By Gretchen J. Hunt Dempsey, DNP, CRNP, CPNP-PC, Anna Lee Brown, DNP, CRNP, WHNP-BC, Stephanie M. Cannon, DNP, CRNP, AGNP-BC, WHNP-BC, Roschanda P. Watkins, DNP, CRNP, FNP-BC, FNP-C, Kina Phillips, DNP, RN, Brandy Tanner, DNP, CRNP, WHNP-BC, and Tedra Smith, DNP, CPNP-PC, CNE, CHSE

Abstract

Background: Currently, the Mother-Baby Unit at a large academic health center lacks standardized guidelines for postpartum depression screening follow-up. The absence of a clinical guideline poses a possible risk to the mother’s health and wellness, resulting from delayed diagnoses and treatment of postpartum depression. The project aims to improve the quality of care, facilitate early identification and intervention for postpartum depression by implementation of clinical guidelines for consistent postpartum depression assessments before discharge.

Methods: The DNP project team targeted maternity patients aged 19 to 46 on the nurse practitioner (NP) service line. The NP’s distributed the Edinburgh Postnatal Depression screening within 12-24 hours postpartum to English-speaking patients. The NP provider compiled and scored screens. After scoring, the NP determined the proper treatment regimen, medication options, need for counseling, patient education on the need to follow up with a postpartum check-up, and symptoms requiring immediate healthcare follow-up. Patients with a score of “13” or greater received an order for social services to complete a two-week mood assessment via phone call and determine need for further follow-up.

Results: Descriptive statistics were used to analyze the data. Data collection included demographic patient information and Edinburgh Postnatal Depression (EPDS) scores, which were gathered from referrals for postpartum mood checks before and after the implementation of the EPDS within 12- 24 hours postpartum. A total of 117 women were screened; 3.41% met the EPDS score criteria of >13 for a two-week mood check.

Conclusion: This project, a collaborative effort among healthcare professionals, researchers, and administrators, aims to enhance the care of women during the acute postpartum phase. The goal is to identify those at risk for postpartum depression who will need intervention with two-week postpartum mood checks. A total of 402 women were identified on the NP rounding list; 29% met eligibility for screening and 3.41% met the current hospital standard EPDS score “13” or higher. Decreasing the postpartum screening guideline to a score of “10” and expanding the screening time frame to include all patients before discharge will help to capture more patients at risk for postpartum depression. The adaptation of changes described to the postpartum screening enables early recognition, diagnosis, and treatment of those suffering from postpartum depression as the new standard of care.

In 2025, The Office on Women’s Health (OWH) reported concerning statistics revealing that 1 in 8 women may experience symptoms related to postpartum depression (PPD) ¹.  OWH 2025, “About the Postpartum Campaign” noted 13.4% of women living in the United States may experience PPD more than a year after giving birth².^.  In 2020, the American Psychiatric Association (APA) reported a rising concern regarding the mental health and well-being of women during antenatal and postnatal periods, noting that 1 out of 7-10 pregnant women and 1 out of 5-8 postpartum women are at risk of experiencing a depressive and or anxiety disorder. To address this growing health concern among women, APA  recommended that obstetric clinicians screen for mood and anxiety disorders twice during pregnancy and once during the postpartum period using validated screening tools³. Prioritizing the mental health and well-being of mothers is essential, as there are potential adverse effects not only on the social, cognitive, physical, and mental health of their children but also on overall family dynamics.

The American College of Obstetricians and Gynecologists (ACOG) 2024 refers to postpartum depression (PPD) as anxiety, sadness, and despair, which can interfere with daily functioning. The emergence of these emotions can occur anywhere from one to three weeks to up to one year after the postpartum period⁴. The potential of early onset of PPD developing within the first one to three weeks post-delivery raises awareness about the timing for screening practices for postpartum depression.

Postpartum depression leads to negative impacts on social, cognitive, physical, and mental health during infant development. The implementation of screening tools such as the Edinburgh Postnatal Depression Screening (EPDS) has proven effective in the prompt identification of postnatal depression symptoms, contributing to better outcomes for mothers and infants.^. The EPDS, a tool used for early identification of postpartum depression, is recommended by ACOG for screening during the perinatal period to support maternal mental health⁵. The use of EPDS during the perinatal and postnatal period has proven effective in identifying signs of anxiety and depression.

The World Health Organization (WHO) advocates for screening for PPD and anxiety using validated tools, followed by treatment regimens that align with PPD care during antenatal and postnatal periods to promote overall postnatal mental health. The WHO emphasizes the assessment of both mother and child, stating “the woman’s and baby’s physical well-being and the woman’s emotional well-being” prior to discharge⁶.  Screening for PPD is typically scheduled for the six-week postpartum visit. However, screening is often missed due to patients being lost to follow-up due to unreliable transportation or inadequate resources.

