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					Postpartum Depression/Attachment
Strategic Plan • 2006




Contents
I. Executive Summary............................................................................. 1-2
II. Introduction....................................................................................... 2-5
.   1..Background.of.Early.Childhood.Mental.Health-Special.Needs.
.   . .Collaborative.and.Postpartum.Depression/Attachment.Workgroup
.   2..Vision
.   3..Goals
.   4..Participants

III. Strategic Planning Process...................................................................5
.   1..Needs.Assessment
.   2..Data.Collection

IV. Data Findings: Parent Focus Groups
    and Provider and Parent Surveys.................................................... 6-14
.   1..Focus.Groups..
.   2..Survey.Results
.   3..Parent.Surveys
.   4..Provider.Surveys

V. Analysis.................................................................................................15
.   1..Information.and.Resources
.   2..Support.and.Emotional.Adjustment
.   3..Treatment.and.Referrals

VI. Recommendations and Strategies......................................................16
VII. Next Steps..........................................................................................16
VIII. Acknowledgements..........................................................................17
IX. Appendix....................................................................................... 18-23




                                                                                        Table of Contents
    I. Executive Summary                                   The.purpose.and.vision.of.the.Postpartum.
                                                           Depression/Attachment.Work.group.is.to.
    Postpartum.Depression.affects.approximately.           support.and.facilitate.the.coordination.and.
    10%.of.women.during.and.after.pregnancy.               collaboration.of.providers.addressing.this.
    with.the.rate.being.up.to.50%.in.women.living.         shared.issue.of.concern.and.that.every.woman.
    in.poverty...With.over.6,000.babies.projected.to.      will.be.aware.of.and.have.access.to.services.in.
    be.born.in.Santa.Barbara.County.in.2006,.              the.area.of.Postpartum.Depression...
    over.600.women.will.be.affected.by.                    In.November.2005.Santa.Barbara.County.
    Postpartum.Depression.in.this.year.alone..             Alcohol,.Drug.and.Mental.Health.Services.
    While.Santa.Barbara.is.often.seen.as.an.affluent.      received.a.grant.from.First.5.of.Santa.Barbara.
    county,.34%.of.the.residents.living.below.             County.to.complete.a.facilitated.strategic.
    200%.of.the.poverty.level...Awareness.about.the.       planning.process,.guided.by.stakeholder.input,.
    incidence.of.this.disorder.has.been.increasing,.       resulting.in.this.report.
    resulting.in.concerns.about.effects.on.women.
    who.are.not.receiving.treatment.and.the.effects.on.    The goals are to:
    their.babies.who.may.not.receive.appropriate.care..       • Give overall direction for
                                                                broadening awareness of PPD/
                                                                Attachment within the community
                                                              • Identify gaps in services and
                                                                unmet community needs
                                                              • Provide education to the
                                                                community and health care
                                                                providers
                                                              • Include goals, objectives, strategies
                                                                and activities to facilitate
                                                                continuity of services for the
    Not.only.can.this.disorder.have.long.term.                  identification, prevention, and
    consequences.for.the.women.who.suffer.from.                 treatment of Postpartum
    it,.but.Postpartum.Depression.can.interfere.                Depression countywide
    with.the.mother’s.ability.to.attach.to.her.infant...
    Infancy.is.a.critical.and.vulnerable.period.in.a.      To.achieve.these.goals,.the.Postpartum.
    child’s.development.and.the.most.important.            Depression/Attachment.Work.Group.conducted.
    factor.in.an.infant’s.healthy.development.is.a.        a.needs.assessment.utilizing.countywide.parent.
    secure.attachment.relationship-a.safe,.consistent,.    and.provider.surveys,.and.targeted.community.
    and.stable.relationship.with.a.primary.caregiver...    focus.groups.                                         Not only can
    From.early.childhood.through.school-age,.
    children.who.have.had.attachment.problems.in.
                                                           With.490.surveys.completed.and.focus.                 this disorder
                                                           groups.held.throughout.the.county,.the.needs.
    infancy.are.more.likely.to.have.trouble.managing.
    their.emotions,.displaying.more.aggressive.
                                                           assessment.resulted.in.some.interesting.findings...   have long term
                                                           Parents.and.providers.were.in.agreement.that.
    behavior.and.are.at.greater.risk.of.developing.
    serious.psychopathology..
                                                           there.is.not.enough.information.and.education.
                                                           about.Postpartum.Depression.and.attachment.
                                                                                                                 consequences
    Conversely,.healthy.infant-parent.relationships.       available.to.new.parents...There.were.also.
                                                           concerns.about.the.amount.of.resources.available.
                                                                                                                 for the women
    have.been.linked.to.a.number.of.positive.
                                                           to.treat.Postpartum.Depression...Providers.were.
    outcomes.for.children.and.serve.as.a.
    buffer.in.the.face.of.later.problems..Secure.          concerned.about.parents’.denial.of.symptoms.
                                                                                                                 who suffer from it,
                                                           and.difficulty.getting.women.to.follow.through.
    attachment.serves.as.a.protective.factor.against.
    psychopathology.or.trauma,.and.is.associated.          on.referrals...There.was.a.difference.between.        but Postpartum
    with.a.range.of.healthy.personality.variables.         the.providers.understanding.of.the.information.
    such.as.lower.anxiety,.lower.depression,.less.         they.gave.to.parents.and.what.the.parents.felt.       Depression can
    hostility,.better.resilience,.and.better.affect.       they.received...While.the.providers.reported.
    regulation..Children.that.had.secure.attachment.       talking.with.patients.and.disseminating.              interfere with the
    relationships.in.infancy.have.higher.self.esteem,.     information.about.Postpartum.Depression,.
    positively.engage.and.respond.to.other.children,.      parents.reported.significantly.less.information.      mother’s ability
    and.are.more.empathetic..In.short,.a.secure.           being.received...This.may.be.attributed.to.
    attachment.provides.for.lifelong.relational.ability.   parents’.inability.to.assimilate.information.at.      to attach to
                                                           stressful.times.or.providers.that.responded.to.the.
                                                                                                                 her infant.
1 Postpartum Depression/Attachment Strategic Plan 2006
survey.may.be.more.likely.to.discuss.Postpartum.       Vision
Depression...Resources.currently.available.such.as.
Postpartum.Education.for.Parents.(PEP).and.211.        The.purpose.of.the.Postpartum.Depression/
Information.and.Referral.line.were.not.widely.         Attachment.Work.group.is.to.support.and.
used.and.could.certainly.be.better.utilized.within.    facilitate.the.coordination.and.collaboration.of.
the.county..                                           providers.addressing.this.shared.issue.of.concern...
                                                       The.vision.is,.every.woman.will.be.aware.of.and.
The.needs.assessment.resulted.in.the.workgroup.        have.access.to.services.in.the.area.of.Postpartum.
developing.recommendations.and.strategies.             Depression..
to.address.the.issues.identified...These.revolve.
around.working.with.community.resources.to.            Goals
increase.awareness.and.build.a.comprehensive.
network.of.community.perinatal.services.and.           The.goal.is.that.the.Postpartum.Depression/
providers.to.strengthen.mental.health.in.the.          Attachment.work.group,.in.cooperation.with.the.
pregnant.and.postpartum.family...                      local.community,.will.develop.and.disseminate.
 .                                                     a.comprehensive,.community.wide.Postpartum.
The.Postpartum.Depression.Work.Group.                  Depression.Education.and.Treatment.Strategic.
will.continue.to.function.in.the.capacity.of.a.        Plan.which.will:
steering.committee.which.will.work.toward.the.
implementation.of.the.strategies.developed.and.           • Give overall direction for
indicated.in.the.strategic.plan.
                                                            broadening awareness of PPD/
                                                            Attachment within the community
                                                          • Identify gaps in services and
II. Introduction                                            unmet community needs
The.Postpartum.Depression/Attachment.
                                                          • Provide education to the
                                                            community and health care
Workgroup.was.formed.under.the.Early.                       providers
Childhood.Mental.Health-Special.Needs.
(ECMH-SN).Collaborative.and.has.met.                      • Include goals, objectives, strategies
regularly.for.nearly.two.years.to.address.                  and activities to facilitate
community.need.and.impact.surrounding.
                                                            continuity of services for the
                                                            identification, prevention, and
Postpartum.Depression...The.Department.of.                  treatment of Postpartum
Alcohol,.Drug.and.Mental.Health.Services.                   Depression countywide
(ADMHS).has.provided.oversight.to.the.
ECMH-SN.Collaborative.for.over.three.years...          To.accomplish.this.goal,.ADMHS.applied.for.
In.this.role.ADMHS.has.charge.of.providing.            and.received.a.grant.from.First.5.Santa.Barbara.
leadership.in.the.development.of.a.coordinated.        County.in.November.2005.to.complete.a.
service.system.for.early.childhood.mental.health.      facilitated.strategic.planning.process,.guided.
and.other.special.needs...                             by.stakeholder.input,.resulting.in.a.formal.
                                                       document...
According.to.the.National.Institute.of.Mental.
Health,.roughly.10.percent.of.pregnancies.
result.in.postpartum.depression...Postpartum.
Psychosis.is.estimated.to.appear.in.one.in.every.
1,000.deliveries....The.awareness.of.postpartum.
depression.has.increased.over.the.years.and.
research.has.shown.that.it.largely.contributes.to.
a.mother/caregiver’s.ability.to.emotionally.attach.
to.her.infant...This.attachment.process.begins.
at.birth,.helping.the.child.develop.intellectually,.
organize.perceptions,.think.logically,.develop.
a.conscience,.become.self-reliant,.develop.
coping.mechanism.(for.stress,.frustration,.fear,.
and.worry),.and.form.healthy.and.intimate.
relationships.(Allen,.et.al.,.1983)...The.effect.of.
a.mother/caregiver’s.inability.to.promote.secure.
attachment.not.only.affects.children,.but.as.they.
grow.to.adulthood.


