In 2015, the Council on Patient Safety in Women’s Health Care convened an interdisciplinary workgroup to develop an evidence-based patient safety bundle addressing maternal mental health. The 13-member workgroup was co-chaired by NPWH Director of Policy Susan Kendig, JD, MSN, WHNP-BC, FAANP, and American Congress of Obstetricians and Gynecologists representative John P. Keats, MD. The workgroup collaborated over several months, reaching consensus and approval of the Maternal Mental Health: Perinatal Depression and Anxiety Patient Safety Bundle in 2016.

The bundle has four key components: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning (Box). Rather than introducing new guidance, the bundle summarizes existing recommendations and matches them with specific resources to facilitate the implementation of best practices in all maternity care settings. The bundle is designed to be applicable in any setting where prenatal and/or postpartum care is provided. It can be adapted for implementation in preconception/interconception care as well.

Why is a maternal mental health bundle important?

First, healthcare providers (HCPs) need to know what is meant by the term bundle as it applies to healthcare. A bundle is a small set of evidence-based interventions that combines medical and improvement science to achieve improved outcomes. When care processes are grouped into simple bundles, HCPs are more likely to implement them by making fundamental changes in how the work is done. When the care processes are evidence based, subsequent outcomes will improve. Bundled interventions encourage interdisciplinary teams to organize work, adapt the delivery system, and deliver all of the bundle components. An emphasis is placed on improving process reliability. The endpoint is improvement of clinical outcomes.¹ 

Second, HCPs need to recognize the scope of maternal mental health safety issues. Perinatal mood and anxiety disorders are among the most common complications of pregnancy. Perinatal depression affects one in seven women.^2,3 Anxiety disorders affect 13%-21% of women during pregnancy and 11%-17% postpartum.⁴ When unrecognized or untreated, these conditions can have a devastating effect on women, their infants, and their families. The spectrum of adverse effects includes poor adherence to healthcare recommendations, smoking, substance abuse, loss of financial and interpersonal resources, and a potential adverse effect on maternal–infant bonding/attachment. Depressive psychosis, an extreme form of perinatal depression, can lead to maternal suicide and/or infanticide. In fact, maternal suicide within a year of delivery is emerging as a major cause of maternal mortality and is probably underreported. Because perinatal mood and anxiety disorders are associated with increased risks for maternal and infant morbidity and mortality, they represent a vital patient safety issue.⁵

Where can HCPs find information about the bundle?

A commentary, Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety, published in the March 2017 issue of the journal Obstetrics and Gynecology, provides information to assist with bundle implementation. This commentary includes a discussion concerning each item within the four key bundle components. In addition, it provides a table listing useful patient/provider educational resources and the websites where these resources can be obtained. Because NPWH provided leadership both in the development of the bundle and in the writing of the commentary (Susan Kendig is the lead author), we at Women’s Healthcare are able to provide you with a link to the full article in Obstetrics and Gynecology.

What is the Council on Patient Safety in Women’s Health Care?

The Council on Patient Safety in Women’s Health Care is a broad consortium of organizations across the spectrum of women’s health established for the promotion of safe healthcare for every woman. The council has a mission to “continually improve patient safety in women’s healthcare through multidisciplinary collaboration that drives culture change” and a vision of “safe healthcare for every woman.” The council membership comprises 19 organizations, including NPWH, as well as patient advocates. NPWH participates in a number of workgroups convened by the council.

One of the major accomplishments of the council has been the development and dissemination of evidence-based patient safety bundles to support ongoing improvement of clinical care and patient outcomes. The council website provides access to live and archived webinars on a variety of topics relevant to promoting a culture of safety in women’s healthcare. The website also provides information on all of the patient safety bundles along with safety resources and tools.

Recommendations

I strongly encourage you to read the commentary, Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety, and to share the information with colleagues who provide prenatal, postpartum, and pre/interconception care. If you provide this care in your own clinical setting, consider using the bundle to facilitate a standardized process to ensure that maternal mental health is always addressed. The bundle is not intended to dictate practice. It is, as described previously, a set of evidence-based interventions that combines medical and improvement science to achieve improved outcomes. The interventions can be adapted in consideration of local resources, but standardization within an institution is important for consistent and safe care.

If you have implemented the bundle in your healthcare setting, please consider writing a short commentary for our journal on the process and outcomes thus far. You can submit your commentaries to me at bkelsey@healthcommedia.com. By sharing our experiences, we can strengthen the resolve to make sure that maternal mental health is always regarded as a safety issue and that it is addressed in an evidence-based manner.

Beth Kelsey is Assistant Professor and DNP Program Director at the School of Nursing, Ball State University, in Muncie, Indiana. She is editor-in-chief of Women’s Healthcare: A Clinical Journal for NPs and NPWH Director of Publications. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Reser R, Pronovost P, Haraden C, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31(5):243-248.
2. Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ). 2005;(119):1-8.
3. Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70(5):490-498.
4. Fairbrother N, Young AH, Janssen P, et al. Depression and anxiety during the perinatal period. BMC Psychiatry. 2015;15:206.
5. Kendig S, Keats JP, Hoffman MC, et al. Consensus bundle on maternal mental health: perinatal depression and anxiety. Obstet Gynecol. 2017;129(3):422-430.