JAN ORIGINAL RESEARCH

A holistic programme for mothers with postnatal depression: pilot study

Melissa Buultjens, Priscilla Robinson & Pranee Liamputtong

Accepted for publication 10 March 2008

Correspondence to P. Robinson: B U U L T J E N S M . , R O B I N S O N P . & L I A M P U T T O N G P . ( 2 0 0 8 ) A holistic pro-

e-mail: priscilla.robinson@latrobe.edu.au gramme for mothers with postnatal depression: pilot study. Journal of Advanced
Nursing 63(2), 181–188
Melissa Buultjens BHSc
doi: 10.1111/j.1365-2648.2008.04692.x
PhD Candidate
School of Public Health, La Trobe University,
Victoria, Australia Abstract
Title. A holistic programme for mothers with postnatal depression: pilot study.
Priscilla Robinson MPH MHSc (PHP) PhD Aim. This paper is a report of a pilot study to identify women’s perceptions of
Senior Lecturer participation in a holistic intervention for postnatal depression.
School of Public Health, La Trobe University, Background. Approximately 10–15% of women suffer from postnatal depression
Victoria, Australia following childbirth. Most programmes for women with postnatal depression in-
clude pharmaceutical interventions; however, evaluation of women’s perceptions of
Pranee Liamputtong BEd MEd PhD
participation in holistic programmes for those suffering from postnatal depression
Professor
School of Public Health, La Trobe University, show that non-pharmaceutical programmes can also be effective.
Victoria, Australia Method. In-depth interviews were conducted in 2004 with a self-selected sample of
10 women prior to and after an intervention to treat postnatal depression.
Findings. The intervention seemed capable of encouraging and facilitating a posi-
tive mother–infant relationship while also effectively reducing the mother’s anxiety
levels. Participants commented on the supportive environment of other mothers and
said that they found playing with their babies difficult and needed guidance and
facilitation to do this.
Conclusion. The pilot programme was well accepted and could easily be used by
midwives, maternal and child health nurses and other appropriately trained allied
health professionals.

Keywords: holistic care, midwifery, pilot study, postnatal depression, public health
nursing

demonstrating the seriousness of this public health issue

Introduction
In developed countries, approximately 10–15% of women
delivering babies are thought to experience postnatal depres-
sion (Astubury et al. 1994, O’Hara & Swain 1996, National
Health and Medical Research Council 2000, Chaudon et al.
2001). Anne Partridge, the Tresillian’s director of nursing and
clinical services, states that each year 35,000 Australian
mothers alone are affected by the emotionally crippling
effects of postnatal depression (Ninemsn Media Centre 2006)
(Murray & Lopez 1997).
Background
Many explanations about the causes of postnatal depression
exist from hormonal (Dalton 1980, Gregoire 1995) to social
(Paykel & Cooper 1992, O’Hara & Swain 1996). Postnatal
depression is characterized by tearfulness, feelings of inade-
quacy, mood swings, inability to cope with the care of the