                          Santa Barbara County Alcohol, Drug and Mental Health Services 2
    The.PPD/Attachment.work.group.is.comprised.            2..Develop.a.community-wide.Postpartum..
    of.a.variety.of.local.agencies.with.an.interest.and.   . Depression/Attachment.Strategic.Plan.
    commitment.to.helping.young.mothers.and.
    their.families.                                        3 .Distribute.and.present.the.Strategic.Plan..
                                                           . to.the.target.communities,.key.decision..
                                                           . makers,.and.funders.to.promote.action.and..
    Postpartum Depression/                                 . implementation.of.the.Plan.
    Attachment Work Group
    Participants                                           Postpartum
      • Alcohol, Drug and Mental Health
        Services (ADMHS)                                   Depression Definition
      • Child Abuse Listening and Mediation                Postpartum.Depression.can.manifest.in.various.
        (CALM)                                             ways,.from.mild.to.severe..The.range.of.mood.
      • Community Providers                                disorders.can.vary.from.general.depression.and.
      • Department of Social Services                      anxiety.during.pregnancy.to.postpartum.psychosis...
      • First 5 Santa Barbara County                       About.10%.of.all.women.experience.some.
      • Postpartum Education for Parents                   depression.during.pregnancy...In.addition.to.the.
        (PEP)                                              frequency.rates.listed.below,.it.should.be.noted.
      • Public Health Department                           that.research.has.shown.a.Postpartum.Depression.
    	 	 Maternal,	Child,	and	Adolescent	Health             incidence.rate.as.high.as.50%.in.women.in.
    	 	 California	Children’s	Service                      poverty...Below.is.a.brief.description.of.each.
      • Sojourn Services                                   disorder.and.some.of.the.common.symptoms:
      • Transitions Mental                                 Baby Blues (not considered a disorder)
        Health Association
      • University of California at                        This.occurs.in.many.mothers.in.the.days.
        Santa Barbara (UCSB)                               immediately.following.childbirth..Characterized.
      • Cottage Hospital                                   by.sudden.mood.swings,.sadness,.crying,.
                                                           irritability,.and.a.sense.of.vulnerability...An.
    Thank.you.to.all.of.you.who.participated.and..         estimated.60-80%.of.all.new.mothers.experience.
    assisted.in.completing.this.project.                   this.emotional.let-down..Symptoms.may.last.
                                                           only.a.few.hours.or.as.long.as.a.week.or.two.after.
    Objectives of the                                      delivery.and.usually.resolve.by.themselves.
    Postpartum                                             Postpartum Depression
    Depression/Attachment
                                                                                                                  About 10% of all
                                                           and Anxiety (PPD)..
    Strategic Plan                                         Approximately.10-20%.of.pregnancies.result.in.         women experience
                                                           PPD.which.can.occur.a.few.days.or.even.a.year.
    1 Conduct.Needs.Assessment.activities.in.the..
    . community.in.order.to:                               after.delivery...This.condition.is.characterized.by.   some depression
                                                           more.intense.feelings.of.sadness,.despair,.anxiety,.
    .   a)..Identify.local.knowledge,.attitudes,..         sleep.problems,.loss.of.interest.in.pleasure.and.      during pregnancy.
    .                                                 .
        . ..beliefs,.behaviors,.and.perceptions.around.    irritability...The.mother.may.have.a.lack.of.
    .   . .Postpartum.Depression.and.attachment            interest.in.her.baby,.and/or.thoughts.of.harming.      However, research
    .   .b).Gain.a.more.in-depth.and.accurate..            herself.or.the.baby...It.often.disrupts.a.women’s.
    .   . ..assessment.of.the.prevalence,.nature,..        ability.to.function,.the.key.sign.that.medical.        has shown a
    .   . ..and.cultural.dynamics.of.Postpartum.           attention.is.necessary...Left.untreated,.symptoms.
    .
    .
        . ..Depression.in.Santa.Barbara.County.
        . ..communities..
                                                           may.worsen.and.become.chronic.                         Postpartum
    .   c)..Identify.unmet.needs.and.strategies.to..       Postpartum Obsessive-                                  Depression
    .   . ..address.them.                                  Compulsive Disorder (OCD)
    .   .   .....•..Countywide.parent.surveys              Characterized.by.intrusive,.repetitive.and.            incidence rate
    .   .   .....•..Countywide.provider.surveys            persistent.thoughts.or.mental.pictures,.often.
    .   .   .....•..Targeted.community.focus.groups        about.hurting.the.baby.resulting.in.a.sense.of.        as high as 50%
    .   .   .....•..Collection.and.review.of.relevant.     horror.about.these.thoughts...Occurs.in.3-5%..
    .   .   . ..research.and.community.resources           of.new.mothers.                                        in women
                                                                                                                  living in poverty.
3 Postpartum Depression/Attachment Strategic Plan 2006
Postpartum Panic Disorder                              Infant Attachment
Episodes.of.extreme.anxiety,.excessive.worry.          Postpartum.Depression.can.significantly.interfere.
or.fears.often.called.a.“panic.attack”...May.          with.a.mother’s.ability.to.attach.or.bond.with.her.
feel.shortness.of.breath,.chest.pains,.dizziness,.     infant....Infancy.is.a.critical.and.vulnerable.period.
agitation.or.irritability..Occurs.in.up.to.10%..       in.a.child’s.development.and.the.most.important.
of.postpartum.women,                                   factor.in.an.infant’s.healthy.development.is.a.
                                                       secure.attachment.relationship-a.safe,.consistent,.
Postpartum Post Traumatic                              and.stable.relationship.with.a.primary.caregiver...
                                                       The.interaction.and.comfort.in.this.relationship.
Stress Disorder (PTSD).                                facilitates.the.child’s.neurological,.intellectual.
Usually.resulting.from.a.traumatic.birth.              and.emotional.growth,.and.can.also.serve.
experience..Symptoms.include.repetitive.               as.a.buffer.against.risk.factors.in.an.infant’s.
flashbacks,.intrusive.thoughts.and.images,.            environment...Certain.risk.factors.have.been.
nightmares,.hyper.vigilance,.depressive..              shown.to.negatively.impact.the.infant-parent.
symptoms.and.anxiety...Occurs.in.up.to.10%..           attachment.relationship,.and.consequently,.the.
of.postpartum.women.                                   child’s.development..Problems.in.the.parent’s.past.
                                                       or.current.life.circumstances.can.make.it.difficult.
                                                       for.them.to.respond.sensitively.or.consistently.to.
Postpartum Psychosis (PPP)                             their.babies..
This.serious.mental.illness.affects.approximately.
.01%.of.new.mothers..Onset.is.severe.and.quick,.       Risk Factors
often.within.three.days.after.delivery..They.
                                                          • A history of abuse in the
may.completely.lose.touch.with.reality,.often.              parent’s childhood
experiencing.hallucinations.and.delusions.(infant.
death,.denial.of.birth,.“need”.to.kill.baby)..Other.      • Domestic violence in the parent’s
symptoms.may.include.anxiety,.mood.instability,.            relationship, or substance abuse
agitation,.and.bizarre.feelings.and.behavior...           • Social isolation, and high levels
Postpartum.psychosis.should.be.treated.as.a.                of overall stress have also been
medical.emergency.                                          linked to problems in the infant-
                                                            parent relationship
Risk factors:                                             • Parental mental illness
   • A personal history of                                • Living in poverty
     non-postpartum mood disorder
                                                       Parents.struggling.with.these.problems.typically.
   • A family history of                               have.an.impaired.ability.to.be.involved.in.the.
     mood disorders                                    child’s.physical.care.and.play,.have.trouble.
   • Significant premenstrual                          appropriately.meeting.the.infant’s.normal.needs.
     mood symptoms before they                         for.attention,.lack.affection.towards.the.child,..
     were pregnant                                     or.have.difficulty.responding.calmly.and.
   • History of a Postpartum
     Depression episode with an
     earlier childbirth
   • Women experiencing several of
     the mild to severe symptoms
   • Women experiencing stressful
     situations, e.g., health problems
     in baby, marital discord/domestic
     violence or not having a partner
   • Difficult or traumatic
     birth experience
   • Social isolation
   • Unmarried adolescent mothers
   • Living in poverty



