Screening fathers for postpartum depression in a maternal-child health clinic: a program evaluation in a midwest urban academic medical center

The program evaluation was conducted in a primary care clinic located within an academic medical center where pediatric and maternal health care are provided in the same setting (UI Health Two-Generation (Two-Gen) Clinic). The aim of Two-Gen is to deliver integrated, comprehensive postpartum primary care to mothers and their children. The clinic is housed within the combined internal medicine and pediatrics (med-peds) clinics at UI Health. The clinic predominately serves a publicly-insured population of economically marginalized, families of color who reside on the South and West Sides of Chicago, Illinois. Two-Gen was designed to systemically address disparities by offering a model of population health that provides comprehensive screening and services to address the health, behavioral health, and social service needs of postpartum mothers and children. The clinic has a collaborative care model that utilizes a transdisciplinary team of primary care physicians, a psychiatrist, social workers, lactation consultants, and care navigators/health coaches. Dyad clinic visits are co-scheduled (at the same time), co-located (in the same exam room), with the same primary care provider.

During the screening period from October 2021 through July 2022 there were approximately 60 mother-infant dyads receiving care in the Two-Gen clinic. We sought to identify all fathers actively involved in a relationship with a patient (mother or infant) in the clinic. Our intention was to be inclusive of biological and non-biological fathers, though only biological fathers were identified during the screening period. We contacted all mothers for whom there was not known intimate partner violence or other safety concern and asked them to identify their child’s father and for their permission to contact him.

A mother-as-gatekeeper model was utilized to minimize unintended and unwanted consequences of contacting fathers, including privacy concerns and potential exacerbation of partner conflict (e.g., intimate partner violence). After receiving the mother’s permission to contact fathers, clinic staff (a female social worker, a male social work master’s student, or a female care navigator) contacted fathers either by phone, text message, or during an in-person clinic visit to explain the screening process, obtain permission to participate, and to administer the screening. Fathers were informed that their information was confidential and would not be shared with their partners unless the father requested it be shared. Providers administered the screening at the clinic visit (in the waiting area, in a separate room, or in the room with the mother/baby if preferred) or by phone. If in-person, interviewers presented fathers with the option of independently completing the screening on a tablet or responding to the questions verbally.

Following the screening, fathers were provided with mental health education and resources, and offered referrals to medical and/or mental health care, regardless of screening results. Clinic social workers met with all fathers with a positive screen or a safety concern immediately following the screening to provide mental health referrals, including assistance in establishing care.

Demographic and social data were collected including age, race/ethnicity, insurance status, marital status, cohabitation, and enrollment with a primary care provider. Mental health history included three yes/no questions about ever receiving a diagnosis, medication, and/or counseling for a mental health problem. Fathers were asked about stress in three domains (financial, relationship with partner, and role as new father) on a scale of one to five, with five being the most stressful. Depression symptoms were measured using the 10-item self-rated EPDS questionnaire [32]. The EPDS is a reliable and validated measure for mood symptoms in fathers [33‐35]. Each item has four short statements/responses about common depressive symptoms experienced over the past seven days. The questions are scored from 0 to 3, with at total range of questionnaire scores from 0 to 30. A higher score indicates a higher level of depression symptoms. For mothers, a cutoff score of ≥ 10 indicates possible depression and is considered a positive screen. For fathers, previous studies suggest using lower cutoff scores ranging from 7 to 10 [34, 35]. For our analysis, ≥ 8 and/or any endorsement of question #10 (thoughts of self-harm) was considered a positive screening. The design of the screening was not qualitative; however, summative comments and quotes from fathers were recorded contemporaneously by the social workers. Authors interviewed the social workers after the pilot to gather their impressions. This information is reported purely for context.

Descriptive statistics (frequencies for categorical measures; means and standard deviations [S.D.] for continuous measures) were computed for sample demographic/social characteristics, mental health history, stress, and EPDS. Data were analyzed using Microsoft Excel and SAS 9.4 statistical software package. The project was approved by the University of Illinois at Chicago Institutional Review Board with a waiver of informed consent under protocol #2022 − 1621 as a clinical quality improvement program.

This program evaluation had multiple limitations. It is a retrospective review of a structured clinical screening intervention, and thus may not fully capture the complex nature of PPD in fathers. The intervention was designed to understand fathers’ willingness to participate in screening and their broader peripartum mental health needs; it was not designed to make a clinical diagnosis of PPD. Our decision to use the lower EPDS cut-off score for fathers increases the risk for over-identification of PPD. Conversely, the wide range of screening timepoints (1 to 15 months postpartum) raises the possibility of under detection of PPD, as some research suggests peak prevalence of paternal PPD around three to six months postpartum, though this data is limited [18, 29].

We were intentional about which fathers were contacted and acknowledge that the mother-as-gatekeeper approach introduces bias into our sample. Fathers where there was a concern or history of abusive, threatening, or dangerous behavior were not contacted. This decision reflects significant concerns about maternal and child safety regarding IPV which are often heightened in the pregnancy and postpartum period [41, 42]. However, fathers who commit IPV may be particularly high-risk in terms of comorbid mental health needs and trauma, and may represent an important, sizeable, though challenging sub-group for which to develop effective screening, treatment, and engagement strategies.

86% of our fathers reported cohabitation with the child’s mother, indicating a shared milieu and potentially strong inter-family effects and needs. However, this high rate of cohabitation may reflect the approach we used, mother-as-gatekeeper, for accessing fathers to screen. A more universal approach to screening might find different results as non-residential fathers may have different needs and experiences.