Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review

Proposing a two-stage screening approach to distinguish between transient and enduring postnatal depressive symptoms: A prospective cohort study

Background

Screening for perinatal depression using the Edinburgh Postnatal Depression Scale (EPDS) improves detection and increases health service utilization. However, previous studies with antenatal samples indicate that positive screenings might reflect transient distress that resolves without intervention, raising concerns about over-pathologizing typical postnatal responses and inefficiencies in referral practices. Therefore, distinguishing between transient and enduring depressive symptoms for appropriate referrals to secondary services is crucial, highlighting the need for a refined screening practice.

Objectives

We aimed to assess the prevalence of transient distress among postnatal women who initially screened positive on the EPDS and evaluate the effectiveness of a refined two-stage screening approach. Three research questions were addressed: Can the "transient phenomenon" be replicated in a postnatal sample? Can initial screening data predict transient status? What are the implications of adopting a two-stage screening approach?

Methods

In a prospective cohort study, 427 postnatal women in Copenhagen who scored above the cut-off on their initial EPDS screening (EPDS-1) underwent a second screening (EPDS-2) 1-4 weeks later, without intervention in between. We analyzed the predictive power for transient versus enduring distress using EPDS-1 total scores, responses to item 10 ("self-harm item"), parity, maternal age, and a history of depression. Three screening scenarios were compared for their clinical and ethical implications: (i) a traditional single screening approach where all individuals screening positive at EPDS-1 are directly referred to secondary services, (ii) a simple two-stage approach where all positive screenings at EPDS-1 undergo a second screening before referral, and (iii) a refined two-stage screening approach where selected criteria determine immediate referral or further screening.

Results

Among women who screened positive, 29.3 % displayed transient distress with a clinically meaningful decrease in EPDS scores. An EPDS-1 score of 15 or more was the most robust predictor of enduring symptoms (OR = 6.28, 95 % CI 3.5-11.8; Absolute Risk = 90.4 %) and was used along with a positive score on item 10 as indicators of immediate referral in scenario-iii. The refined two-stage approach reduced unnecessary referrals by 24 %, directly referred 60 % of women with enduring symptoms, and effectively managed suicidal risk.

Conclusions

A substantial proportion of postnatal women experience transient symptoms that are distinguishable from enduring symptoms through a refined two-stage screening strategy. This approach significantly improves referral efficiency and minimizes over-pathologization, enhancing clinical practice in perinatal mental health.

Barriers and Facilitators to Accessing Mental Health Supports Among Black Perinatal Women: Application of the Patient-centered Access Framework

Black perinatal women experience high rates of mental health disorders including depression and traumatic stress disorders, but also face significant disparities in access to mental health treatment. We conducted focus groups with 43 Black perinatal women in the Southeastern U.S. to understand barriers and facilitators that affect their access to mental health services during pregnancy and post-partum as well as recommendations to promote culturally response trauma screening and services. This study leveraged Levesque's patient-centered access framework to inform coding and analysis. Barriers to access and corresponding recommendations were identified among all five dimensions and abilities of the patient-centered access framework. Medical mistrust was a key theme that spanned several dimensions-including the likelihood of seeking care and comfort disclosing mental health concerns to a provider. Study recommendations included the need for provider training on delivering trauma-informed, culturally responsive care, increased transparency about trauma screeners to mitigate patient mistrust, and the establishment of integrative care approaches to reduce time and cost barriers to accessing mental health supports.

Improving the maternity experience for Black, African, Caribbean and mixed-Black families in an integrated care system: a multigroup community and interprofessional co-production prioritisation exercise using nominal group technique

BACKGROUND

Ethnic inequities in maternity care persist in England for Black, African, Caribbean and mixed-Black heritage families, resulting in poorer care experiences and health outcomes than other minoritised ethnic groups. Co-production using an integrated care approach is crucial for reducing these disparities and improving care quality and safety. Therefore, this study aimed to understand the alignment of health and local authority professional perspectives with community needs on how to improve maternity experiences for this ethnic group within a London integrated care system (ICS).

