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Running head: PERINATAL SCREENING

The effectiveness of perinatal screening on preventing infanticide


Karin Troy
The University of North Carolina at Pembroke

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Introduction

Recently, the uproar of child homicide has become more familiar to society. According to
Spinelli (2004), Every day an infant is killed in the United States (p. 1549). Several cases from
parents leaving children in over-heated cars during the summer to parents simply murdering their
children have gained tremendous media attention. Typically, it is safe to say that infants are
becoming victims to the individual he/she may trust the mostthe mother. With such tragic
events frequently occurring, the prevalence of postpartum depression has gained much
recognition in this matter. For this reason, many of the perpetrators are committing these crimes
and pleading insanity from postpartum depression. Therefore, the PICO question aims to
understand how mentally ill mothers can benefit from antepartum screening opposed to no
screening in preventing the occurrence of infanticide?
Background of Social Problem
According to one study, 10-15% of new mothers endure Postpartum Depression
following delivery (Kaminsky, Carlo, Muench, Nath, Harrigan, & Canterino, 2008). Importantly,
mothers suffering from Postpartum Depression, usually have a history of psychotic episodes, live
in isolation, come from low socioeconomic background, and have poor housing and marital
relationships, says Nicolson (as cited in Radano, 2007, p. 242) However, Nonacs reports that up
to 85% of women experience some type of mood disturbance following pregnancy (as cited in
Radano, 2007, p. 240) Thus, it is important to note that new mothers with previous psychotic
illness are at higher risk for experiencing some form of PPD(Postpartum Depression). In
addition, 41-57% of these at-risk mothers also experience comorbid obsessive compulsive
thoughts that include images and thoughts of harming the infant (Spinelli, 2009). Many of the
mothers included in these demographics suffer from additional illnesses such as bipolar disorder,

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schizophrenia, and major depression prior to childbirth (Spinelli, 2009). Yet, 62% of this
population reports having hallucination and delusions of a powerful force influencing their
decisions to commit suicide or harm their infant (Spinelli, 2009).
The demographic characteristics reported in the study by Shelton et al. (2010), proves
why the social characteristics of the women committing these devious acts remain unclear.
Specifically, the characteristics of this study include the age, rage, socioeconomic status,
occupational status, living arrangements, and criminal history. The mean age was 20.91 years ,
with a mode of 18 years. Yet, 34% of the offenders were considered lower class and 29.5% were
middle class while the remaining percent consist of lower middle class, upper middle class and
upper class. Also, the occupational status of the offenders were mainly students which consist of
48%. On the other hand, 36% were employed while only 14% were unemployed offenders.
However, 95.4% of the offenders lived with someone else at the time of the offence and 64% of
those offenders were living with a parent. However, the criminal history of these offenders
reported that 60% had committed one to two offenses prior to the act of infanticide. Just a few of
the prior offense include harassment, resisting arrest, assault, burglary, and runaway.
Infanticide dates back to the time of the Greeks when infants were sacrificed for the sake
of preserving space in the community (Spinelli, 2004). Following these devious acts, laws
protecting these infants made punishment for the perpetrators of this crime unforgettable. Recent
studies by Spinelli (2009) report that 4% of mothers suffering from postpartum psychosis
commit infanticide (p. 406). The most common cases include incident in which the mother
abandons their child to die, or simply beat them to death, suffocate them and in some cases cut
them into pieces. Also, many of these mothers attempt suicide shortly after committing

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filicide/infanticide. Most importantly, England and Wales reports that infanticide account for
about 25% of all child homicides (Shelton et al., 2010).
Over the past few years, this epidemic has caused several legislative debates that resulted
in the enactment of Safe haven laws in many states (Radano, 2008). National examples include
Andrea Yates that drowned all five of her kids, Susan Smith drove her 2 kids in a lake, and Mary
Ellen who suffocated her 5 week old infant and committed suicide. The National Child Abuse
and Neglect Data System reports that in 2008 1,740 children died from abuse (Huffington Post,
2011). This problem affects everyone because these mentally ill perpetrators are purposely
murdering children and receiving lower life sentences due to insanity (Shelton, Muirhead, &
Canning, 2010). As stated by Perlin, society uses rationalization and denial to explain the actions
of the mentally ill mother (as cited in Shelton et al., 2010, p. 816).
Although, the prevalence of these child homicides are underrepresented, the United
States has been criticized for not passing specific legislation for infanticide (Shelton et al., 2010).
However, because the prevalence of infanticide is low, the level of concealed criminality has
risen (Shelton et al., 2010). Also to mention, not only does this disorder result in infant death, it
has also been linked with poor infant and child outcomes educationally, linguistically, and
cognitively (Rhodes & Segre, 2013). Therefore, not only does this epidemic affect the mentally
ill mothers but also innocent children that suffer because the mother is mentally ill and not able
to provide efficient and necessary care for the child.
Mental illness during the antepartum period contributes to the high risk of infanticide. For
example, women dealing with schizophrenia are more likely to kill an infant due to the stressors
brought upon by postpartum depression (Spinelli, 2004). The mildest form of postpartum is often
called baby blues, which include rapid mood changes, irritability and anxiety (Radano, 2007).

