Enablers and barriers to seeking help for a postpartum mood disorder

Barriers to perinatal mental health care experiences by midwives and obstetricians and their patients: A rapid review

INTRODUCTION

While perinatal mental health concerns are common, little attention is paid to noticing or addressing these concerns. Midwives and obstetricians are uniquely positioned to universally screen their patients for mental health conditions during the perinatal period, and provide referrals for additional mental health supports if relevant. Previous studies on perinatal mental health care have focused primarily on midwifery care, excluding perinatal healthcare providers such as obstetricians. This rapid review aims to examine the barriers to accessing mental health care during the perinatal period as experienced by obstetricians, midwives, and their patients.

METHODS

A rapid review of literature was conducted on barriers to perinatal mental health care as experienced by patients, midwives, and obstetricians. The search strategy included published literature from PubMed, CINAHL, PsycINFO, and Web of Science published between 2000 and 2020. All documents were screened by two researchers and disagreements were resolved through consensus with a third reviewer. After data from all included articles were extracted, thematic analysis was conducted, and findings were compared with related reviews that focused on mental health access for individuals who accessed midwifery care.

RESULTS

Of the 539 references and documents that were screened, 31 articles met the inclusion criteria. In the extraction phase, country, study objective(s), study design, perspective(s), barriers, and the dimension(s) impacted along the pathway to accessing care were retrieved from the 31 included articles. After all barriers were classified using the Supply-Side Dimensions of Access, we developed a classification framework to further examine stigma at the societal, institutional, and individual levels.

DISCUSSION

While midwives utilize a more holistic approach to care as compared with obstetricians, the barriers identified through this rapid review indicate that obstetricians and their patients face similar struggles to accessing and providing mental health care. Moreover, stigma plays a large role in the barriers experienced by patients, midwives, and obstetricians - at individual and institutional levels.

CONCLUSION

Obstetricians encounter similar stigma-related barriers as midwives in detecting mental health concerns, as well as connecting clients to available mental health resources and supports. Therefore, to effectively eliminate barriers to accessing perinatal mental health care, a systemic change must be enacted throughout all three layers to address the deep-rooted stigma associated with accessing mental health care during the perinatal period.

Effectiveness of aromatherapy for intrapartum and postpartum emotional problems among parturient women: A meta-analysis of randomized controlled trials

AIM

Perinatal negative emotions are common in parturient women, but the problems are often ignored. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that investigated the effectiveness of aromatherapy for intrapartum anxiety (IPA) and postpartum emotional symptoms (PES).

METHODS

We searched PubMed, Embase, Cochrane library, and ClinicalTrials.gov to identify suitable RCTs for analysis, and the study was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Nine RCTs were included. The meta-analysis showed aromatherapy reduced IPA during the early to active phase (standardized mean difference [SMD]: -1.56 [-2.55, -0.61]) and during the transition phase (SMD: -3.30 [-4.97, -1.63]) when compared with controls. For the postpartum period, the meta-analyses showed a reduction of postpartum depression (PPD) at week 2 (SMD: -0.43 [-0.82, -0.03]), and a non-significant trend toward the reduction of PPD at weeks 4-6 (SMD: -0.70 [-1.40, 0.01]).

CONCLUSION

Our study found some evidence supporting the effectiveness of aromatherapy in reducing intrapartum anxiety and PES. We recommend the optional use of aromatherapy for intrapartum and postpartum care.

Contemplating Help-Seeking in Perinatal Psychological Distress-A Meta-Ethnography

Perinatal psychological distress (PPD) may cause delays in help-seeking in the perinatal period, which is crucial for families with small children. Help-seeking theories focus on rational processes of behavior wherein ‘help-seeking’ is viewed as a decision-making process, in which action is preceded by recognizing a problem. We identified the phase prior to actual help-seeking actions as a life situation and a phenomenon through which to gain a deeper understanding from women’s own perspectives. The aim of this study was to integrate and synthesize knowledge of women’s experiences of contemplating seeking help for PPD. We chose interpretative meta-ethnography by Noblit and Hare (1988) and implemented eMERGe guidelines in reporting. The search was performed systematically, and the 14 included studies were evaluated with Critical Appraisal Skills Programme checklist (CASP). We identified seven themes and a metaphor in a lines-of-argument synthesis, showing that contemplating help-seeking is a multidimensional phenomenon. We did not observe a straightforward and linear process (as previous research suggests) but instead a complex process of contemplating help-seeking. A clinical implication is that service providers should work with outreach and develop their tools to connect with mothers with PPD. Another suggestion is to improve training in mental health literacy prior to or during pregnancy.