 2008 The Authors. Journal compilation  2008 Blackwell Publishing Ltd 181
M. Buultjens et al.
baby, increasing guilt about the birth and guilt about
malfunctioning as a mother (Affonso et al. 1991, Berggren-
Clive 1998). Most affected women develop symptoms of
depression in the first 3 months postpartum (Cooper et al.
1988, Brugha et al. 1998) lasting between 2 weeks and
12 months (Pariser et al. 1997). At present, the economic
and social costs of depression in Australia during pregnancy
or in the first postnatal year have not been estimated.
However, there are numerous personal and financial costs
including increased access to primary care and mental
health services for lengthy periods of time (Office of Mental
Health 2000). Moreover, potential problems that depres-
sion is known to generate include unemployment, poverty,
stigmatization, and marital separation and divorce (Boyce
1994).
International research indicates that the mother–infant
bond is impaired by maternal depression (Cummings &
Davies 1994, O’Hara 1994) and many studies have
explored the link between postnatal depression and later
problems in children’s cognitive and social-emotional devel-
opment (Downey & Coyne 1990). This highlights the
importance of effective preventative and treatment interven-
tions in the perinatal period. Although there is evidence that
antidepressants are relatively safe for nursing infants (Stowe
et al. 1997) many women avoid medication (Appleby et al.
1997) so it is important that non-pharmacological and non-
hormonal interventions be explored for use in the perinatal
period.
Various researchers have examined holistic non-pharma-
ceutical and non-hormonal interventions for their potential to
prevent and treat individuals with postnatal depression.
Many women prefer not to take antidepressants, or refuse
medication if it necessitates cessation of breastfeeding (Battle
et al. 2007). A number of empirical studies support and
illustrate the efficacy of non-biological and non-hormonal
interventions for the prevention and treatment of postnatal
depression.
Intervention treatments for postnatal depression are well
documented (Elliott 1989). There are numerous studies
conducted worldwide that illustrate the positive influence
cognitive strategies have on women with postnatal depres-
sion (Meager & Milgrom 1996, Cooper & Murray 1997,
Cooper et al. 2003). Using a combination of counselling
and cognitive–behavioural techniques, such as problem-
solving, home visits were provided by health visitors
(Maternal and Child Health Nurses) in Cambridge (Seeley
et al. 1996). Data were reported for the 70 women who
were seen by their health visitor during the evaluation
period and they were compared with 30 historical controls.
Results found that there was a highly significant reduction
182  2008 The Authors. Journal compilation  2008 Blackwell Publishing Ltd
in EPDS scores between the women in the intervention and
control group.
Similar results are reported by O’Hara et al. (2000) using
therapy focusing on interpersonal relationships and role
transitions in ninety nine depressed new mothers, and Cooper
and Murray (1997) using one of three interventions (non-
directive counselling, cognitive–behavioural therapy and
dynamic psychotherapy) in 194 depressed primiparous
women.
In addition to personal interventions, group therapy has
been found to be highly effective (Fleming et al. 1992,
Meager & Milgrom 1996, Chen et al. 2000). As noted by
Milgrom et al. (2003), group therapy for women suffering
postnatal depression is valuable as they can discuss and share
similar experiences, fears and unrealistic expectations which
can in turn enhance a mother’s ability to cope. A pilot study
conducted in 1996 examined a group therapy programme
that combined an educational component with cognitive–
behavioural therapy (Meager & Milgrom 1996). While
women in the treatment group still exhibited some depressive
symptoms at the conclusion of the treatment, results exhib-
ited a statistically noteworthy reduction in pre- to postinter-
vention scores on the Beck Depression Inventory and EPDS,
in comparison to the control group.
The study
Aim
The aim of the study was to identify women’s perceptions of
participation in a holistic intervention for mothers with
postnatal depression.
Design
A pilot study, using in-depth interviews, was carried out in
2004.
Participants
A self-selected sample of 10 women were recruited from a
unit providing counselling and support to mothers and
families experiencing postnatal depression at a metropolitan
hospital in Australia. Participants were all aged over 18 years
and their infants were under 1-year old. Midwives, psychi-
atric nurses and mothercraft nurses distributed invitations to
women inviting them to take part in the study. The unit
manager then discussed the study with each of the mothers
who agreed to participate. Sampling was conducted until no
new themes emerged from the data. Data saturation was
JAN: ORIGINAL RESEARCH
attained in this study at the 10 interviews. Saturation was
achieved with 10 mothers.
Intervention
Through educating to facilitate a positive and interactive
connection (EPIC), this intervention was formed as a
discrete, holistic, non-obtrusive and psychosocial pro-
gramme. The EPIC concept was derived from direct
observations of depressed mothers interacting with their
infant and the theoretical basis was based on an in-depth
review of the literature which included the advantages of
evidence based group treatment. Each class that the mothers
attended consisted of several components, as shown in
Table 1.
Data collection
In-depth interviews were chosen as the method of data
collection as they provide the opportunity to talk to partic-
ipants in great depth and detail, enabling us to listen to and
learn from the women (Liamputtong & Ezzy 2005). Two
interviews were carried out with each participant. The first
was conducted prior to participation, and recorded the
mother’s sense of attachment to her infant and her expecta-
tions of the EPIC programme. At the conclusion of the
sessions, women were re-interviewed to gain an understand-
ing of their perceptions of participation. Each interview
lasted approximately 1 hour. An interview schedule outline
of open-ended questions was constructed to prompt women,
ensure consistency and encourage them to speak freely. To
begin the interview, participants were invited to talk about
their perceptions of attachment to their infants and then the
interview schedule was used.
Evaluation forms were distributed following each session
inviting attendees to rate on a Likert scale (with a range of
Table 1 The EPIC programme
Component Activity
One Education
Milestones
Social and learning activities
How to promote play
Two Circuit of Activities
Guided, interactive stimulus for
mother and baby
Three Creativity
Mother-centred therapeutic activity
intended for infant’s nursery
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A holistic programme for mothers with postnatal depression
1–10) how they experienced the group and whether the
information was relevant and informative. They were also
asked to describe their feeling of well-being at the conclusion
on the session on a scale from 1 (being worse) to 10 (being
better).
Ethical considerations
The relevant university and hospital ethics boards approved
the study. An information sheet detailing the study was given
to potential participants by nursing staff and those who wished
to take part were briefed by the unit manager. Written consent
was obtained and it was emphasized that participation was
voluntary and that there would be no adverse consequences of
withdrawing. Participants’ contact details were then passed to
the researcher, who was independent of the hospital.
Data analysis
All interviews were transcribed for data analysis and anon-
ymized. Thematic analysis was used to analyse the data.
Findings
The socio-demographic characteristics of the 10 participants
are presented in Table 2. These show that on average the
mothers were just over 34 years of age and they had been
married for almost 7 years. Most were Australian and whilst
one mother reported an income of less than $50,000, half
reported an income of $50–99,000 and four had an income
greater than that (1 Australian $ = US $ 0Æ94 = £0Æ47 = 0Æ62
Euros). Eight had tertiary education, and for six mothers this
was their first child. The themes identified in the data were:
the mothers’ sense of attachment to their infants, their views
about play for their infants and their appraisals and thoughts
about EPIC sessions.
Objective
To empower mother through developing skills and knowledge
To build the communication between mother and baby
To enhance maternal responsiveness
To empower mother through positive experience with her infant
To encourage face-to-face contact between mother and baby
To boost mood levels
To give positive distraction from current problems and anxieties
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M. Buultjens et al.

