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Building A Relationship, Creating Proximity, and Treating Postpartum Depression: The Rocking Chair Project

Posted Mar 16 2013 10:00pm

Posted on | March 14, 2013 |

This week, an important paper appeared in JAMA that drew the attention of my wife, Trish Magee, an early childhood educator, and me. The article focused on the study of postpartum depression with a special eye toward economically disadvantaged women.(1)

We were interested for a number of reasons. First, between 1992 and 1997, Trish ran the first “Ready To Learn” program, designed by Ernest Boyer of the Carnegie Foundation, in Philadelphia, PA.(2) This was a comprehensive and multi-faceted early intervention, parenting education program that targeted at-risk economically disadvantaged pregnant women during the pre-natal period, and provided enriched programs and support throughout pregnancy and continuing until the child reached age five.

The second reason for our interest related to a 501C3 non-profit program that we founded together in 2004, and have run for the past decade, called the Rocking Chair Project .(3) Through cooperation with 2nd year Family Medicine residents throughout the nation, the program identifies at-risk mothers about to give birth, and coordinates a physician home visit within 3 weeks of the birth. During that visit, the physician assembles a glider rocking chair and ottoman, a gift of nurturing for mother, child and family that engenders confidence, trust and committment. As important, the Family Medicine residents, utilizing an enriched curriculum  (with input from Ed Zigler, professor emeritus at the Yale Center in Childhood Development and Claire Lerner, “Zero To Three”, Washington, DC) – quietly screen mothers for depression in their own home environments and provide practical advice that reinforces nurturing and health of both mother and child.(4,5,6)

The third reason for our interest is that I will be presenting a keynote address tomorrow at the 80th Annual Kenney Research Day at Brown University’s Albert School of Medicine on Home-Centered Health Care. Our daughter-in-law, Susanna Magee MD, is the Director of Maternal and Child Health for the Department of Family Medicine at Brown. She has been Medical Director for the Rocking Chair Project from the start, and her research interests include the impact of home visitation on maternal health with a focus on postpartum depression.(7)

The confidence and trust engendered in postpartum home visits reinforces an ongoing relationship between doctor and patients according to post visit surveys of the participating physicians. Over the past decade, thousands of visits have occurred; thousands of chairs delivered; and thousands of at-risk mothers and children positively impacted.(3,4,5)

The results of the JAMA study therefore did not come as a surprise to us. For example, the fact that 1/3 of all births in the United States are to mothers covered by Medicaid. Or the fact that for 40% of these individuals, the initial depressive episode occurs postpartum, but for 33% difficulties arise during pregnancy, and for 27% depressive episodes appeared prior to pregnancy. Nor were we caught off guard by the fact that 1 in 7 in the study group of 10,000 women experienced postpartum depression.(1)

The good news is that economically disadvantaged women in the study were more likely to permit a home visit than their well-off counterparts. The visits lasted 2 hours, and the participants were given a $40 gift card in return for participation. Specifically, “African American, publicly insured, younger, and less highly educated women” were more willing to open their doors.(1)

The study reinforced what has been known for some time, that postpartum depression “increases the risk for multiple adverse outcomes among women and their offspring. Maternal depression interferes with child development and increases the rates of insecure attachment and poor cognitive performance. Suicide accounts for about 20% of postpartum deaths and is the second most common cause of mortality in postpartum women.”(1)

The study noted that during the immediate post-pregnancy period,  “Massive withdrawal of gonadal steroid levels contributes to mood instability in these neurobiologically and genetically vulnerable women. Sleep deprivation and interference with circadian rhythms during late pregnancy, labor, and breast-feeding promote mood destabilization.”(1)

What was surprising to them and us was that, “22.6% of the screen-positive women had bipolar disorder.”(1)This emphasized the point that it is not just about making the diagnosis, but also developing a plan of treatment, and a relationship of confidence and trust that assures an optimal outcome for mother and child.”

Our experience tells us that for mother and child at-risk from postpartum depression, home visitation aided by empathetic caregivers with tangible rewards (whether it be a beautiful glider rocking chair or a gift card) is the best way to link diagnosis and ongoing successful treatment. Others studies underway are reporting similar results.(7)

As the authors said this week, “Although centralized depression screening by telephone as in this study is feasible in the early postpartum period, the challenge is to design a therapeutic program to support and retain women through diagnostic evaluation and treatment to maternal recovery and optimal function.”(1)

We agree. Yale’s Ed Zigler said: ”The Rocking Chair intervention is a relatively inexpensive way for parents to develop the growth inducing relationship with a very young child. There can be no relationship without real proximity in which the interactions are characterized by warmth and concern. That’s the Rocking Chair Project.”(4)

Home visits are clearly the way to go. But these visits must be well thought out, orchestrated, and allow for the exchange of empathy as well as knowledge. That is exactly what Family Medicine residents have been doing as part of our program over the past ten years. For those interested in learning more about the Rocking Chair Project, go to www.rockingchairproject.org .

For Health Commentary, I’m Mike Magee.

References:

1. Wisner KL et al. Onset Timing, Thoughts od Self-Harm, and Diagnoses in Postpartum Women With Screen Positive Depression Findings. JAMA Psychiatry. 2013. http://archpsyc.jamanetwork.com/article.aspx?articleid=1666651

2. Boyer E. Ready To Learn: A Seven Step Strategy. 1992. http://1.usa.gov/Yu70AU

3. Rocking Chair Project. www.rockingchairproject.org.

4. Zigler E. The Rocking Chair Project: A Relationship Requires Proximity. Yale Center in Child Development. November 12, 2007. NY, NY. http://rockingchairproject.org/Zigler_Remarks.pdf

5. Lerner C. A Scripted Guide to Making The Most of the Rocking Chair Project Home Visit. 2011. http://rockingchairproject.org/A_Scripted_Guide_for_the_Home_Visit.pdf

6. Gagliardi A. The Rocking Chair Project: Theoretical Assumptions and Evidence To Date. Yale Center in Child Development. 2008.   http://rockingchairproject.org/Yale_Research_Paper.pdf

7. Sutter MB, Lakin A, Magee S. Resident Hime Visits In The First Month of Life: Impact on Family Outcomes and Resident Education. 80th Annual Kenney Research Day Program. Memorial Hospital of Rhode Island, Albert Medical School of Brown University. March 15, 2013.

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