The Lived Experience of Postpartum Depression: A Review of the Literature

Postpartum depression has been studied from a variety of perspectives and by many disciplines. The aim of this article is to review qualitative literature exploring the first-person accounts of women diagnosed with postpartum depression and highlight the absence of work in madness discourse. Searches of multiple databases (Cumulative Index to Nursing and Allied Health Literature, Sociological Abstracts, Sociology Database, Web of Science, Genderwatch, PILOTS, MedLine from PubMed, PsycINFO) were undertaken. There is a significant gap in literature that exists in relation to the lived experience of women diagnosed with postpartum depression who do not identify as mentally ill.

Insecure Attachment and Other Help-Seeking Barriers among Women Depressed Postpartum

When untreated, postpartum depression (PPD) can severely, negatively affect maternal health, child development, and the wellbeing and functioning of the entire family. Yet, despite screening and treatment programs for PPD, many women who experience depression with onset in the postpartum year do not communicate their symptoms. Negative relational experiences early in life, such as not receiving sensitive help and support when needed, often result in so-called insecure attachment styles, and there is evidence that these may contribute to the development and maintenance of PPD. However, the role of insecure attachment styles in non-help-seeking is unknown for this group. Using mixed quantitative and qualitative methodology, we identified help-seeking barriers of women who experienced depression with onset in the postpartum year but who had not sought help for their depression (N = 37), and explored links to their attachment orientations as assessed through both self-reported attachment style and narrative based attachment script assessment. The sample was non-normative regarding attachment, with an over-representation of avoidant attachment styles. Help-seeking barriers varied systematically with the mother's adult attachment style. Specifically, convictions of a strong self and lack of trust in healthcare professionals constituted a common barrier among women with avoidant attachment styles, while unrealistic expectations about motherhood constituted a barrier for women with secure attachment styles. This new knowledge on how barriers to communicating symptoms and seeking help when suffering from PPD vary systematically with attachment orientation can help formulate individualized, and therefore more efficient, approaches to addressing non-help-seeking behavior in women who suffer in silence.

Optional Web-Based Videoconferencing Added to Office-Based Care for Women Receiving Psychotherapy During the Postpartum Period: Pilot Randomized Controlled Trial

Background

Depression and anxiety during the postpartum period are common, with psychotherapy often being the preferred method of treatment. However, psychological, physical, and social barriers prevent women from receiving appropriate and timely psychotherapy. The option of receiving psychotherapy through videoconferencing (VC) during the postpartum period presents an opportunity for more accessible and flexible care.

Objective

The aim of this study was to assess the feasibility, acceptability, and preliminary effectiveness of optional VC added to usual office-based psychotherapy, with a psychotherapist during the postpartum period.

Methods

We conducted a pilot randomized controlled trial with 1:1 randomization to office-based care (treatment as usual; TAU) or office-based care with the option of VC (treatment as usual plus videoconferencing; TAU-VC) for psychotherapy during the postpartum period. We assessed the ability to recruit and retain postpartum women into the study from an urban perinatal mental health program offering postpartum psychotherapy, and we evaluated the uptake, acceptability, and satisfaction with VC as an addition to in-person psychotherapy. We also compared therapy attendance using therapist logs and symptoms between treatment groups. Symptoms were assessed at baseline and 3 months postrandomization with the Edinburgh Postnatal Depression Scale, Generalized Anxiety Disorder 7-item, and Parental Stress Scale. Furthermore, 3-month scores were compared between groups with intention-to-treat linear mixed-effects models controlling for baseline score.

Results

We enrolled 38 participants into the study, with 19 participants in each treatment group. Attendance data were available for all participants, with follow-up symptom measures available for 25 out of 38 participants (66%). Among the 19 TAU-VC participants, 14 participants (74%) utilized VC at least once. Most participants were highly satisfied with the VC option, and they reported average savings of Can $26 and 2.5 hours in travel and childcare expenses and time per appointment. There were no significant differences between the 2 groups for psychotherapy attendance or symptoms.

Conclusions

The option of VC appears to be an acceptable method of receiving psychotherapy for postpartum women, with benefits described in costs and time savings. On the basis of this small pilot sample, there were no significant differences in outcomes between office-based care with or without the option of VC. This study has demonstrated the feasibility of such a program in an urban center, which suggests that a larger study would be beneficial to provide evidence that is more conclusive.