METHODS

Between March and June 2024, five workshops were conducted with health professionals, local authorities, voluntary, community and social enterprise (VCSE) sector and the public from Black, African, Caribbean and mixed-Black heritage backgrounds across the North West London ICS. Using the nominal group technique (NGT), attendees prioritised ideas to improve the experience of maternity care for families from Black, African, Caribbean and mixed-Black heritage backgrounds, which were thematically synthesised using framework analysis.

RESULTS

Fifty-four attendees, covering primary, secondary, regional and national health professionals, public health teams from three local authorities, VCSE sector and the public, generated 89 potential interventions across 11 themes. All attendees prioritised improving staff knowledge and capacity in culturally competent care and communication. Community-identified needs for advocacy mechanisms and mental health support throughout the maternity pathway were not reflected in professional priorities.

CONCLUSION

The study highlights the need for an integrated, community-centred approach beyond hospital settings when addressing ethnic inequities in maternity care, recognising key differences between community and professional priorities within an ICS. Leveraging lived experience expertise to lead the NGT community workshops was essential in building trust and buy-in of the overall prioritisation process.

Task-sharing and telemedicine delivery of psychotherapy to treat perinatal depression: a pragmatic, noninferiority randomized trial

Task-sharing and telemedicine can increase access to effective psychotherapies. Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) is pragmatic, multisite, noninferiority, four-arm trial that tested the non-inferiority of provider (non-specialist vs. specialist providers) and modality (telemedicine vs. in-person) in delivering psychotherapy for perinatal depressive symptoms. Across three university-affiliated networks in the United States and Canada, pregnant and postpartum adult participants were randomized 1:1:1:1 to each arm (472 nonspecialist telemedicine, 145 nonspecialist in-person, 469 specialist telemedicine and 144 specialist in-person) and offered weekly behavioral activation treatment sessions. The primary outcome was depressive symptoms (Edinburgh Postnatal Depression Scale (EPDS)) and the secondary outcome was anxiety (Generalized Anxiety Disorder (GAD-7)) symptoms at 3 months post-randomization. Between 8 January 2020 and 4 October 2023, 1,230 participants were recruited. Noninferiority was met for the primary outcome comparing provider (EPDS: nonspecialist 9.27 (95% CI 8.85-9.70) versus specialist 8.91 (95% CI 8.49-9.33)) and modality (EPDS: telemedicine 9.15 (95% CI 8.79-9.50) versus in-person 8.92 (95% CI 8.39-9.45)) for both intention-to-treat and per protocol analyses. Noninferiority was also met for anxiety symptoms in both comparisons. There were no serious or adverse events related to the trial. This trial suggests compelling evidence for task-sharing and telemedicine to improve access to psychotherapies for perinatal depressive and anxiety symptoms. ClinicalTrials.gov NCT04153864.

Staff-reported barriers and facilitators to the implementation of healthcare interventions within regional and rural areas: a rapid review

BACKGROUND

Individuals in rural areas consistently demonstrate higher mortality and morbidity rates, and poorer access to healthcare, compared to their metropolitan counterparts. Optimizing the implementation of evidence-based interventions can reduce these inequities. Existing literature outlines numerous barriers and facilitators to the implementation of healthcare interventions, but these are generally not specific to rural areas. This rapid review aims to synthesize barriers and facilitators to the implementation of healthcare interventions in regional and rural healthcare services as reported by healthcare staff, including clinicians, managers, and administrators.

METHODS

A systematic search for peer-reviewed publications was conducted using CINAHL, PsycINFO, Medline, and Embase databases (1/1/2000-29/08/2023). Eligible publications were primary research articles published in English, assessing staff-reported barriers and facilitators to implementing healthcare interventions within regional and rural areas of high-income countries. Qualitative, quantitative, and mixed-methods designs were included. Eligible healthcare settings encompassed acute, sub-acute, primary care, community health, and aged care. Barrier and facilitator data were coded and grouped into sub-themes and broader themes, with results presented narratively.