                           Santa Barbara County Alcohol, Drug and Mental Health Services 4
    consistently.to.the.infant’s.distress..All.of.these.
    factors.disrupt.the.infant’s.ability.to.attach.to.
                                                            III. Strategic
    their.parents,.and.the.consequences.for.the.            Planning Process
    child.are.profound.and.long-lasting..From.              An.experienced.facilitator.was.contracted.
    early.childhood.through.school-age,.children.           to.coordinate.the.strategic.planning.process.
    who.have.had.attachment.problems.in.infancy.            with.the.Postpartum.Depression/Attachment.
    are.more.likely.to.have.trouble.managing.their.         work.group,.involving.community.members,.
    emotions.and.to.have.aggressive.behavioral.             stakeholders.and.parents/family.members
    problems..They.have.pervasive.problems.in.peer.
    relationships;.they.are.more.likely.to.be.isolated.     The.group.met.initially.to.outline.needs.
    socially,.to.be.controlling.in.peer.interactions,.or.   assessment.activities,.identify.resources.and.
    to.be.perceived.as.“mean”.by.peers.or.teachers..        additional.collaborating.partners.and.to.delegate.
    They.are.more.likely.to.experience.depression,.         tasks...Regular.ongoing.meetings.focused.on.
    anxiety,.or.hostility..They.are.less.persistent.when.   developing.a.parent.survey,.focus.group.format,.
    solving.problems,.less.confident,.and.generally.        and.provider.survey...All.information.was.
    more.dependent.on.adults..Adolescents.who.              provided.in.English.and.Spanish...An.electronic.
    have.experienced.attachment.difficulties.are.           web.based.version.as.well.as.a.paper.survey.
    more.likely.to.commit.violent.crimes,.experience.       were.developed.to.facilitate.ease.of.use...Focus.
    mood.disorders,.be.victimized.and.become.               groups.utilizing.the.surveys.and.focus.group.
    pregnant..From.childhood.to.adulthood,.                 format.were.planned.and.facilitated.countywide.
    they.are.at.greater.risk.of.developing.serious.         in.targeted.communities...Surveys.were.also.
    psychopathology..                                       distributed.by.various.agencies.throughout.
                                                            the.county...Provider.surveys.were.mailed.and.
    Conversely,.healthy.infant.parent.relationship.
                                                            distributed.to.physicians,.nurse.practitioners,.
    has.been.linked.to.a.number.of.positive.
                                                            nurses,.doulas,.mental.health.providers,.
    outcomes.for.children.and.serves.as.a.buffer.in.the.
                                                            midwives.and.other.service.providers.
    face.of.later.problems..Secure.attachment.serves.
    as.a.protective.factor.against.psychopathology.or.      Focus Groups
    trauma,.and.is.associated.with.a.range.of.healthy.
                                                            . • CALM Great Beginnings
    personality.variables.such.as.lower.anxiety,.
                                                            	 	 Santa	Barbara	
    lower.depression,.less.hostility,.better.resilience,.
    and.affect.regulation..Children.that.had.secure.          • CALM-Staff with infants
    attachment.relationships.in.infancy.have.higher.        	 	 Santa	Barbara	
    self.esteem,.positively.engage.and.respond.               • Family First (ARC)
    to.other.children,.and.are.more.empathetic..            	 	 Vandenberg/Lompoc	
    Securely.attached.children.are.more.self.reliant,.        • Good Samaritan TC House
    more.enthusiastic.and.self.efficacious..They.are.       	 	 Santa	Maria	                                     It was highlighted
    more.likely.to.be.accepted.by.their.classmates.
    and.are.better.at.forming.close.relationships,.and.
                                                              • Healthy Start
                                                                Guadalupe
                                                                                                                 by several mothers
    are.judged.to.be.more.resilient.
                                                              • Healthy Start
                                                                Los	Alamos	
                                                                                                                 that medical
                                                              • Healthy Start
                                                                New	Cuyama	
                                                                                                                 providers did
                                                              • PACE Teen Parenting Program                      not believe their
                                                                Santa	Barbara	
                                                              • People Self Help Housing                         concerns about
                                                                Carpinteria	
                                                              • Postpartum Education for Parents (PEP)           depression and
                                                            	 	 Santa	Barbara	
        A secure attachment                                   • Tribal TANFF                                     anxiety and were
                                                            	 	 Solvang
        provides for lifelong                                                                                    dismissed without
        relational ability.                                                                                      help or referrals to
                                                                                                                 essential services.
5 Postpartum Depression/Attachment Strategic Plan 2006
IV. Data Findings:                                   CALM Staff with infants
                                                     Santa	Barbara	
Parent Focus Groups                                  This.group.comprised.both.clinical.and.clerical.
and Provider and                                     staff.from.CALM,.all.of.who.had.a.child.
                                                     born.in.the.last.year...This.was.a.lively.and.
Parent Surveys                                       talkative.group...Some.of.the.members.of.the.
                                                     group.shared.some.very.person.experiences.
In.order.to.gain.a.more.in-depth.and.accurate.       that.they.had.never.spoken.about..Many.had.
assessment.of.the.prevalence,.scope.and.treatment.   negative.experiences.with.doctors.and.nurses.
needs.of.Postpartum.Depression/Attachment.in.        mainly.around.not.having.enough.time.or.
Santa.Barbara.County’s.communities,.the.Work.        receiving.enough.or.important.information,.
Group.conducted.needs.assessment.activities.in.      feeling.rushed,.and.judgmental.attitudes...One.
the.community...The.purpose.of.gathering.the.        commented.“It.would.be.nice.if.they.acted.like.
data.was.to.identify.local.knowledge,.attitudes,.    they.cared”...The.group.felt.they.were.helped.by.
beliefs,.behaviors,.perceptions.and.environmental.   midwives,.Postpartum.Education.for.Parents,.
factors.which.contribute.to.Postpartum.              Welcome.Every.Baby.visits,.Mamatoto,.Goleta.
Depression.and.attachment.problems;.and.             Valley.Cottage.Hospital,.La.Leche.League,.
to.gain.an.understanding.of.what.treatment.          Therapists,.colleagues.at.CALM...They.felt.it.was.
and.support.would.be.feasible.and.effective.at.      important.to.give.more.information.and.include.
reducing.the.incident.of.Postpartum.Depression.      dad’s.more..In.addition,.they.wanted.more.
and.resulting.infant.attachment.issues...The.        information.in.general.about.the.birth.process,.
following.is.a.summary.of.the.data.collected.from.   depression,.insurance.and.pediatricians.
surveys.and.focus.groups.
                                                     Family First (ARC)
Description of Focus Groups                          Vandenberg/Lompoc		
held Countywide                                      This.group.was.comprised.of.both.English.
                                                     and.Spanish.speaking.mothers.whose.children.
CALM Great Beginnings Program                        have.been.diagnosed.as.special.needs..While.
Santa	Barbara	                                       they.received.more.postpartum.information.
This.was.a.group.of.mono-lingual.Spanish.            than.some.of.the.other.parents.(because.of.
speaking.women...Even.though.they.had.never.         their.children’s.diagnoses),.in.many.cases.they.
met.each.other.before,.they.spoke.openly.            expressed.having.higher.levels.anxiety.and.
about.very.personal.information.and.seemed.          depression..They.highlighted.experiences.where.
very.grateful.for.the.opportunity.to.share.their.    information.about.the.acute.situation.of.their.
postpartum.experiences...They.were.very.eager.to.    child.was.provided.(i.e.,.in.the.NICU,.CMS,.
continue.meeting.and.are.now.participating.in.a.     etc.).but.information.for.them.as.parents.on.
weekly.support.group.at.CALM..They.identified.       Postpartum.Depression.and.Attachment.was.
lack.of.information,.resources,.and.support.as.      either.not.provided,.or.not.provided.in.ways.
problems..They.also.felt.it.would.be.helpful.to.     they.could.absorb.as.new.parents.of.a.child.with.
provide.more.information.to.dads...Regarding.        special.needs..Also,.it.was.highlighted.by.several.
medical.providers,.they.felt.rushed,.ignored,.and.   mothers.that.medical.providers.did.not.believe.
had.difficulty.communicating..There.were.also.       their.concerns.about.depression.and.anxiety.
some.feelings.of.disrespect.due.to.being.Latino..    and.were.dismissed.without.help.or.referrals.to.
The.group.felt.WIC,.CALM,.home.visitors.and.         essential.services..On.a.positive.note,.they.did.
family.were.helpful.                                 confirm.that.they.received.support.from.family,.
                                                     birth.classes,.Welcome.Every.Baby,.NICU,.
                                                     nurses,.and.WIC..They.felt.it.would.be.helpful.
                                                     to.receive.more.support.through.groups,.as.well.
                                                     as.information.on.developmental.delays,.services.
                                                     available,.and.life.skills.training.