Paternal Perinatal Mental Health: At-Risk Fathers’ Perceptions of Help-Seeking and Screening

Given the prevalence of paternal perinatal mental health concerns, researchers have suggested introducing routine screening. However, little is known about the acceptability of perinatal screening measures in male populations. Furthermore, the need for screening is influenced by men’s perinatal help-seeking behaviors. A thematic analysis of interview data from nine men at risk of paternal perinatal depression and/or anxiety investigated both acceptability of screening and help-seeking behaviors. Themes indicate that routine screening is desired, but acceptability is influenced by perceptions of its intention and possible outcomes. Findings also suggest that barriers to men’s perinatal help-seeking are likely to be minimized by increased awareness and normalization. Future research and clinical practice should account for complexities raised by men’s perceptions of health care services.

Women's help-seeking behaviours within the first twelve months after childbirth: A systematic qualitative meta-aggregation review✰

INTRODUCTION

Women within the first 12 months after birth often do not seek professional help for post-childbirth morbidities. This systematic review uses the Behavioural Model of Health Services Use (BMSHU) to assess the barriers and facilitators to women's help-seeking from health professionals during the first twelve months after childbirth.

METHOD

A qualitative meta-aggregation was used for the review. Systematic searching of Medline via Ovid, CINAHL, EMBASE and Web of Science revealed an initial 691 papers, of which 48 were reviewed. Nine qualitative papers, peer-reviewed, English papers and published from 2000 to 2017, were identified. Studies selected according to the pre-defined protocol were assessed using The Joanna Briggs Institute Critical Appraisal Tools (JBIQARI).

RESULTS

Seventy-five findings were identified from the approved articles and aggregated into seven categories. Key themes that emerged were that women did not seek help because they accepted problems as a part of the motherhood role or because they feared being judged negatively. Women shared their issues with family and friends as trusted people. Low health literacy was a barrier to seeking help, as was lack of access to proper care and poor advice from families. The women's cultural context was an essential influence in whether or not they sought help. According to BMSHU, a model of key influences on women's help-seeking for maternal morbidities introduced.

Barriers to Help-Seeking Behavior Among Women With Postpartum Depression

Postpartum depression affects approximately 900,000 women annually, but only approximately 6% of these women seek psychological help (Postpartum, Progress, 2016). This lack of help-seeking behavior must be addressed to decrease the negative effects of postpartum depression on maternal and infant outcomes. The purpose of this article is to describe the barriers that prevent women from seeking psychological help and provide suggestions to address these barriers.

Migrant women's experiences, meanings and ways of dealing with postnatal depression: A meta-ethnographic study

Aim

To conduct a meta-ethnographic study of the experiences, meanings and ways of ‘dealing with’ symptoms or a diagnosis of postnatal depression amongst migrant women living in high income countries.

Background

Prevalence of postnatal depression is highest amongst women who are migrants. Yet many women do not seek help for their symptoms and health services do not always respond appropriately to migrant women’s needs. Studies have reported migrant women’s experiences of postnatal depression and it is timely to synthesise findings from these studies to understand how services can be improved.

Design

A meta-ethnographic synthesis of 12 studies reported in 15 papers

Data sources

Five databases were searched for papers published between January 1999 and February 2016

Review methods

The quality of included studies was assessed using the Critical Appraisal Skills Program tool. The synthesis process was guided by the seven steps of meta-ethnography outlined by Noblit and Hare.

Findings

Four key metaphors were identified: “I am alone, worried and angry—this is not me!”; ‘Making sense of my feelings’ ‘Dealing with my feelings’ and ‘What I need to change the way I feel!’. Primarily women related their feelings to their position as a migrant and as women, often living in poor socio-economic circumstances and they were exhausted keeping up with expected commitments. Many women were resourceful, drawing on their personal strengths and family / community resources. All the studies reported that women experienced difficulties in accessing appropriate services.

Conclusion

The meta-ethnographic study demonstrates the impact of migration on perinatal mental health, particularly for women lacking family support, who have no employment, a precarious migration status and/or relationship conflict. Migrant women are resourceful and this requires support through appropriate services. Further research is needed to evaluate effective support strategies for migrant women in the perinatal period.

Antenatal psychosocial risk status and Australian women's use of primary care and specialist mental health services in the year after birth: a prospective study

BACKGROUND

Poor mental health in the perinatal period can impact negatively on women, their infants and families. Australian State and Territory governments are investing in routine psychosocial assessment and depression screening with referral to services and support, however, little is known about how well these services are used. The aim of this paper is to report on the health services used by women for their physical and mental health needs from pregnancy to 12 months after birth and to compare service use for women who have been identified in pregnancy as having moderate-high psychosocial risk with those with low psychosocial risk.