RESULTS

Thirty-nine publications met the inclusion criteria. Most studies were conducted in Australia or the USA (both n = 18, 46%), within primary care (n = 13, 33%) or hospital settings (n = 12, 31%) in rural (n = 22, 56%) or regional (n = 9, 23%) locations. Implementation barriers and facilitators were grouped into four overarching themes: intervention-level (intervention feasibility and fit; complexity; privacy and confidentiality); staff-level (staff attitudes and beliefs; knowledge, skills, and confidence; staff roles and professional identity), patient-level (patient characteristics; attitudes), and system-level (leadership support; environmental resources and context; geographic vastness; networks and communication).

CONCLUSIONS

These findings provide essential guidance for policymakers, healthcare leaders, and researchers in planning and designing future implementation efforts in regional and rural healthcare settings. By considering factors across intervention, staff, patient, and system levels, stakeholders can address challenges and leverage local strengths to enhance implementation success and reduce health disparities.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023470736. Registered 19/10/2023.

The continuity relationship makes caring for women with anxiety and depression easier, but it is also a heavy responsibility

BACKGROUND

Perinatal depression and anxiety, experienced by about 20 % of women, are a risk factor for associated morbidities for mothers and babies, including risk of suicide and preterm birth. Traditionally this group of women have not been able to access midwifery continuity of care despite the known benefits.

AIM

This study aims to explore the experiences of midwives providing continuity of care to women with perinatal mental health disorders and women's experiences of receiving care in a continuity of care model.

METHODS

We used a mixed methods design incorporating a qualitative exploratory study using a qualitative descriptive approach [1] to understand midwives experiences. We also explored the women's experience of receiving continuity of care and observed mothers interacting with their babies. The quantitative data was collected using the Parenting Interactions with Children Checklist of Observations (PICCOLO) [2], described in detail below, to measure these interactions.

RESULTS

Two overarching themes were generated: Continuity is protective, with subthemes Safe in their hands, Healing from previous trauma and Sustaining breastfeeding; and Having exceptional care deserves equitable access, with sub-themes Having your choices respected, Having a meaningful birth experience, Providing exceptional care requires support.

CONCLUSION

This study adds to current literature that indicates midwifery continuity of care as emotionally protective, which is particularly important for women with perinatal mental health conditions and may have ongoing positive effects that foster wellbeing. Experienced as providing 'exceptional' care, our findings demonstrate an urgent need to increase access to such models, and ensuring midwives have equally 'exceptional' training, support and referral pathways, to ensure their sustainability.

Anxiety Sensitivity in the Perinatal Period: A Scoping Review

Background

Anxiety Sensitivity (AS), the trait-like tendency to interpret anxiety-related sensations as harmful, is a well-established risk factor for anxiety disorders and other mental health conditions. Less is known about the role of AS in perinatal mental health-encompassing pregnancy and the postpartum period-despite the heightened risk for anxiety and anxiety-related disorders such as Obsessive Compulsive Disorder and Posttraumatic Stress Disorder (PTSD).

Objective

The goal of this scoping review was to examine 1) the state of research on AS in perinatal populations, 2) its relationship with mental health and pregnancy-specific outcomes, and 3) its integration into clinical interventions.

Methods

We conducted a systematic literature search using PubMed, Scopus, PsycInfo, CINAHL. Study inclusion criteria were: 1) participants were pregnant or <1 year postpartum, and 2) AS was assessed.

Results

Twenty studies met inclusion criteria. Most studies examined cross-sectional or prospective relationships between AS and mental health and related outcomes, finding positive association between AS and PTSD symptoms, depression symptoms, anxiety symptoms, fetal health anxiety, pregnancy-related anxiety, and fear of childbirth. Results were more mixed for aspects of pain during labor (e.g., anesthetic consumption). Two Randomized Clinical Trials and two case studies included AS as an outcome measure.