                        Santa Barbara County Alcohol, Drug and Mental Health Services 6
    Good Samaritan TC House                               Healthy Start
    Santa	Maria	                                          Los	Alamos	
    This.was.a.group.of.women.in.treatment.for.           This.was.a.lively.group.of.primarily..
    alcohol.and.or.drug.abuse...They.felt.they.           mono-lingual.Spanish.speaking.women,.two.
    received.little.information.about.Postpartum.         fathers,.a.few.bilingual.moms.and.two.English.
    Depression...Two.women.expressed.they.had.            speaking.moms..The.English.speaking.moms.
    been.depressed.but.did.not.know.they.could.get.       appeared.to.be.undeterred.by.the.language.
    any.help...They.felt.isolated.and.alone...They.       difficulty.as.the.group.was.primarily.conducted.
    felt.the.Welcome.Every.Baby.program.was.              in.Spanish..The.group.felt.they.were.given.little.
    very.helpful.and.at.least.half.said.that.doctors.     information.about.Postpartum.Depression.
    were.not.at.all.helpful...They.would.have.liked.      or.attachment,.they.were.given.a.bunch.of.
    more.information.before.the.baby.was.born,.           information.but.felt.too.overwhelmed.to.look.
    what.to.expect,.and.more.information.about.           at.it..They.felt.supported.by.Welcome.Every.
    breastfeeding.                                        Baby,.family.and.other.mothers...They.felt.that.
                                                          the.doctors.did.not.listen.to.them.and.were.not.
                                                          available..The.fathers.felt.they.were.not.involved.
                                                          and.wanted.more.information.in.order.to.help.
                                                          their.wives.and.be.more.supportive.

                                                          Healthy Start
                                                          New	Cuyama	
                                                          This.was.a.group.of.monolingual.Spanish.
                                                          speaking.mothers.who.were.very.lively.and.
                                                          expressive..The.staff.at.this.site.had.similar.
                                                          feelings.as.the.Guadalupe.site.in.terms.of.
                                                          thinking.Postpartum.Depression.was.not.an.
                                                          issue...She.was.amazed.at.the.response.from.the.
                                                          women.and.wants.to.provide.more.services.for.
                                                          them..The.women.all.seemed.surprised.that.
                                                          others.had.similar.feelings.and.they.all.laughed.
                                                          and.cried.together..They.received.little.to.no.
    Healthy Start                                         information.about.Postpartum.Depression.or.
    Guadalupe	                                            attachment.and.had.many.fears.about.sharing.
    This.was.a.group.of.mono-lingual.Spanish.             their.feelings,.including.that.people.would.
    speaking.mothers..Prior.to.the.group.starting,.       talk.about.her,.her.kids.would.be.taken.away,.
    the.staff.shared.that.she.did.not.think.they.had.     and.that.she.would.be.rejected...They.felt.it.
    any.issues.with.Postpartum.Depression.and.that.       would.be.helpful.to.have.an.orientation.or.
    the.Hispanic.culture.sees.things.differently...She.   class.that.would.give.information.and.support.
    was.surprised.by.the.response.of.the.mothers...       around.what.to.expect.after.having.a.baby,.
    The.group.took.much.longer.than.they.expected.        such.as.Postpartum.Depression.symptoms,.
    and.the.women.wanted.to.continue.meeting...           breastfeeding,.caring.for.baby,.etc...They.felt.
    Half.of.this.group.reported.not.receiving.any.        they.did.not.get.questions.answered.by.medical.
    information.about.changing.moods.after.having.        staff.and.felt.they.needed.more.time.and.
    a.baby..They.felt.that.Welcome.Every.Baby.was.        information.at.doctor.appointments.
    helpful.but.strongly.stated.they.would.have.
    liked.more.information.about.Postpartum.
    Depression.and.what.to.expect.after.having.a.           The fathers felt they were
    baby...They.felt.it.was.easier.to.say.everything.
    was.okay.rather.than.trying.to.keep.the.nurse.          not involved and wanted
    around.for.longer.than.they.“should”...They.felt.
    it.was.very.important.for.moms.to.know.that.            more information in order
    they.are.not.alone...They.thought.there.should.
    be.mandatory.support.groups.throughout.the.
                                                            to help their wives and be
    pregnancy,.but.especially.two.months.after.             more supportive.
    giving.birth.and.that.this.support.should.come.
    for.every.child,.not.just.the.first.one.


7 Postpartum Depression/Attachment Strategic Plan 2006
PACE Teen Parenting Program                                               Postpartum Education for Parents (PEP)
Santa	Barbara	                                                            Santa	Barbara	
This.was.a.group.of.teenage.mother’s.at.Santa.Barbara.High.School...      This.is.an.ongoing.support.group.that.meets.weekly.and.is.facilitated.
They.were.a.little.difficult.to.engage,.possibly.because.they.may.        by.a.trained.parent.volunteer..There.was.a.cross.section.of.new.parents.
have.felt.pressured.to.attend,.didn’t.feel.comfortable.sharing.or.        with.infants.under.three.months.old..They.were.eager.to.talk.and.
trust.the.group.leaders..In.addition,.developmentally,.it.may.have.       knowledgeable.about.Postpartum.Depression.and.attachment..There.
been.difficult.for.them.to.understand.the.questions.and.express.          was.a.lot.of.discussion.about.system.improvement.and.they.recognized.
themselves.appropriately..This.is.a.very.vulnerable.population;.a.lot.    the.importance.of.support.from.medical.providers.
of.the.girls.have.been.involved.in.the.criminal.justice.system,.and/or.
been.victims.of.abuse.and.domestic.violence..The.Adolescent.Family.       Tribal TANFF
Life.Program.program.through.Public.Health,.which.was.the.main.           Solvang	
case.management.support.that.these.girls.receive,.has.ended.as.of.
                                                                          This.was.a.group.of.Native.American.women.who.receive.case.
June,.2006..At.this.writing,.the.State.has.not.released.a.Request.for.
                                                                          management.services.through.Tribal.TANFF...They.were.somewhat.
Application.for.funding.continuing.services.
                                                                          guarded.and.there.were.several.interruptions.due.to.people.arriving.
                                                                          late..They.received.very.little.information.about.Postpartum.
People Self Help Housing                                                  Depression.and.in.fact.were.not.aware.of.what.it.was...After.some.
Carpinteria.                                                              education,.several.shared.feelings.they.had.and.not.knowing.how.
This.group.was.monolingual.Spanish.speaking.women.who.live.in.            to.deal.with.them..They.felt.it.would.be.helpful.to.have.a.lot.more.
a.low.income.housing.complex..They.came.to.a.community.room.              education.around.Postpartum.Depression,.attachment.and.what.to.
to.attend.the.focus.group..They.received.little.to.no.information.        expect.after.having.a.baby..They.did.not.like.the.idea.of.“parenting”.
about.Postpartum.Depression.or.attachment...They.shared.feelings.         classes,.rather.felt.the.focus.should.be.on.wellness,.family.issues,.how.to.
of.depression,.loneliness.and.not.having.enough.support,.especially.      deal.with.stress,.etc...Regarding.the.medical.providers,.they.did.not.feel.
for.those.who.had.newly.immigrated...They.would.have.liked.to.have.       listened.to,.didn’t.feel.comfortable.asking.questions,.and.would.have.
more.information.prior.to.giving.birth.and.did.not.feel.comfortable.      liked.more.options.provided.
asking.questions.of.healthcare.providers.




