creates a thing called a best practice advisory, BPA.

It's an alert system that pops up in the chart when the chart is open that says, "This patient has screened positive for perinatal depression." The provider or the clinic staff can click on that, and there are some quick choices rapidly. It takes them just literally just a few seconds to click what they would like to have to happen with that patient. 

So automatically the patients are getting the information about what to do to get resources, and the provider is getting directed to, "You can click this and refer them to counseling, to medication management, to social work." We've been for a long time wanting to have the one big red button. 

Katie: The big red button. The easy button.

Dr. Latendresse: The big red button, "Refer," so that the clinic flow doesn't have to come to a screeching halt. You can hit the button, and it'll automatically go to the mental health professionals, who will then take the reins and do all the coordination of, "Where does this person need to go to? Do they need to see collaborative care? Consider medication? Do they need to be connected with a counselor who can do talk therapy? Did I write them a prescription so I can put that they're already on medications?" and that sort of thing.

So we're trying to automate this as much as possible all the way from patient being informed and can be empowered to engage in things and giving them the resources, including the free resources, all the way through to the provider that automatically they've got a decision-making tool that they can engage. The overall idea, of course, is to identify and triage and direct these patients to the most appropriate resource.

Katie: Hats off to you. That is just amazing work. And as a provider, I can tell you that it meets a need for me too. If that automation that you were talking about comes up like that and it's a flag on the chart that says, "Your patient screened in a way that this is a thing you need to pay attention to," and it's just right there, man, that's just brilliant. I'm really impressed.

Dr. Latendresse: Well, thank you. And of course, it doesn't work the same in rural settings. Many of the rural settings and rural clinics don't have access to the same resources. For example, they don't have this huge team of IT people who are programming Epic to do what they want them to do.

We have primarily worked with the public health system in our state to help with this, because there's a lot more engagement with the public health system in rural communities and they look to the public health clinics for a variety of things, from WIC certification to immunizations, to well-baby checks, and a variety of things. And these public health clinics are much more engaged in community events. There's a lot more interaction there.

We set up an electronic health screening for them, which was a big hit. And then recently, this last year, the state Department of ÑÇÖÞ×ÔοÊÓƵ took over that screening, which we thought to be a really nice win to sustain that and continue it going forward.

So they have the same access to the video conference groups, community groups. And interestingly enough, many of the rural individuals find that they would prefer to join groups that nobody from their community is part of that group because . . .

Katie: People know each other.

Dr. Latendresse: We all know each other, and there's still a lot more stigma in rural areas regarding mental health than there is in urban areas. So they would prefer not to see a mental health professional in their community because, hey, it might be their husband's sister who's the counselor, and they don't want to see that person. They'd rather have more anonymity and confidentiality in the kinds of things they engage in.

So joining these groups with people from other areas, including other rural locations, but they don't know each other, and including some of our urban folks in the same groups has worked really well for them. 

Katie: There's a thing I want to take a moment to address that's been on my mind about the social domain, and that's mommy blogging. I just see this so much where we live in this age where social media presents this kind of highly curated version of motherhood, and especially around kind of rural and traditional lifestyle content.

It's all sort of beautifully staged, and you've got beautiful mothers in flowing dresses with photographs taken right at the golden hour, and perfectly groomed ÑÇÖÞ×ÔοÊÓƵren in homemade outfits, and fresh bread and cows being milked by rosy-cheeked family members.

It promotes these messages about "natural," and I'm doing quotes as I say that, and traditional values and self-sufficiency. And it really sort of troubles me because it's this idealized version of rural motherhood and it's so disconnected from the reality that your research is telling us about.

These are real mothers struggling with real isolation and limited access to healthcare and not being able to prioritize their own needs, much less sew prairie dresses and take pictures at the golden hour.

I mean, they create these impossible standards, and I think that almost worsens depression and anxiety when people are already vulnerable. And then you're on social media and seeing the other farmers.

Dr. Latendresse: Yeah, that goes for both rural and urban, too. I mean, I guess that's the issue I take with social media, is that what people portray of themselves in their lives is commonly not reality. It's over-sensationalized.

You see people get on social media, and they're crying and wailing, and then they get off, and they're fine. Or conversely, which is probably the thing that more likely happens, is life is romanticized, and they want to portray this wholesome, got-it-all-together, things are great.

If you're someone who's having difficulty and you're looking for even a community of people or to see, "How do I compare to others?" It's that comparison theory, right? When you start comparing yourself to others, and especially on social media, it's like, "I don't look like she . . . I mean, she looks like she's got it all together. She's happy, she's healthy, she's wholesome." Like you said, the golden hour. "And that's not how I feel."

So it isolates people. Individuals can start feeling like they're the only one that feels the way they do, so there must be something wrong with them. So that does perpetuate worsening symptoms and worsening of isolation.

That's one of the things in our groups that people have said. It's like, "I found out that I'm not the only one experiencing this. There are other people that are experiencing the same thing. We don't all have it together. We are all struggling." But together, they become comfortable talking about their experiences and not worrying that someone's going to judge them or report them or whatever it is. They're in it together, and they feel better together, and they don't get the misinformation.

So that's my other issue with social media, is that everybody's an expert, right? They know exactly what you need and how to take care of it and fix it. And if you only do this or only do that . . .

Katie: And just for the small price of . . . Yeah, Gwen, your research really gives me hope about a way to use technology that actually connects people in real life, whether that community is existing on the video platform or people actually are able to move offline and meet in person. But that is the best use of some of this technology. So I love that you're doing this.

I mean, at the end of the day, we are social creatures, and that authentic support and the evidence-based care is what new mothers need, not these crazy impossible standards and idealized images and just being sold things.

But I do want to say if you're struggling during the fourth trimester or anywhere throughout your pregnancy, or even if you're not pregnant or in the postpartum period, please reach out to your healthcare providers, the support in your community, your friends, your family. Seek virtual options if local resources aren't available or aren't comfortable.

Just remember that asking for help is a sign of strength, not weakness. There's a national crisis hotline that's 988. There are also probably other local resources through your local health department, as Gwen mentioned.

So Gwen, I want to say thank you for coming on, and I really appreciate it.

Dr. Latendresse: My pleasure. And I just wanted to say, too, there are both national and statewide resources that are specific . . . I know you mentioned 988, but there are some very specific to ÑÇÖÞ×ÔοÊÓƵbearing individuals. One in particular is Postpartum Support International. And they also have several languages that are spoken. It's a free resource. And then there is a local Utah chapter for .

Katie: Thank you so much for those resources. That's really helpful, Gwen. I appreciate it.

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