METHODS

One hundred and six women were recruited to a prospective longitudinal study with five points of data collection (2-4 weeks after prenatal booking, 36 weeks gestation, 6 weeks postpartum, 6 months postpartum and 12 months postpartum) was undertaken. Data were collected via face-to-face and telephone interviews, relating to psychosocial risk factors, mental health and service use. The prenatal psychosocial risk status of women (data available for 83 of 106 women) was determined using the Antenatal Risk Questionnaire (ANRQ) and was used to compare socio-demographic characteristics and service use of women with 'low' and 'moderate to high' risk of perinatal mental health problems.

RESULTS

The findings indicate high use of postnatal universal health services (child and family health nurses, general practitioners) by both groups of women, with limited use of specialist mental health services by women identified with moderate to high risk of mental health problems. While almost all respondents indicated that they would seek help for mental health concerns most had a preference to seek help from partners and family before accessing health professionals.

CONCLUSION

These preliminary data support local and international studies that highlight the poor uptake of specialist services for mental health problems in postnatal women, where this may be required. Further research comparing larger samples of women (with low and psychosocial high risk) are needed to explore the extent of any differences and the reasons why women do not access these specialist services.

Barriers and Facilitators to the Use of Mental Health Services by Women With Elevated Symptoms of Depression and Their Partners

This qualitative descriptive study explored the barriers and facilitators to the use of mental health services reported by women with elevated symptoms of depression in the postpartum period and their partners. Data were collected through individual semi-structured interviews of 30 heterosexual couples. Content analysis revealed five principal barriers and facilitators: (a) accessibility and proximity, (b) appropriateness and fit, (d) stigma, (e) encouraged to seek help, and (f) personal characteristics. The study highlights the importance of barriers and facilitators to be taken into consideration in order to promote the use of mental health services for women with elevated symptoms of depression in the postpartum period.

The everyday life information seeking behaviours of first-time mothers

Purpose

– The purpose of this paper is to investigate the everyday life information seeking behaviours of first-time mothers, as they encounter new, significant and pressing information needs which arise alongside their new responsibilities.

Design/methodology/approach

– A qualitative approach combined narrative interviews with participatory methods to facilitate engagement and remain sensitive to the social context.

Findings

– Mothers particularly valued the experiential nature of information received from peers or family members. However, fear of judgement influenced their use of interpersonal sources, both on- and off-line. Their accounts of information seeking contained instances of confusion, tension, conflict and information overload. Feeling under pressure to be “good mothers”, they withheld information needs from others, including healthcare professionals.

Research limitations/implications

– There was a notable absence of younger ( < 20 year old) and/or less educated mothers in the study. This corresponds to previous findings which report that very young mothers are reluctant to participate in support groups with older mothers. They remain an understudied and potentially marginalised group.

Practical implications

– The findings show how social support groups can mitigate for societal pressures which impact upon mothers’ information behaviour, allowing them to connect and share information within a trusted environment. The study highlights the importance of healthcare and information services professionals remaining sensitive to such pressures. Relatedly, the finding that public libraries are used very little has implications for audience engagement and service provision.

Originality/value

– Focused upon first-time mothers’ information behaviours during the early stages of parenthood, the study provides insight into how relationships and experiences with others influence information seeking behaviours. It provides evidence that fear of judgement can influence information seeking behaviour, helping us to understand why some information sources, although considered important and useful, can be used very little.

Predictors of depressive symptoms in older Japanese primiparas at 1 month post-partum: A risk-stratified analysis

AIM

Older maternal age has become more common in Japan. Studies suggest that older maternal age and primiparity are associated with post-partum depression. The present study aimed to identify predictors of post-partum depression in older Japanese primiparas at 1 month post-partum.

METHODS

Participants were 479 primiparas aged 35 years and over, drawn from a prospective cohort study. Data were collected using self-report questionnaires. Depression was measured with the Japanese version of the Edinburgh Postnatal Depression Scale. Stepwise logistic regression analysis was conducted on binary outcome variables of depression at 1 month post-partum, along with a stratified analysis based on the risk status of depression.

RESULTS

Five predictors were identified: (i) the depression score during hospital stay; (ii) financial burden; (iii) dissatisfaction with appraisal support; (iv) physical burden in daily life; and (v) concerns about infant caretaking. Stratified analysis identified dissatisfaction with instrumental support in the low-risk group, and the Child-care Value Scale score as unique predictors in the high-risk group.