                                                                     Santa Barbara County Alcohol, Drug and Mental Health Services 8
                                                    Survey Results
                                    Postpartum Depression/Infant Attachment
                                             Parent Survey Results
                                       There were 380 responses to the web-based survey.
                           112 (29%) of the responses were in Spanish (separate report on page 10-11).

                                                        Ethnicity of Parents
               ...African.American                           3%         Hispanic/Latino-Latina                   53%
               ...Asian/Pacific.Islander                     3%         Multiracial                              .3%
               ...Caucasian/White                            28%        Native.American                          1%
                                  *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding.




                 Gender of Parents                                        Age of Parents
               ...Female         96%       ...Unknown      2%             Age.Range              15.–.53.years
               ...Male           2%                                       Mean.Age               29.years
                                  *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding




                                       Region of County the Parents Live in or Near
             ......Carpinteria                2%           ......Santa.Barbara                                   42%
             ......Goleta                     7%           ......Santa.Maria                                     25%
             ......Guadalupe                  5%           ......Santa.Ynez,.Buellton,.Solvang                    5%
             ......Lompoc                     8%           ......Summerland,.Montecito                           .3%
             ......Orcutt                    .5%
                                  *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding



9 Postpartum Depression/Attachment Strategic Plan 2006
                                       Questions for Mothers
                    In the month before you knew you were pregnant, did you:
                                                     Yes                                 No
      ........Smoke?                                  8%                                 87%
      ........Drink.alcohol?                         22%                                 75%
      ........Use.drugs?                              5%                                 90%
                          *Details.of.tobacco.and.alcohol.use.appear.at.end.of.report.
                      *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding



Yes   Somewhat          No
84%       8%            3%           Did.you.have.support.from.your.family/significant.others..
                                     after.your.baby.was.born?
18%       10%          67%           Were.there.any.complications.with.the.labor.and/or.delivery?
18%       5%           73%           Were.there.problems.with.your.baby.after.birth?
83%       4%           11%           Do.you.have.access.to.transportation.to.get.what.you.need..
                                     for.your.baby.and.family?
7%        2%           88%           Have.you.ever.called.the.PEP.warm-line?
72%       1%           22%           Have.you.ever.had.a.visit.from.a.nurse.since.your.baby.was.born?
52%       7%           39%           Did.anyone.ever.talk.with.you.about.bonding.with.your.baby?
50%       7%           42%           Did.anyone.ever.talk.with.you.about.your.emotional.adjustment..
                                     to.the.pregnancy?
59%       9%           30%           Did.anyone.ever.talk.with.you.about.postpartum..
                                     depression.or.anxiety?
92%       1%            6%           Do.you.have.access.to.a.telephone.to.make.phone.calls..
                                     whenever.you.need.to?
5%        3%           92%           Are.you.taking.any.medication.for.depression?
30%       3%           65%           Do.you.know.about.“211”.–.the.phone.number.you.can..
                                     call.if.you.would.like.a.referral.for.services.or.resources?
15%       13%          69%           Do.you.have.any.difficult.feelings.about.being.a.parent.that..
                                     surprise.you.and.that.you.may.not.understand?

                      *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding




                                                Santa Barbara County Alcohol, Drug and Mental Health Services 10
                                Postpartum Depression/Infant Attachment
                                 Parent Survey - Spanish Survey Results
                                           112 of the responses were in Spanish


                                                   Ethnicity of Parents

               Caucasian/White                            2%         Unknown                               27%
               Hispanic/Latino-Latina                    72%

                               *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding.




              Gender of Parents                                        Age of Parents
              Female          97%       Unknown         1%             Age.Range           15.–.53.years
              Male             1%                                      Mean.Age            28.years
                               *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding




                                    Region of County the Parents Live in or Near
             ...Carpinteria                4%          ...Santa.Barbara                                    43%
             ...Goleta                     4%          ...Santa.Maria                                      15%
             ...Guadalupe                 13%          ...Santa.Ynez,.Buellton,.Solvang                     5%
             ...Lompoc                     6%          ...Summerland,.Montecito                             0%
                               *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding




11 Postpartum Depression/Attachment Strategic Plan 2006
                                       Questions for Mothers
                    In the month before you knew you were pregnant, did you:

                                                     Yes                                 No
      ........Smoke?                                 2%                                  96%
      ........Drink.alcohol?                         3%                                  96%
      ........Use.drugs?                             1%                                  96%
                          *Details.of.tobacco.and.alcohol.use.appear.at.end.of.report.
                      *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding



Yes   Somewhat          No
82%       13%           4%           Did.you.have.support.from.your.family/significant.others..
                                     after.your.baby.was.born?
20%       9%           71%           Were.there.any.complications.with.the.labor.and/or.delivery?
26%       4%           71%           Were.there.problems.with.your.baby.after.birth?
71%       6%           22%           Do.you.have.access.to.transportation.to.get.what.you.need..
                                     for.your.baby.and.family?
1%        1%           96%           Have.you.ever.called.the.PEP.warm-line?
69%       0%           30%           Have.you.ever.had.a.visit.from.a.nurse.since.your.baby.was.born?
24%       3%           73%           Did.anyone.ever.talk.with.you.about.bonding.with.your.baby?
30%       5%           63%           Did.anyone.ever.talk.with.you.about.your.emotional.adjustment..
                                     to.the.pregnancy?
34%       9%           57%           Did.anyone.ever.talk.with.you.about.postpartum..
                                     depression.or.anxiety?
80%       0%           17%           Do.you.have.access.to.a.telephone.to.make.phone.calls..
                                     whenever.you.need.to?
5%        2%           93%           Are.you.taking.any.medication.for.depression?
20%       1%           78%           Do.you.know.about.“211”.–.the.phone.number.you.can..
                                     call.if.you.would.like.a.referral.for.services.or.resources?
21%       13%          67%           Do.you.have.any.difficult.feelings.about.being.a.parent.that..
                                     surprise.you.and.that.you.may.not.understand?

                      *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding




                                                Santa Barbara County Alcohol, Drug and Mental Health Services 12
                   Postpartum Depression/Anxiety & Infant Attachment Task Force
                                        Provider Survey
                                           There were 110 responses to the survey.


                                                           Type of Provider

                 .....Pediatrician                         8%        ......Nurse.Practitioner               6%
                 .....Family.Practitioner                  1%        ......Mental.Health.Provider          40%
                 .....Gynecologist/Obstetrician            4%        ......Psychiatrist                     1%
                 .....Nurse                               11%        ......Midwife                          2%
                 .....Doula                                6%        ......Other                           21%

                                                          Gender of Provider
                                 .........Female          78%        ............Male         19%

                                *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding



                           Region of Santa Barbara County in which services are provided

                 .........North.County.(Guadalupe,.Santa.Maria,.New.Cuyama)..                             24%
                 .........Central.County.(Lompoc,.Buellton,.Santa.Ynez.Valley)..                          16%
                 .........South.County.(Carpinteria,.Santa.Barbara,.Goleta).                              72%
                             *Providers.may.be.offering.services.in.more.than.one.region.of.the.County.



      Estimate of the percentage of the providers clients/patients that have experienced PPD in the last year.

                         ..........0-10%            36%         ........30-40%                       3%
                         ........10-20%             26%         ........More.than.40%                4%
                         ........20-30%             14%         ........Don’t.know                  13%
                                *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding


                 Have you had any special training or continuing education on PPD/Attachment?

                                           ........Yes      52%      ........No         39%
                                *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding



                           What additional training would you like on PPD/Attachment?

               ....1-day.conference                66%       ....CEUs,.MCEs.or.classes                      36%
               ....Book.references                 26%       ....Professional.journal.resources             21%
               ....On-line.courses                 25%       ....Other                                       5%
                                                   *Providers.may.check.all.that.apply


13 Postpartum Depression/Attachment Strategic Plan 2006
                What are your current sources for information on PPD/Attachment?

        Local.agencies.(e.g.,.CALM,.PEP,.WEB,.CPSP)                         70%        Internet           45%
        Professional.Journals                                               32%        None                4%
        CEUs,.MCEs.or.classes                                               19%        Other              13%
                                       *Providers.may.check.all.that.apply

.   .       .      .       .       ...............................     .       ..........Yes   Somewhat No
        Do you or someone you work with talk with parents about                      71%          12%     16%
        PPD/Attachment during or after pregnancy?
        Do you provide pamphlets or brochures on                                     40%          34%     24%
        PPD/Attachment to your clients/patients?