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The next level of depression is postpartum mood disorders that develops within 3 months of
delivery and includes depression, insomnia, fatigue, suicidal thoughts, and thoughts of death
(Nonacs, as cited in Radano, 2007). Lastly, the most dangerous form of this categorical illness is
postpartum psychosis, which is rare but very risky for mothers with any current mental illness
present. Most of the time, these mothers may have delusional beliefs and auditory hallucinations
that instruct her to harm herself and the infant (Radano, 2007). Therefore, it is imperative to
investigate whether Antepartum screening compared to no screening of mentally ill mothers can
prevent the occurrence of infanticide?
The search for peer reviewed articles included several databases such as PsychInfo,
PsychArticles, SocIndex, Academic Search Complete, and CINAHL Plus. Each database was
searched with keywords such as mentally ill mothers and infanticide; infanticide; infanticide
interventions; mentally ill mothers and postpartum depression; mentally ill mothers and filicide;
and mothers that kill their infants or children. The results were highly skewed when 3 keywords
were used, therefore, I had to narrow down the keywords to one phrase or two keywords.
Based on the information presented in Appendix B, several of the articles cited within my
paper are basic literature reviews. However, extra references were needed for comparison of
interventions used to approach this postpartum epidemic. While many of the studies presented
stress the importance of screening, some articles prefer pharmacology. Throughout this paper, I
will examine the effective of each intervention that has been tested in hopes of diminishing
postpartum depression symptoms that result in acts of suicide and infanticide.
Synthesis of Literature

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Technically, infanticide has never been resolved because the issue has just begun to raise
awareness in many communities around the world. Also, the tragic events such as the crimes
Casey Anthony, Andrea Yates, and Susan Smith committed are some of the mind boggling
instances that continue to wow society. Yet, many of these mothers receive little to no
incarceration because they plead insanity. Although, not all cases of infanticide are committed by
mentally ill mothers, perinatal screening could be an important asset to the lives of many
innocent children. For this reason, over the past ten years many states have been debating on
relevant legislation for this this phenomenon. As a result, 36 states enforce legislation for cases
of infanticide (Shelton, 2010).
However, accurate information as to how effective perinatal screening is on preventing
infanticide has not been determined. Yet, many perinatal researchers have brought forth much
attention to the importance of ensuring that the health care providers and social services
providers are accurately trained to catch the signs of PPD and conduct screening properly
(Rhodes & Segre, 2013). Several approaches have been suggested such as individual
psychotherapy, support groups, crisis intervention, and pharmacotherapy. It is extremely
important for mental health professionals to know the risk factors associated with infanticide.
Research suggest that some red flags for considering intervention could be history of mental
illness, numerous pregnancies, family history of mental illness, denial, and fear of stigma
(Spinelli, 2004). Also, using a parenting assessment could be helpful in determining the mental
state and possible risk of the mother committing infanticide (Ostler & Kopels, 2010). However,
antepartum screening for mothers with a history of depression would be the most appropriate
first step towards preventing infanticide.

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The Edinburg Postnatal Depression Scale is a great way for clinicians to monitor the
emotions and mood changes of clients based on a 10 point scale rated by the client (Spinelli,
2004). The research does not encourage just one intervention because it requires a multifaceted
collaboration of several approaches. Postpartum depression occurs in several stages, which is
part of the reason why one intervention will not work with every client. In other words,
pharmacotherapy would be enough to stabilize the symptoms of early postpartum blues, but a
mother experiencing suicidal thoughts may need inpatient hospitalization (Ostler & Kopels,
2010). For the mothers in the most severe stage of postpartum psychosis, electroconvulsive
therapy is considered an effective approach (Radano, 2007). In regards to pharmacotherapy,
some clinicians suggest that using lithium as a mood stabilizer near the third trimester and after
delivery for early treatment of postpartum illness (Spinelli, 2009). Most importantly, many
sources stress the importance of early detection through screening tools similar Edinburgs
Postnatal Depression Scale. Completing a thorough investigation of the psychopathology of the
mother has been considered the most accurate way of determining the presence of postpartum
psychosis (Spinelli, 2009). On the other hand, simply knowing targeting the most known risk
factors or red flags is suggested as well. Knowing the symptoms of each stage of postpartum
illness is a very important aspect in choosing the best intervention. As the threat level increases,
the capacity of the intervention and treatment options do as well.
Intervention Recommendation
While the client population used in my intervention is mentally ill mothers of all ages, the
research studies use mothers of all ages that were at risk for postpartum illness. While my
objective was very similar to many of my sources, intervention strategies were very appropriate
for my client population. The literature explains the different stages of postpartum depression