Table 2 Participant demographics I’ve been here. Although I love him, now I’m starting to feel like I
love him and I think there’s a big difference. (Melinda)
Age of participant Mean 34Æ2
Range 12 I think it’s still growing. Yeah, I love her but it hasn’t been a
Length of marriage Mean 6Æ95 years
completely enjoyable experience. I think that you need time and also
Range 17Æ5 years
Marital status Married 9 you need fun happy times too. (Renee)
Partnered 1
The women viewed reasons as to what they believed could
Religion Greek Orthodox 1
Catholic 2
help increase the bond between them and their infant. Of the
Anglican 2 10 women, four said that if their babies were more settled
Not otherwise stated 1 they could enjoy them more and they would feel more relaxed
No religion specified 4 within themselves. Vanessa stated:
Ethnicity Australian 8
Italian 1 Well, I guess if he was more settled I’d relax more and things would
Greek 1 perhaps fall into place a bit better.
Approximate household income $0–$49,000 1
(Australian dollars) $50,000–$99,000 5 Similarly, the women added that if they had more positive
$100,000–$149,000 3 and fun time with their baby, it would strengthen the
$150,000+ 1 attachment and bond. Likewise, another mother said that
Level of education Year 11 1
playing with her infant spurred her on, as when her baby
Year 12 1
Tertiary 8
smiled back at her she found it rewarding. Nancy said:
Number of other children 0 6
By playing with her. If she is happy when I’m playing with her, it can
1 1
be enjoyable and rewarding.
2 3