The EPDS should ideally be completed before discharge from the hospital to ensure the most accurate results. Integrating the EPDS into postnatal care during the acute postpartum phase provides an opportunity for early diagnosis and treatment. Studies have shown that early screening of postpartum depression raises awareness of critical issues that women face in the acute postpartum period. The lack of a standardized clinical process poses a risk to the mother’s health and wellness, resulting from delayed diagnoses and treatment of PPD⁷.

Purpose
This DNP quality improvement (QI) project aim was to increase early diagnosis and treatment of PPD to improve the quality of care, enhance maternal mental health, and strengthen the well-being of women during the early postpartum phase. The team implemented a standardized ‘mood check’ guideline using the EPDS to screen for PPD symptoms before discharge from the mother-baby unit.  

Setting and Population
The project, conducted at a hospital in a large academic health center located in the Southeastern region of the United States, included women from all socioeconomic backgrounds aged 19 to 46. This DNP project included English-speaking women from all ethnic groups (see Table 1). The site provided post-delivery care to mothers and their infants; however, there was no standardized screening process for PPD before discharge.                

Table 1. Demographics

Methods
The EPDS was chosen for its ease of use, validity, and minimal cost⁸.  The EPDS can be administered by a wide range of healthcare professionals, including NPs, midwives, and primary care providers. There is no formalized training or specific equipment required to complete the 10-minute EPDS screening process which ensures mothers can be screened in a timely manner. Its brevity ensures the screening can be conducted routinely without imposing significant time constraints on providers or patients⁸. The simplistic scoring systems make it a valuable screening tool for fast-paced, low provider to high patient volume acute healthcare settings. The minimal cost ensures that the tool can be integrated into routine postpartum care without a significant financial burden on healthcare facilities.

The DNP team chose the NP service line for implementation due to sample size and patient acuity; this allowed for more accessible data collection and sustainability of the pilot  phase. Two NPs rounded daily on postpartum patients. The NPs received education and training on the EPDS screening tool process two weeks before implementation. Instructions included an overview of the standardized method for administering the EPDS, as well as the exclusion and inclusion criteria. The NP providers were responsible for distributing and collecting the EPDS tool 12-24 hours after delivery. After participants completed the EPDS tools, the NP providers collected and scored the EPDS tool and followed up with an appropriate treatment regimen based on the EPDS score. Immediate scoring allowed the provider to counsel the patient and discuss a management plan, including referral for counseling.

Referrals for social workers (SWs) were sent by the NP via the electronic health record when the EPDS scored 13 or above. Women with an EPDS score of 13 or greater were referred for a SW one-week postpartum mood assessment as part of their discharge treatment plan. Patients with a score less than 13 on the EPDS received education from the NP on the signs and symptoms of PPD and instructions on when to contact their provider or the maternity evaluation unit. The EPDS included a question on “thought of harming myself.” If the patient answered anything other than “no, never,” an inpatient consult with an NP, obstetrician, SW, or psychiatric was ordered⁹.  

Data Analysis

Descriptive statistics were used to analyze mothers at risk for developing PPD during the implementation phase from May 9, 2024, to June 30, 2024. The team conducted manual chart
reviews for patient identification of historical data, i.e., history of PPD, current use of a psychoactive drug, demographic information, and number of pregnancies (see Table 2).  Screening rates were determined by comparing the number of patients screened to those with a score of “13” or above.  

Four participants had an elevated EPDS score which ranged from 13 to 17.  Of the four women,
one received a consult for SW and initiation of medication treatment.

Table 2. Data Analysis

Outcomes
During the QI project, 402 patients were on the NP service line. Of these, 117 completed the
EPDS tool, accounting for 29.1% of the patient population, with an average age of 27 at the time of assessment completion. Four of the 117 women (3.41%) screened positive for an EPDS score of 13
or greater. Of the 117 women screened, three patients (2.56%) scored 10-12 on the EPDS
(see Table 3). Two benefits of lowering the EPDS scoring threshold to 10 or greater offers enhanced sensitivity and improved early detection in individuals at risk for PPD⁸. Early identification of these symptoms allows healthcare providers to intervene more effectively, offering timely support and treatment to mothers in need. This proactive approach helps mitigate the adverse effects of postpartum depression on both the mother and child, promoting better health outcomes for the family unit.

TABLE 3.  Outcomes-Elevated EPDS 12-24 Hours Post Delivery

Discussion and Implications for Practice

Many barriers are present preventing access to healthcare services for both mother and child.
According to Place et al. 2024, barrier issues include interpersonal relationships, provider shortage, insufficient dedicated time to perform PPD assessments, language, organizational and institutional barriers. Suggested approaches to overcome current barriers include peer groups, utilization of community healthcare workers, Medicaid expansion, telehealth, text messaging services, co-location
of mental health and healthcare related services⁹.

The DNP team obtained early buy-in from administration and staff through feedback before the project’s implementation phase. The team shared information on the importance of EPDS screening during inpatient care to foster sustainability of the QI initiative. Standardizing the process for EPDS screening improves patient outcomes through early diagnosis and treatment, reinforcing the project’s long-term impact and success. The EPDS provides a standardized method for healthcare professionals to proactively screen symptoms of depression and anxiety in the postpartum period. Overall, the EPDS screening tool is invaluable in early diagnosis of mothers with postpartum depression¹⁰ .