        Do you know about the PEP warm-line?                                         53%          43%     N/A

        Have you referred clients/patient to the PEP warm-line?                      44%          9%      N/A
        Do you know about “211,” the county-wide phone number                        76%          21%     N/A
        for resources and service referrals?
        Have you referred clients/patients to “211”                                  48%          26%     N/A
        for resources and referrals?

                       *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding

        Do you discuss the use of drugs during and after pregnancy                    78%         15%     N/A
        with your clients/patients?
        Do you discuss the use of alcohol during and after                            78%         14%     N/A
        pregnancy with your clients/patients?
        Do you discuss smoking during and after pregnancy                             70%         20%     N/A
        with your clients/patients?
                       *Percent.may.not.add.to.100%.due.to.missing.data.and/or.rounding

                   What services do you believe to be most helpful to your patients
                 in helping them avoid or cope with symptoms of PPD and anxiety?

          Web.home.visits                 38%                    Support.Groups                     64%
          Medication                      36%                    PEP.warm-line                      33%
          Counseling                      67%                    Parenting.groups.or.classes        47%
          Public.Health.Nursing           28%                    Other                              16%
                                       *Providers.may.check.all.that.apply




                                                         Santa Barbara County Alcohol, Drug and Mental Health Services 14
    V. Analysis
    .
                                                            Support and
    The.following.is.based.on.the.focus.groups.
                                                            Emotional Adjustment
    and.surveys,.and.serve.as.the.key.findings.             Parents
                                                            •..For.the.most.part,.women.felt.supported.and..
    Information and Resources                               . received.helpful.information.from.WEB....
    Parents                                                 •. A.small.proportion.of.women.felt.that.all.the..
    •..Those.who.participated.in.programs.such.as..         . attention.was.focused.on.the.baby.and.that..
    . Postpartum.Education.for.Parents,.Welcome..           . they.would.have.liked.questions.about.their..
    . Every.Baby,.CALM,.Mamatoto.and.WIC..                  . own.feelings.
    . received.more.information.and.support.                •..Most.helpful.services/supports.were.family..
    •..Overall,.women.reported.feeling.that..               . members,.friends,.other.mothers,.and..
    . physicians.are.too.rushed.and.appear..                . therapists.
    . uninformed.about.resources.for.emotional..            •..Support.groups.in.general.about.parenting,..
    . support..Women.reported.not.feeling.enough..          . adjusting,.self.care,.and.other.relevant.topics..
    . attention.is.paid.to.the.mother’s.emotional..         . were.helpful.and.desired.
    . state.during.pregnancy.and.postnatal..
    . months/years.                                         •..Breastfeeding.support.through.WEB.and..
                                                            . other.agencies.was.helpful.
    •..A.majority.of.the.participants.did.not.know..
    . what.Postpartum.Depression.was.or.the..               •..In.general,.although.not.across.the.board,..
    . importance.of.infant.attachment.and.received..        . support.from.pediatricians.and.OB/GYN.was..
    . little.to.no.information.prior.to.or.after.having..   . focused.on.the.baby.and/or.physical.health.
    . their.baby.                                           •..Support.groups.and.Postpartum.Depression..
    •.   22%.of.women.reported.drinking.alcohol.in..        . treatment.were.not.felt.to.be.accessible.and..
    .    the.month.before.they.knew.they.were..             . available.to.all.
    .    pregnant...This.highlights.the.importance.of..     •..There.was.a.lot.of.anxiety.around.breastfeeding..
    .    education.around.the.effects.of.drugs.and..        . and.some.felt.like.“bad”.mothers.if.they.did..
    .    alcohol.on.unborn.fetuses.                         . not.breastfeed...Some.women.reported.feeling..
    •..When.women.did.receive.information,..                . overly.pressured.to.breastfeed.
    . it.was.reportedly.too.general.to.be.helpful.and..
    . was.provided.with.little.explanation...People..       Providers
    . felt.too.overwhelmed.to.take.in.all.the.changes..
    . and.paperwork...Information.sometimes.did..           •..Providers.felt.there.was.a.need.for.more..
    . not.include.resources.to.seek.out.if.help.was..       . support.services.for.parents.(e.g.,.support..
    . needed.or.desired.                                    . groups,.therapy,.and.in-home.support)..
                                                            . available.in.English.and.Spanish.
    •..Monolingual.Spanish.speaking.mothers..
    . reported.difficulty.in.communicating.needs.                                                               .
                                                            •...Providers.struggle.with.lack.of.time.and.ability.
    . and.asking.for.help.and.some.felt..                   . to.explain.Postpartum.Depression.and..
    . discriminated.against.by.health.professionals.        . attachment.to.new.parents.in.an..
                                                            . understandable.way.
    •..Parents.wanted.more.information/education..
    . and.support.around.breastfeeding.                     •..Socioeconomic.variables.such.as.basic.needs..
                                                            . issues,.financial.problems,.and.racism.interfere..
                                                            . with.parents.ability.to.cope.and.cause.anxiety.
    Providers
    •..Providers.felt.there.was.a.need.for.more..
    . community.outreach.and.education..
    . with.information.and.referral.sources..
    . available.to.new.parents,.health.and.mental..
    . health.providers.
    •..Providers.felt.there.are.not.enough.resources..
    . available.in.the.community.for.support.and..
    . treatment.of.Postpartum.Depression.
    •..Education,.support.and.other.services.need.to..
    . be.provided.during.pregnancy.and.continue..
    . after.pregnancy.




15 Postpartum Depression/Attachment Strategic Plan 2006
                       V. Analysis (continued)                               Providers
                                                                             •..Better.communication.and.coordination..
                       Treatment and Referrals                               . between.service.providers.is.needed.
                                                                             •..Parent’s.obstacles.of.stigma,.shame.and.denial..
                       Parents                                               . of.symptoms.interfere.with.their.ability.to..
                       •..The.stronger.the.relationship.the.parent.had.      . follow.through.on.treatment..
                       . with.the.provider,.the.more.the.parents.were..
                                                                             •..Providers.wanted.more.training.and..
                       . able.to.benefit.from.the.services..Thus,..
                                                                             . information.about.Postpartum.Depression.
                       . treatment.and.services.based.on.a.relationship..
                       . model.appeared.to.be.more.effective.                •..Providers.had.difficulty.getting.new.parents..
                                                                             . to.attend.appointments.and.follow.through..
                       •..Services.that.addressed.the.parent’s.emotional..   . on.referrals.
                       . experience.and.difficulties,.in.addition.to..
                       . their.emerging.relationship.with.their.infant,..
                       . were.generally.considered.more.supportive..
                       . and.helpful.
                       •..Parents.reported.not.knowing.where.to.go.to.
                       . get.help.when.they.had.Postpartum.. .
                       . Depression.symptoms.




                                                                             VIII.


                      From the Data
A majority of the        Z There were a total of 11 focus groups held around the County and 380 responses to
                             the web-based survey received from parents countywide.
participants did
                         Z The respondents were reflective of the county population distribution with a higher
not know what                response from the Latino/a population. (Santa	Barbara	County	is	approximately		
                         	   35%	Latino/a	while	our	respondents	were	53%	Latino/a).		
Postpartum
                         Z For the Provider survey there were 110 responses with the majority being Mental
Depression was or            Health Providers (40%) and about 32% medical providers.

the importance of        Z There was a difference between the providers understanding of the information they
                             gave to parents and what parents felt they received. For instance, 71% of the
                             providers stated they talked to parents about PPD/Attachment during or after
infant attachment            pregnancy, while only 59% of the parents overall, and 34% of the surveys
                             completed in Spanish, stated that someone talked with them about PPD.
and received little
                         Z Providers for the most part were aware of “211” (76%) and referred their parents
to no information            to it (48%) which demonstrates a good awareness of a fairly new resource.
                             However, parents were less informed with only 30% overall and 20% of the
prior to or after            Spanish respondents knowing about 211.

having their baby.       Z Similarly, significantly more providers knew about the PEP Warmline, informed
                             parents of it - yet the parents did not utilize the service.

                         Z Most of the providers (52%) reported having some special training on
                             PPD/Attachment and were interested in having more training.
                             This indicates some willingness to participate in ongoing education.

                                               Santa Barbara County Alcohol, Drug and Mental Health Services 16
    VI. Recommendations and Strategies
    Recommendations
    Z Increase maternal depression awareness in the healthcare, early care and education,
        and family support communities.
    Z Perform outreach and education to expectant and new mothers to address stigma
      and patient barriers and to educate them about available resources.
    Z Assure earlier identification of maternal depression in healthcare settings by
      addressing barriers to recognition, screening, assessment, and referral; creating
      continuity of services.
    Z Invest in evidence-based interventions that improve the mother-child relationship,
        providing a continuity of care with available and accessible services.
    Z Build a comprehensive network of community perinatal services and service providers
        to strengthen mental health in the pregnant and postpartum family.