Note: 1$Australian = 0Æ94 $US = 0Æ47 Sterling = 0Æ62 Euros.
Retrieved from http://www.rba.gov.au/Statistics/exchange_rates.html
on 27 February, 2008.
Mothers’ sense of attachment to their infants
For the women in the study, their sense of attachment and
bond with their infant appeared tarnished by their depression
in varying ways and to different degrees. Vanessa com-
mented:
Um…look I think because I was so sick after having my child that our
bond was damaged by my depression…I think it probably took me a
little longer to bond with my baby than it would a mum that doesn’t
have depression.
Rachel described how her bond with her infant was instan-
taneous, but then started to disappear.
For Melinda, she believed that coming to a unit such as the
mother/baby unit, had helped in many ways. But above all it
helped to build the bond between her and her son. This was
the case because it enabled them to spend quality time getting
to know each other in a supportive environment.
Coming to place like this. I think every mother should come to a unit
like this. It allows you to gradually fill this new position, and you
have constant support…especially emotional support.
Mothers’ views about play for their infants
All mothers participating in the study agreed that play for
their infant was an important activity. However, few could
answer why it was important and nine of the women also
added that they were not sure how to facilitate play and felt
that because of their depression, it was not something that
came effortlessly. Renee honestly answered:

Yeah, I think so…I felt like I had this instant bond and it was just Yeah, but it’s hard to know what play is for such a small baby.
disappearing. I felt like I almost shut off from him because he was so
Nancy commented:
unsettled and I was just trying to get through the days.
I’m a bit stuck at the moment as to what to do with her. I was
All the women remarked that the bond with their infant was
actually enquiring with the maternal health nurse as to where I go
something that they felt they had to work at and while they
with playtime…I think she’s getting bored. I don’t really know what
did not feel a great sense of attachment initially, it was
to do.
developing.
Out of the 10 women, three suggested that while they did
Um…only since I’ve been here. I feel guilty about it but the only time
value play as important, they did not take time out to play
spent with him that I’ve gotten to know him as a person is only since