CONCLUSION

These results highlight the importance of early assessment of depressive symptoms and the provision of continuous care.

Causes of women's postpartum depression symptoms: Men's and women's perceptions

OBJECTIVES

To describe men's and women's perceptions of the causes of women's PPD symptoms and to explore similarities and differences between men's and women's perceptions.

DESIGN

Qualitative-descriptive study involving in-depth semi-structured individual interviews and content analysis.

SETTING

In-home interviews of participants recruited in two tertiary care hospitals, both in urban centres of the province of Quebec, Canada.

PARTICIPANTS

Both members of 30 heterosexual couples from which women scored at least 12 on the Edinburgh Postnatal Depression Scale.

FINDINGS

Participants described nine causes underlying women's depressive symptoms: societal expectations and pressure on women, physical health problems, transition to parenthood, social connectedness, personality and past psychological history, child health and temperament challenges, unmet care needs, unmet expectations for childbirth, and other life stressors. With one exception, all causes were endorsed by both men and women. Only men mentioned societal pressure on women.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Men and women mainly perceived similar causes, which could be explained by socio-cultural factors and extended paternal leaves. Understanding men's and women's perceptions could help tailoring health- care professionals' interventions to couples' needs.

Stressful events during pregnancy and postpartum depressive symptoms

BACKGROUND

Understanding the influence of perinatal stressors on the prevalence of postpartum depressive symptoms (PDS) and help-seeking for PDS using surveillance data can inform service provision and improve health outcomes.

METHODS

We used Massachusetts Pregnancy Risk Assessment Monitoring System (MA-PRAMS) 2007-2010 data to evaluate associations between selected perinatal stressors and PDS and with subsequent help-seeking behaviors. We categorized 12 stressors into 4 groups: partner, traumatic, financial, and emotional. We defined PDS as reporting "always" or "often" to any depressive symptoms on PRAMS Phase 5, or to a composite score ≥10 on PRAMS Phase 6 depression questions, compared with women reporting "sometimes," "rarely" or "never" to all depressive symptoms. The median response time to MA-PRAMS survey was 3.2 months (interquartile range, 2.9-4.0 months). We estimated prevalence ratios (PRs) and 95% confidence intervals (95% CIs) using modified Poisson regression models, controlling for socioeconomic status indicators, pregnancy intention and prior mental health visits.

RESULTS

Among 5,395 participants, 58% reported ≥1 stressor (partner=26%, traumatic=16%, financial=29% and emotional=30%). Reporting of ≥1 stressor was associated with increased prevalence of PDS (PR=1.68, 95% CI: 1.42-1.98). The strongest association was observed for partner stress (PR=1.90, 95% CI: 1.51-2.38). Thirty-eight percent of mothers with PDS sought help. Mothers with partner-related stressors were less likely to seek help, compared with mothers with other grouped stressors.

CONCLUSIONS

Women who reported perinatal common stressors-particularly partner-related stressors-had an increased prevalence of PDS. These data suggest that women should be routinely screened during pregnancy for a range of stressors and encouraged to seek help for PDS.

Treatment-seeking behaviors and attitudes survey among women at risk for perinatal depression or anxiety

OBJECTIVE

To identify treatment preferences, help-seeking steps, and responses from social support persons among women at risk for perinatal depression or anxiety.

DESIGN

Prospective descriptive survey of women at risk for depression or anxiety.

SETTING

Private hospital in central Ohio.

PARTICIPANTS

From an original sample of 220 women recruited between the third trimester of pregnancy and 2 months postpartum, we selected 36 women reporting clinically significant levels of depressive or anxious symptoms to complete a telephone survey. An additional 17 family members were surveyed as identified social support persons.

METHODS

Two telephone interviews including survey and open-ended responses were administered to participants approximately 6 weeks apart. Social support persons also received survey interviews assessing their opinions about the participants' mood changes.

RESULTS

More participants reported consulting friends and family about symptoms (83%) than consulting health care professionals (50%). However, most participants and their social support persons disagreed about the primary illness cause (66%). Approximately two thirds of participants recalled receipt of depression screening and feedback, but far fewer received referral or treatment via pharmacotherapy (36.1%) or psychotherapy (16.7%).

CONCLUSION

Findings suggest screening and referral can be enhanced through expanding perinatal mental health education to target social support persons as they are often consulted by women when determining whether depression exists or should be treated. Further, a more active, personalized referral processes should be used routinely in addition to screening and education to facilitate appropriate treatment.