    Strategies
    Z Work with the Perinatal Substance Abuse task force and primary care providers to
        implement universal perinatal substance abuse and mental health screening.
    Z Utilize existing community resources and networks of care to launch maternal
        depression awareness education, screening and advocacy to the general population
        including populations with special needs, unserved, and new parents.
    Z Utilizing new research and resources, identify educational materials, e.g. brochures,
        and place them in familiar and frequented settings like child care centers,
        doctor’s offices, and grocery stores.
    Z Develop continuity of Postpartum Depression treatment resources countywide.
    Z Educate the community about the Postpartum Education for Parents (PEP) Warmline             22% of women
        and expand support groups and education to North County.
    Z Promote 211 as a countywide, bilingual resource for support and referrals to new parents.
    Z Offer trainings and in-services to Healthcare Providers.                                    reported drinking
    Z Distribute and present the Postpartum Depression/Attachment Strategic Plan
        to the target communities, key decision makers, and funders to promote action and
        implementation of the plan.                                                               alcohol in the
    Z Targeted outreach and education to vulnerable populations: parents involved in
        domestic violence, drug/alcohol addiction, with children in NICU, parents with
        mental illness, teen mothers, homeless parents, children with high medical needs and
        women who experienced a traumatic birth.
                                                                                                  month before
    Z Identify existing and new resources to develop a continuum of services from support
        groups to psychiatric care to address risk factors of Postpartum Depression and
        attachment issues.                                                                        they knew they

    VII. Next Steps
                                                                                                  were pregnant
    The Postpartum Depression Work Group will continue to function in the capacity of a
    steering committee which will work toward the implementation of the strategies developed
    and indicated in the strategic plan.




17 Postpartum Depression/Attachment Strategic Plan 2006
Acknowledgements
Thanks to our Postpartum Depression/Attachment Work Group who dedicated their
time and vast experience and energy to complete this project.

Angela.Antenore,.Consultant            CALM.                                   Cottage Hospital                        Sojourn Services
                                       Rose.Bristol                            Janet.Langsfelder                       Mary.Bucher
ADMHS.                                 Estela.Campos                           Sandra.Jensen.                          Marya.Malinowski
James.Broderick,.PhD                   Deborah.Holmes                                                                  Anne.McElhinney
April.Howard                           Jose.Moctezuma                          First 5
Suzanne.Grimmessey-Kirk                Ryan.Smith                              Patricia.Wheatley                       Transitions MHA
Sandy.Fahey                            Su.Wyatt                                                                        Frank.Ricceri
                                                                               PEP
ADP.                                   Anna.Kokotovic,.PhD                     Jane.Honikman.                          UCSB
Stan.Speck                             Community                                                                       Michael.Bates
                                                                               Public Health Department                .
CHC                                    Sharleen.Dolan,.PhD                     Carole.Ferrari
Emma.Posades-Espinosa                  Kim.Gerber,.PhD                         Sylvia.Johns
                                       Nora.Keenan                             Sandra.Copley


Special thanks to
  • Ryan Smith for sharing his research and expertise, particularly on Infant Attachment.
  • First 5 Santa Barbara County for making this possible and supporting the ongoing
    efforts of the Postpartum Depression Steering Committee.
Sources
Honikman,.Jane..Postpartum Depression-Learning About PPD. .WIC.Nutritionist.Newsletter,.Volume.6.Series.1,.Provided.by.Mead.Johnson.
and.Company;.2006

Onunaku.N..Improving Maternal and Infant Mental Health: Focus on Maternal Depression...Los.Angeles,.CA:..National.Center.for.Infant.and.Early.
Childhood.Health.Policy.at.UCLA;.2005.

Smith,.Ryan.M.A..Infant Attachment: Causes, Consequences, and Treatment Implications..Child.Abuse.Listening.and.Mediation;.2004



                                                                Santa Barbara County Alcohol, Drug and Mental Health Services 18
                                                                 IX. Appendix
                                               Postpartum & Infant Attachment Survey
       Yes    Somewhat           No     Questions for both parents
                                        1.. Did.you.have.support.from.your.family/significant.others.after.your.baby.was.born?

                                        2.. Were.there.any.complications.with.the.labor.and/or.delivery?

                                        3.. Were.there.problems.with.your.baby.after.birth?

                                        4.. Do.you.have.access.to.transportation.to.get.what.you.need.for.your.baby.and.family?

                                        5.. Have.you.ever.called.the.PEP.warm-line?

                                        6.. Have.you.ever.had.a.visit.from.a.nurse.since.your.baby.was.born?

                                        7.. Did.anyone.ever.talk.with.you.about.bonding.with.your.baby?

                                        8.. Did.anyone.ever.talk.with.you.about.your.emotional.adjustment.the.pregnancy?

                                        9.. Did.anyone.ever.talk.with.you.about.postpartum.depression.or.anxiety?

                                        10.. Do.you.have.access.to.a.telephone.to.make.phone.calls.whenever.you.need.to?

                                        11.. Are.you.taking.any.medication.for.depression?

                                        12.. Do.you.know.about.“211”.–.the.phone.number.you.can.call.if.you.would.like.a.referral.for..
                                             services.or.resources?

                                        13.. Do.you.have.any.difficult.feelings.about.being.a.parent.that.surprise.you..
                                             and.that.you.may.not.understand?

        Questions for Mothers: In the month before you knew you were pregnant, how many times did you:
                                      Smoke?
                                      Drink.alcohol?
                                      Did.you.use.drugs?
       Other information
       My.ethnicity.is:
       My.age.is:
       My.gender.is:
       I.live.in/near.the.City.of:.


       The.most.helpful.thing.for.me.after.my.baby.was.born.was:

       The.most.difficult.thing.for.me.after.may.baby.was.born.was:

       Parents.in.this.community.who.have.had.a.baby.within.the.last.year.could.really.benefit.from:

       Any.other.comments:




19 Postpartum Depression/Attachment Strategic Plan 2006
                       Encuesta sobre el Afecto con el Bebé & Vida Después del Parto
      Hasta
Sí    cierto    No       Pregunta
      punto

                         1.. ¿Recibió.apoyo.de.parte.de.su.familia/.de.su.pareja.después.del.nacimiento.de.su.bebé?

                         2.. ¿Tuvo.usted.complicaciones.en.el.parto.o.al.dar.a.luz?

                         3.. ¿Tuvo.problemas.su.bebé.después.de.nacer?

                         4.. ¿Tiene.usted.acceso.a.un.modo.de.transporte.para.conseguir.lo.que.necesita.para.usted.y.para.su.familia?

                         5.. ¿Ha.llamado.alguna.vez.a.la.línea.de.apoyo.llamada.PEP?

                         6.. ¿Le.visitó.una.enfermera.en.algún.momento.después.del.nacimiento.de.su.bebé?

                         7..   ¿Ha.hablado.usted.en.algún.momento.con.alguien.sobre.como.establecer.una.relación.de.lazos.afectuosos/atadura.emocional.con.su.bebé?

                         8.. ¿Ha.hablado.en.algún.momento.con.alguien.sobre.como.usted.se.adaptó.emocionalmente.al.embarazo?

                         9.. ¿Ha.hablado.en.algún.momento.con.alguien.sobre.la.depresión.o.la.ansiedad.después.del.parto?

                         10.. ¿Tiene.usted.acceso.a.un.teléfono.para.hacer.llamadas.cuando.lo.necesita?

                         11.. ¿Está.tomando.medicamentos.para.la.depresión?

                         12.. ¿Conoce.el.número.de.teléfono.“211”.--.al.que.puede.llamar.si.necesita.recibir.recomendaciones.para.servicios.o.recursos?

                         13.. ¿Tiene.usted.sentimientos.difíciles.sobre.el.hecho.de.ser.una.madre.(un.padre).que.le.sorprenden.y.que.quizás.no.entiende?

Preguntas para las Madres: En el mes antes de saber que estaba embarazada, ¿Cuántas veces usted:
                       Fumó?
                       Bebió.alcohol??
                       Usó.drogas?

Otra información
Mi.herencia.étnica.es:
Mi.edad.es:
Mi.género.(sexo).es:
Vivo.en./.cerca.de.la.Ciudad.de:.

La.cosa.que.más.me.ayudó.después.del.nacimiento.del.bebé.fue:

La.cosa.más.difícil.para.mí.después.del.nacimiento.del.bebé.fue:

Algo.que.podría.beneficiar.a.padres.de.esta.comunidad.quienes.han.tenido.un.bebé.en.el.año.pasado.es:

Otros.comentarios:.