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with their infant. Rachel, who did take time out to play with
her infant, remarked:
Yes, I do more so now…I struggled when he was really little – I just
didn’t know what to do with him, it’s hard…I guess being a first time
mum we just make things up as we go.
In talking to the mothers about their expectations of the EPIC
sessions, participants felt very positive about them, and went
on to tell us what they had hoped to get out of these groups.
Um…perhaps some ideas…I’m still stuck on what or how I should
play with him…I really think for mothers with depression – it’s
something we really need to work at. Play doesn’t come easily.
(Katrina)
I hope to learn to communicate more with her. Which I hope will
help me to bond more with her…and basically how to play with her,
because I go so far and then I get stuck. (Nancy)
Mothers’ appraisals and thoughts about EPIC
We asked them to describe to us how they found the group.
All of them responded with positive statements such as:
Oh, I thought it was really good because having the play with the kids
and then…it was just nice to do something for yourself. (Vanessa)
Yeah, it was good fun. It was just nice to have that distraction and
that time to ourselves, and something totally different from what we
do all the time. It was also nice to concentrate on something creative
which I wouldn’t normally do. (Stephanie)
Similarly, Melinda spoke of how she found it very enjoyable.
However, she believed that one of the activities was perhaps a
little intimidating and this, to her, was due to their lack of
self-esteem.
Um…very enjoyable. It was perhaps a little intimidating in one part.
A lot of us girls put ourselves out there in the group things, and I
thought ‘Yay’ for Belinda for going first when we did the bowling and
hoops activities. Because on top of our issues we probably lack self-
esteem…once Belinda did it, I was fine. But the creative activity I
thoroughly enjoyed.
All of the women believed that these sessions did help build
the bond between them and their infant in varying ways, as
the following descriptions illustrate:
Yes, the groups gave me special time with my baby in an encouraging
environment. (Sonia)
I must admit I came out of the groups feeling really good all
day…yeah, I found it really beneficial…my baby was a bit unsettled,
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A holistic programme for mothers with postnatal depression
but he got lots of cuddles out of it and it was really nice to be in that
environment. (Joanne)
The mothers found that the groups did help with their
depression and commented that regular ongoing groups
could further aid in their recovery from postnatal depression.
Nancy elaborated:
Definitely. I think that creating that bond between you and your
child, that it really helps…It really assists you in feeling the love
between you and your child, and when you can feel that it actually
makes you feel there’s a brighter future. When you feel all that love
you tend to forget about all the bad things and bad times. These
groups encouraged and facilitated lots of fun and positiveness.
While the sessions were made up of several components,
participants spoke specifically on how the special times with
their baby made them feel more positive about their
relationship and how that quality time helped them. Renee
told us that:
Um…yeah, because it’s a distraction. I haven’t really thought about it
in the context of postnatal depression, but I did really enjoy the time.
I know that part of my depression with me is not feeling that I have
quality time with her, so in that sense, yeah, it was definitely
beneficial and helpful.
Rachel too commented that:
Yeah, well, I think the better that you feel about the bond between
you and your baby, the better able you are to cope…The things they
do, like when they smile and stuff – that’s the reward. So yeah, I think
your group is really valuable.
Others spoke of how the creative activity became a positive
and therapeutic distraction for them.
Well, I’ve been here for a couple of weeks and I think this would have
to be the best group I’ve been too. The way you structured the group
meant that I could enjoy my baby but also enjoy doing something for
myself with my baby. The creative activity was therapeutic, and I
found myself focusing solely on that rather than my postnatal
depression. (Melinda)
Another concept that was noted was the increased appreci-
ation that the mothers gained towards play as Renee
commented:
I have a better sense of what to do with play, especially with little
ones.
Nancy proudly said:
That was the first time that I’d ever done something like that with
her. In a way I feel like the group has shown me how to enjoy my
baby…through play. There is actually a group that I found out about
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M. Buultjens et al.
and they do something similar with the baby activities. I really want
to do that because I enjoyed your groups so much.
On a similar note, there was a general consensus that in view
of the importance of plays that they would all make more
time to play with their baby.
Yes, for sure…you know, when I get home I’ll have other things to do
and I’m just going to want to lie in bed and play with him! (Rachel)
The final activity conducted in the group, facilitated a
creative motivation for the mothers to focus on besides their
depression. While talking to them in the interview, four
women added that they would like to pursue this as an outlet
for themselves. Joanne told us:
I spent the rest of the day thinking, ‘Well, maybe I could do
something like that for my girlfriend’s kids’ – or something along
those lines, because I really got a lot out of it. To come out at the end
with something that I’ve done which I didn’t expect is really nice.
Evaluation forms distributed to each mother after attendance
of these groups rated the groups favourably. The women
were asked if they would attend more sessions if they became
available. The responses were extremely positive. Of approx-
imately 100 evaluation forms that were distributed, all scored
at least 8.
Discussion
Study limitations
The pilot study was restricted to only 10 self-selected mothers
at a mother and baby unit in a single hospital, who were all
suffering from clinical postnatal depression (PND). Women
with less or more severe illness were not included. We cannot
therefore draw any inferences from this study for the use of
EPIC as a general hospital treatment, as a population
intervention, or for other conditions or circumstances.
Discussion of findings
While the study was restricted to only 10 participants at one
specific mother–baby unit, the analysis indicates many
benefits for the mothers. A programme such as EPIC is easy
to reproduce and transferable in hospitals, maternal health
centres and private settings, and could be delivered by