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that mothers experience and how each level becomes more of a threat to the child. For example,
the first stage can be treated with a clinician offering support, giving information about support
groups and reassuring the client that she is not alone. But a mother in a severe stage of
postpartum is considered a psychiatric emergency. Notably, much of the research suggest
extensive screening in the perinatal period, so this information strengthened my perspective on
how much of a difference these intervention can have on my client population.
Although, early detection using antepartum screening can be effective, I would advocate
for the collaboration of directed interviews by clinicians for encouragement and support and
appropriate pharmacology to alleviate mood disturbances as an intervention. As stated earlier,
preventing the risk of infanticide from at risk mothers must be executed using a multifaceted
approach addressing all arenas of possible complications during the perinatal period. Research
suggest than many mothers that commit infanticide hid their pregnancy because they were
ashamed or the baby was unwanted. For the most part, many of these mothers were not married,
were young, and had very little family support throughout the pregnancy.
Consequently, it is important that support and enlightenment for motivation is given and
these mothers are screened for possible thoughts of suicide and infanticide. Therefore, I would
recommend that my clients initially undergo a thorough medical history and physical
examination testing for possible cases of depression and dysfunctions. In addition, I would
encourage the client to use the proactive approach of taking lithium towards the third trimester of
pregnancy to alleviate mood changes. In addition, I would educate the client about adoption, safe
haven laws, support groups, and the possible occurrence of postpartum illness and the symptoms
that follow shortly after childbirth. Then, depending on the results of the test, I would choose the
best evidence based approach for dealing with the clients stage of postpartum depression.

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Implementation Plan

A large portion of the literature explains how societys perspective of postpartum depression is
the reason that new mothers are left untreated. Many people think that postpartum depression is
normal and unnecessary for treatment. However, the voices still unheard is the portion of women
with history of a mental illness such as bipolar disorder and schizophrenia that give birth and are
immediately at high risk of postpartum psychosis. This population is the reason that antepartum
screening should be mandatory because these women need help. The emergence of postpartum
depression is bigger than what societys perspective holds. With that being said, my
implementation plan is to use the lack of importance as a motivator to give this population a
voice. The only issues that may hinder my implementation plan would be language barriers for
the screening tools, cooperation of the new mothers to be tested for depression, and the financial
burden of making hospitals administer screening test to every mother that gives birth.
Evaluation Plan
Monitoring infanticide rates is very hard because the issue is underreported and many
times the mother become distant and decide not to attend follow up appointments. However, in
this case follow up should be mandatory for high risk mothers that have no support. For the
mothers with family support, this task is much easier. However, because postpartum depression
usually alleviates after a few months, paying a simple visit or phone call to check on the client
would be enough. For those under psychological treatment, contacting the psychiatrist to monitor
improvements would help as well. For data collection, I could sit down with the client once a
month just to give a follow screening as to whether depression is increasing or decreasing. Also,
collecting data as to how long a client experienced postpartum illness during the intervention to
see how the different approaches of the intervention affect the clients individually.

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In order to determine the effectiveness of my intervention, I would the feedback from the
clients. Simply asking them if they felt that any part of the intervention contributed to helping
them overcome postpartum depression. If they feel that it was unnecessary then obviously it was
not effective, but if they feel slightly appreciative then I know that I have had an impact on
preventing infanticide. Specifically, if my intervention can alleviate the symptoms of postpartum
depression early then the help of the clinician and follow up is only strengthening the mental
state of the client. The key in preventing infanticide from mothers suffering postpartum
depression is early detection and follow up support from people who care.
Conclusion
All in all, my aim was to demonstrate how much of an impact antepartum screening can
have on the mentally ill mother committing infanticide. Postpartum depression is a very serious
condition that many mothers deal with alone because they are ashamed and afraid to tell
someone they are experiencing crazy thoughts. Many people overlook the importance of this
illness and focus on the delivery of the baby more than mental state of mother following birth.
Not only do hospitals need to make screening mandatory during the perinatal period but they
also need ensure that thorough exams are administered to determine which mothers are at high
risk of postpartum depression. These women need support and reassurance because they have no
idea how to deal with these emotional disturbances. Postpartum depression should be screened
and treated effectively and efficiently in hopes of saving a childs life.