                                                                               Santa Barbara County Alcohol, Drug and Mental Health Services 20
                                                    Focus Groups Handout #3:
                                                Discussion Questions • Spring, 2006
  Pregnancy.and.parenthood.bring.great.changes...These.things.may.change.the.way.you.feel.about.your.body,.your.personal.relationships,.and.make.
  you.question.your.previous.priorities.in.areas.such.as.work.and.social.life...For.some,.it.is.a.time.of.fluctuating.moods.and.emotions.that.aren’t.always.
  easily.understood.

  Today.you.will.be.asked.a.little.about:
       1.. The.things.that.cause.or.caused.you.the.greatest.challenges,.
       2.. How.you.coped.with.all.the.changes.you.are.going.through,.and,.
       3.. A.little.about.what.you.think.other.new.parents.might.find.helpful.

  Discussion Questions:

       1.. Did.you.receive.any.information,.services,.support.or.advice.about.your.changing.moods.and.feelings?..If.so,.what.did.you.find.most.useful?

       2.. Where.did.you.get.any.of.that.from?.(e.g.,.healthcare.providers,.WEB.home.visits,.friends,.relatives,.books,.magazines,.others?)

       3.. Which.services.have.been.most.helpful?.Least.helpful?

       4.. In.thinking.about.the.support.&.information.you.think.would.be.helpful/useful.(specifically).regarding.postpartum.depression,.anxiety.and.
           infant.attachment,.what.did.you.not.get.that.you.would.have.liked?.

       5.. As.a.new.parent,.what.would.you.say.were.your.biggest.challenges.that.had.the.most.impact.on.your.outlook.or.self-confidence,.or.caused.
           you.the.most.anxiety?

       6.. How.was.the.experience.of.having.a.baby.different.or.similar.to.what.you.expected?

       7.. What.could.healthcare.providers.do.to.help.parents.feel.confident.and.ready.to.cope.with.the.changes.of.becoming.a.parent?..

       8.. What.kinds.of.things.would.you.like.to.ask/have.asked.your.healthcare.providers.that.you.haven’t/didn’t?.

  .......9...Any.other.comments?



                              Postpartum Support and Counseling Resources and Referrals
                 This.project.came.out.of.the.Early.Childhood.Mental.Health.and.Special.Needs.Collaborative.because.of.concerns.about..
                the.stress.and.difficulties.pregnancy.and.childbirth.can.bring...The.“baby.blues”.and.feelings.of.stress.or.anxiety.are.normal....
              However,.even.“normal”.feelings.can.be.overwhelming.and.you.may.need.some.help.or.someone.to.talk.to.about.your.feelings....
          Your.feelings.may.also.be.more.serious.and.can.affect.your.relationship.with.your.baby...Below.is.a.list.of.places.you.can.call.to.get.help.


                Child Abuse Listening and Mediation (CALM)                                    Public Health Department Maternal Child
                  1236.Chapala.St.,.Santa.Barbara,.CA.93101                                             Health Referral Line
                               (805).965-2376                                                             1.(800).288-8145
             Postpartum Education for Parents (PEP) Warmline                         Family Service Agency Information and Referral Helpline
                            (805)..564-3888                                                                  call.211
                      Community Health Centers (CHC)                                          Alcohol, Drug and Mental Health Services
                       1414.S..Miller,.Suite.9,.Santa.Maria                                               1(888).868-1649
                                (805).928-7757




21 Postpartum Depression/Attachment Strategic Plan 2006
                                                      Postpartum Depression/Anxiety
                                                    & Infant Attachment Provider Survey

Please Check All That Apply:
What type of                                                             c	    Pediatrician                                          c	    Nurse.Practitioner
Provider are you?                                                        c	    Family.Practitioner                                   c	    Mental.Health.Provider
                                                                         c	    Gynecologist/Obstetrician                             c	    Psychiatrist
                                                                         c	    Nurse                                                 c	    Midwife
                                                                         c	    Doula                                                 c	    Other:
What is your gender?                                                     c	 Female                     c	 Male

In which part of Santa Barbara County do you                             c	 North.County.(Guadalupe,.Santa.Maria,.New.Cuyama)..
provide Services?                                                        c	 Central.County.(Lompoc,.Buellton,.Santa.Ynez.Valley)..
                                                                         c	 South.County.(Carpinteria,.Santa.Barbara,.Goleta).

What is the ethnicity of the majority of your                            c	    African.American                                c	 Multiracial
clients/patients in your practice?                                       c	    Asian/Pacific.Islander                          c	 Native.American
                                                                         c	    Caucasian/White                                 c	 Other.(please.specify)
                                                                         c	    Hispanic/Latino(a).Chicano(a)

In your offices and field visits services are
provided in languages in addition to English
please list.


Please Check All That Apply:
Do you or someone you work with talk with                                 c	 Yes
parents about PPD/Attachment during or after                              c	 No
Pregnancy?                                                                c	 Sometimes

Do you provide pamphlets or brochures on PPD/                             c	 Yes
Attachment to your clients/patients?                                      c	 No
                                                                          c	 Sometimes

What services do you believe to be most helpful to                        c	    WEB.home.visits                            c	    PEP.warm-line
your patients in helping them avoid or cope with                          c	    Medication                                 c	    Parenting.groups.or.classes
symptoms of PPD and anxiety?                                              c	    Counseling                                 c	    Public.Health.Nursing
                                                                          c	    Support.groups                             c	    Other:.(please.specify)

Please.estimate.the.percentage.of.your.clients/patients.that.have.experienced.PPD.in.the.last.year:
c	 0-10.%          c	 10.-.20%                       c	 20-.30%                    c	 30-40%                      c	 More.than.40%                     c	 Don’t.know


Please Respond To The Following Questions:
As.a.provider.in.our.community,.what.do.you.think.is.missing.regarding.PPD/Attachment.that.is.needed.by.your.clients.(e.g.,.services,.support,.information)?


What.is.your.biggest.challenge.in.talking.about.PPD/Attachment.issues.with.clients/patients?


As.a.provider,.what.do.you.think.are.the.biggest.challenges.facing.new.parents.that.have.the.most.impact.on.their.outlook.and.self-confidence,.or.cause.them.the.most.anxiety?


What.could.healthcare.providers.do.to.help.parents.feel.confident.and.ready.to.cope.with.the.changes.of.becoming.a.parent?




                                                                                      Santa Barbara County Alcohol, Drug and Mental Health Services 22
       Please Check All That Apply And Respond If Necessary:
       Have you had any special training or continuing     c	 Yes         c	 No            If.yes,.please.describe:
       education on PPD/Attachment?

       What additional training would you like on          c	   1-day.conference                      c	 CEUs,.MCEs.or.classes
       PPD/Attachment (Check all that apply)?              c	   Book.references                       c	 Other:
                                                           c	   On-line.courses
                                                           c	   Professional.journal.resources

       What are your current sources for information       c	 Local.agencies.(e.g.,.CALM,.            c	 Internet
       on PPD/Attachment (check all that apply)?              PEP,.WEB,.CPSP,.etc.)                   c	 None
                                                           c	 Professional.Journals                   c	 Other:.(please.specify).
                                                           c	 CEUs,.MCEs.or.classes


       Please Check “Yes” or “No” And Respond To The Following Question:
       Do you discuss the use of drugs during and after pregnancy with your clients/patients?                         c	 Yes        c	 No

       What questions do you ask
       clients/patients about their
       use of drugs? And, what do
       you tell them?

       Do you discuss the use of alcohol during and after pregnancy with your clients/patients?                       c	 Yes        c	 No

       What questions do you ask
       your clients/patients about
       their alcohol use? And what
       do you tell them?
       Do you discuss smoking during and after pregnancy with your clients/patients?                                  c	 Yes        c	 No
       What questions do you ask
       your clients/patients about
       smoking? And, what do
       you tell them?


      Please Check One:
      Do you know about the PEP warm-line?                                                                              c	 Yes       c	 No
      Have you referred clients/patient to the PEP warm-line?                                                           c	 Yes       c	 No
      Do you know about “211,” the county-wide phone number for resources and service referrals?                        c	 Yes       c	 No
      Have you referred clients/patients to “211” for resources and referrals?                                          c	 Yes       c	 No
      To what other types of service providers have you made referrals? (Please specify)


                                                          Thank you for your time!




24 Postpartum Depression/Attachment Strategic Plan 2006
          Santa Barbara County
Alcohol, Drug and Mental Health Services

				
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