Several limitations and barriers were noted during the implementation. This project included a
small sample size due to specific criteria for English-speaking individuals and the use of the NP
service line. During the project implementation, the Spanish version of the EPDS was not available
in the electronic charting system.  Higher acuity patients were listed on the resident service line,
which led to a missed opportunity in PPD identification. Limited staff participation due to increased
NP service line patient load, leading to time constraints.

Reviewing data analysis detected that 3.41% of the participants potentially benefited from
EPDS screening within 12-24 post-delivery. An additional 2.56% of the women with scores 10-12
could benefit from lowering the threshold of EPDS score screening. Overall, the potential benefits
of the participants equate to 5.97% for the early detection of PPD, and depending on the size of the family unit, potentially impacting numerous lives. Facilitating earlier inpatient detection and
intervention through EPDS screening can help reduce the long-term impacts on maternal and child overall health and wellness

Conclusion

This QI project, will enhance the care of women during the acute postpartum phase to identify
those at risk for postpartum depression. The project results support the implementation of a
standardized guideline for early screening for PPD prior to discharge. Early screening provides the opportunity for early intervention for postpartum women. Implementing the EPDS screening tool
in the hospital setting is feasible and cost-effective.

Gretchen J. Hunt Dempsey is a Nurse Faculty Instructor at the University of Alabama at Birmingham. Anna Lee Brown is a Women’s Health Nurse Practitioner at Orlando Health Winnie Palmer Hospital for Women and Babies. Stephanie Cannon is a WHNP at the University of Alabama at Birmingham. Roschanda Watkins is a full-time Family Nurse Practitioner. Kina Phillips is the Director of Nursing at Caregivers of Pleasant Grove. Brandy Tanner is an Advanced Practice Provider Manager at the University of Alabama at Birmingham. Tedra Smith is a Professor at the University of Alabama at Birmingham. The authors have no actual or potential conflicts of interest in this article’s contents. The QI project was executed without any sources of internal or external funding. Due to the absence of financial support, the project relied solely on the commitment and resources provided by the DNP team. As a result, no external funding organizations were involved in the design, implementation, interpretation, or reporting of the QI project.

References

 ¹Office on Women’s Health (OWH) U. S. Department of Health & Human Services. Talking Postpartum Depression. 2025. https://womenshealth.gov/TalkingPPD

 ²Office on Women’s Health (OWH) U. S. Department of Health & Human Services About the Postpartum Campaign. 2025. https://womenshealth.gov/talkingPPD/about

 ³American Psychiatric Association (APA). Position Statement on Screening and   Treatment of Mood and Anxiety Disorders During Pregnancy and Postpartum. 2020. https://www.psychiatry.org/getattachment/bf2c29a1-98f5-4c8f-9e4a-4119fa64bcca/Position-Pregnancy-Postpartum-Mood-Anxiety-Disorders.pdf³

⁴American College of Obstetricians and Gynecologists (ACOG). Postpartum Depression.2024. https://www.acog.org/womens-health/faqs/postpartum-depression

⁵American College of Obstetrics and Gynecologists. Optimizing postpartum care. 2018. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing postpartum-care

 ⁶World Health Organization (WHO). WHO recommendations on Maternal and Newborn   Care for a Positive Postnatal Experience. 2022   https://iris.who.int/bitstream/handle/10665/352658/9789240045989-eng.pdf?sequence=1

⁷Trinh TG, Schwarze CE, Müller M, et al. Implementing a Perinatal Depression Screening in Clinical Routine: Exploring the Patientʼs Perspective. Geburtshilfe und Frauenheilkunde. 2022;82(10):1082-1092. doi: https://doi.org/10.1055/a-1844-9246

⁸Khanlari S, Barnett AM B, Ogbo FA, Eastwood J. Re-examination of perinatal mental health policy frameworks for women signaling distress on the Edinburgh Postnatal Depression Scale (EPDS) completed during their antenatal booking-in consultation: a call for population health intervention. BMC Pregnancy and Childbirth. 2019;19(1). doi: https://doi.org/10.1186/s12884-019-2378-4

⁹Place JMS, Renbarger K, Van De Griend K, Guinn M, Wheatley C, Holmes O. Barriers to help-seeking for postpartum depression mapped onto the socio-economical model and
recommendations to address barriers. Front Glob Womens Health. 2024; 5: 1335437. July 2024. doi: 10.3389/fgwh.2024.1335437

¹⁰Zafman K, Riegel M, Wu J, Leitner K, Srinivas S. Evaluating the importance of immediate postpartum depression screening. Green Journal. 2022 https://journals.lww.com/greenjournal/abstract/2022/05001/evaluating_the_importance_of_immediate_postpartum.266.aspx.