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References

Kaminsky, L., Carlo, J., Muench, M., Nath, C. Harrigan, J., and Canterino, J. (2008). The
Journal of Maternal-Fetal and Neonatal Medicine. 21(5), 321-325.
Noveck, J. (2011). Mothers who kill children. Huffington Post.
Ostler, T. and Kopels, S. (2010). Scizophrenia and filicide. Current Womens Health Reviews.
(6), 58-62.
Radano, L. (2007). Postpartum mood disorders:when mothers killthe case of mary ellen
moffitt. Oxford University Press.
Rhodes, A. and Segre, L. (2012) Perinatal depression: a review of US legislation and law. Arch
Womens Mental Health. (16) 259-270.
Shelton, J., Muirhead, Y., and Canning, K. (2010). Ambivalence toward mothers who kill: an
examination of 45 U.S. cases of maternal neonaticide. Behavioral Sciences and the Law.
(28) 812-831.
Spinelli, M. (2004). Maternal infanticide associated with mental illness: prevention and the
promise of saved lives. Am J Psychiatry. 161:(9) 1548-1556.
Spinelli, M. (2009). Postpartum psychosis:detection of risk and management. Am J Psychiatry.
166(4).

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Appendix A: Record of Database Search Form


Database

Search Terms

Qualifier
s

No. No. Screen Out


of
After Reading
Hits Titles and
Abstracts

Academic
Search
Complete
Academic
Search
Complete
PsychInfo
CINAHL
Plus with
Full Text
Social
Sciences
Full Text

Infanticide and postpartum depression

None

14

12

No. of
articles
considered
appropriat
e for topic
2

Infanticide and intervention

None

11

10

Infanticide and Psychosocial factors


Postpartum depression and infanticide

None
None

26
24

24
20

2
4

Mental illness, infanticide, mothers,


and postpartum depression

None

15

13

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Appendix B: Research Article Summary

Author
and
Year

Purpose
and/or
Hypothesis

Kamins
ky et al.
, 2008

Comparing
selfcompleted
Edinburgh
Postnatal
Depression
Scale to
directed
interviews

Shelton,
Muirhea
d, and
Canning
, 2010

Examine
legal
outcomes of
neonaticde
offenders and
identify
potential
variable that
influence
conviction.

Research
Design
(e.g.
randomiz
ed
control,
cross
sectional,
etc.
Case
study
design

Cohort
design

Demograp
hic
characterist
ics of study
participant
s

All
patients
presenting
for
postpartum
care in the
prenatal
clinic.

Sampling Results or
Technique Main
and
Findings
Measures

Random
SelfSampling- completed
surveys
questionaires
can improve
the detection
of
postpartum
depression
and lead to
improved
antepartum
pregnancy.
Female
Systemati The mothers
offender
c
are perceived
who
sampling- as less
committed Case
culpable by
neonaticide records
the system
and
from
and appear to
charged
prosecutor be more
with crime s and
redeemable
related to
medical
perpetrators
the
examiners of child
offense.
homicide.

Study
Limitations

Evaluations
as to when
to perform
screening
and
methods to
implement
access to
care are still
needed.

Sample size
of the study
limits
generalizabi
lity and case
material.

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14

Jones
and
Coast,
2012

Explores the
key role of
social
relationships
in the
postpartum
period.

Case
study
design

Systematic
reviews
specific to
selection
criteria and
search
strategy.

Systemati
c
samplingstudies
including
high and
medium
quality.

Low support
and poor
relationships
with family
were
associated
with
postpartum
depression.

Segre,
OHara,
and
Fisher,
2013

To improve
depression
treatment in
high risk low
income
groups.

Case
study
design

Social
workers,
case
managers,
nurses,
physicians,
and
psychologi
st

Systemati
c-self
reported
knowledg
e before
and after
training

Dennis
and
Vigod,
2013

Determine
the
contribution
of
interpersonal
violence and
substance
abuse with
depressive
symptomatol
ogy.
Examine the
effects of
prenatal
stress on
postpartum
depressive
symptoms
among
African
American
adolescents.

Longitudi
nal Study
design

Women 18
years old
and able to
understand
English.

Systemati
cquestionai
res

The program
gave a
practical
education
that was
useful and
pretest and
post test
scores
improved.
8 weeks after
delivery,
depressive
symptomatol
ogy is
associated
with child
abuse.

Descriptiv First time


e design
adolescent
father
whose
partner
were in the
third
trimester.

Systemati
cPerceived
stress
scale

William
s,
Mance,
Caldwel
l, and
Antonuc
ci, 2012

Prenatal
stress was
related to
depressive
symptoms
but the
fathers had
no influence
on the
depressive
symptoms.

More
qualitative
research
needed to
conceptuali
ze the link
between
mental
well-being
and social
support.
Participatio
ns
evaluation
of
satisfaction
and learning
were
limited to
their self
report.
The
findings
were
inconsistent
with
previous
research.

The sample
was not
representati
ve of the
adolescent
father
population
with
depression
symptoms