midwives, nursing professionals and allied health workers.
There are many behavioural predictors that depressed
mothers may display, one of which is the absence of laughter
or play with their infant (Beeber 2002). In this study, none of
the women noted laughing with their infant, and while they
186
believed play to be important for their infant, playing was not
something that came effortlessly. Field (1998) also tells of
how women with postnatal depression struggle to engage
their infants in play and talk.
While the mothers spoke highly of this intervention, two
strong themes emerged. First, the EPIC sessions helped to
build the bond between mother and baby and secondly these
groups helped the mother’s recovery from postnatal depres-
sion.
Strengthening the mother–infant relationship is vital. The
mother–baby relationship evolves over a period of time with
mothers displaying love, acceptance and warmth towards the
baby. As Raphael-Leff (1991) comments and we found in this
study, depressed mothers may not interact with their baby,
and although physically present, may be emotionally
detached and unresponsive. Numerous studies document
the importance of positive mother-infant attachment, and if
dismissed it can have lasting consequences. These include
multiple effects on the baby’s psychological and cognitive
development (Lyons-Ruth 1996, Stein et al. 1999). Using play
and psychotherapeutic techniques as a discrete tool for
enhancing the mother–infants bond is valuable. According
to Ulrich Mueller, a professor of psychology specialising in
child development at the University of Victoria, Vancouver
Island, a mother and baby exchange smiles in a rhythmic and
synchronized way that is important for the development of
attachment and intellectual development. Furthermore, if a
parent responds to a baby’s smile with an expressionless face
the infant becomes upset; infants of depressed mothers show
fewer signs of happiness and smile less often than infants of
non-depressed mothers (Mullens 2007:52). From our obser-
vations, play is a positive facilitator for both babies (who
enjoy stimulation and attention) and mothers (who reap the
rewards of a happy smiling baby). In a supportive group
setting environment, mothers can put aside the mundane
tasks of feeding and settling and enjoy motherhood.
Various explanations were given as to how these sessions
reduced the mothers’ anxiety levels. The women’s explana-
tions told of how the postnatal experience was overwhelming
and that their confidence and ability to carry out the tasks of
motherhood were affected. The group setting was perceived
as a safe and supportive environment. The gathering together
of these women signified an alliance. A feminist perspective of
these groups is that they symbolize a time for the mothers to
come together in a setting that encouraged expression and
reinforced the mothers’ personal power through the varying
activities and words of others. Through the positive rein-
forcement facilitated to these women, confidence and greater
self-esteem grows. This is valuable as women with postnatal
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JAN: ORIGINAL RESEARCH
What is already known about this topic
• Depression is a common and disabling complication in
the postpartum period, affecting approximately 10–
15% of women in developed countries.
• Many factors can contribute to causing depression
during the perinatal period, including lack of social
support, life stress and marital conflict.
• Many women reject medication to treat postnatal
depression, especially while breastfeeding, because they
are concerned about its possible harmful effects on the
developing infant.
What this paper adds
• Psychotherapeutic and non-pharmaceutical interven-
tions such as EPIC can be effective for treating women
in the perinatal period.
• Supporting and facilitating a positive and interactive
connection between mother and baby can positively
assist mothers rehabilitating from postnatal depression.
depression express feelings of worthlessness, become with-
drawn and lack self-esteem (Wood et al. 1997, Beck 2001,
Nicolson 2001, Ugarriza 2002).
The women participating in this study commented posi-
tively on the group setting. Various group treatments have
been tried worldwide with much success. As with this study,
group therapy in the area of postnatal depression can be
effective (Hickman 1992). The mothers in this study com-
mented that they felt very positive at the completion of each
group and they were a much-needed distraction.
The mothers in our study gained an appreciation and
better understanding of what play is for infants, toddlers
and children alike. The phrase, ‘its child’s play’, has a much
greater meaning than these women imagined. Through play,
babies discover the world around them and create the
groundwork for future learning. It is also the tool they use
to work through problems and fears as well as a means to
work out what they cannot say with words. Play allows an
infant to gain skills and knowledge. It develops their sense
of self, promotes social skills and provides abilities for
language, problem-solving, imagination and creativity, all of
which are important for future educational and lifelong
success.
From a qualitative position, this investigation into the
responses of postnatally depressed women to the EPIC
programme was valuable. While it is not the answer to
solving every mother’s depression, it has shown the potential
 2008 The Authors. Journal compilation  2008 Blackwell Publishing Ltd
A holistic programme for mothers with postnatal depression
to facilitate the mother’s recovery. Future studies repeating
this work are needed to see if EPIC makes a measurable
difference in a larger more regional population.
Conclusion
This small pilot study suggests that EPIC both encourages
and facilitates a positive mother–infant relationship, and aids
mothers in their recovery from postnatal depression. Prac-
tical, educational, pleasurable and therapeutic sessions
offered in a supportive setting are capable of greatly helping
these women in differing ways. The EPIC programme can be
provided by midwives, maternal and child health nurses and
other appropriately trained health professionals. It is non-
invasive, could be added to the suite of interventions
currently available for new mothers, and could be provided
for women in hospital settings.
While additional drug treatment may be required, natural
therapies such as EPIC could be incorporated into treatment
plans.
Author contributions
MB and PL were responsible for the study conception and
design. MB performed the data collection. MB, PR and PL
performed the data analysis. MB, PR and PL were responsible
for the drafting of the manuscript. MB and PR made critical
revisions to the paper for important intellectual content. MB
and PR provided statistical expertise. PR and PL supervised
the study.
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