Conclusions

This review extends previous findings in the general population by highlighting associations between AS and perinatal mental health. Future research should expand the breadth scope of outcomes assessed and investigate AS as a modifiable target in interventions to enhance perinatal mental health outcomes.

An implementation facilitation intervention to improve the musculoskeletal X-ray reporting by radiographers across London

BACKGROUND

The National Healthcare Service (NHS) radiology service delivery in London is representative of the current pressures and challenges faced in England of Musculoskeletal (MSK) X-ray reporting workforce shortages, and national turnaround time (TATs) targets. The implementation project evaluated facilitation as a strategy to achieve the NHS England 50% target for all MSK X-rays to be reported by radiographers.

METHODS

The project was an eight-month multi-centre (n = 5 London NHS Trusts) study applying the Promoting Action on Research Implementation in Health Services (PARIHS) framework with embedded mixed-methods evaluation. Initial observational data using the Context Assessment Index (CAI) tool and the Workplace Culture Critical Analysis Tool (WCCAT) set the implementation interventions which comprised external facilitation, to support internal facilitators action learning activities. Evaluation data comprised monthly reporting performance, systems mapping, interviews.

RESULTS

System mapping allowed a perspective beyond the characteristics of the NHS Trusts involved (small single site hospitals to large multi-sites hospitals) of mixed clinical duties, scope of practice, reporting session allocation, and equipment used. CAI scores for workplace culture demonstrated x ¯ = 73.7% (SD 6.8; 95%CI 8.49), leadership scored x ¯ = 69.3% (SD 7.3; 95% CI 9.17), and evaluation scored x ¯ = 75.5% (SD 6.9; 95% CI 98.63). WCCAT observations provided themes for facilitation focusing on remote reporting, insourcing backlogs, prioritising worklists to reduce breaching TATs, reporting metrics, and reducing auto reporting. The combined reporting of MSK X-rays by London radiographers during this study achieved x ¯ = 53.7%.

CONCLUSION

This study had an innovative approach using an implementation facilitation framework to improve service delivery. The clinical workplace context in which MSK X-ray reporting by radiographers occurs was key to implementing change. The complexities of sustaining and upscaling MSK X-ray reporting by radiographers to meet the NHS England target of 50% are varied and require local champions to facilitate and drive change at organisational levels. It is recommended that there are dedicated 'resources' to sustain implementations with a community of practice for support. Workplace leadership and stakeholder networks are needed to sustain improved working practices and embrace regular evaluation and monitoring of service delivery performance.

Canadian Network for Mood and Anxiety Treatments 2024 Clinical Practice Guideline for the Management of Perinatal Mood, Anxiety, and Related Disorders: Guide de pratique 2024 du Canadian Network for Mood and Anxiety Treatments pour le traitement des troubles de l'humeur, des troubles anxieux et des troubles connexes périnatals

BackgroundThe Canadian Network for Mood and Anxiety Treatments (CANMAT) publishes clinical practice guidelines for mood and anxiety disorders. This CANMAT guideline aims to provide comprehensive clinical guidance for the pregnancy and postpartum (perinatal) management of mood, anxiety and related disorders.MethodsCANMAT convened a core editorial group of interdisciplinary academic clinicians and persons with lived experience (PWLE), and 3 advisory panels of PWLE and perinatal health and perinatal mental health clinicians. We searched for systematic reviews of prevention and treatment interventions for perinatal depressive, bipolar, anxiety, obsessive-compulsive and post-traumatic stress disorders (January 2013-October 2023). We prioritized evidence from reviews of randomized controlled trials (RCTs), except for the perinatal safety of medications where reviews of large high-quality observational studies were prioritized due to the absence of RCT data. Targeted searches for individual studies were conducted when systematic reviews were limited or absent. Recommendations were organized by lines of treatment based on CANMAT-defined levels of evidence quality, supplemented by editorial group consensus to balance efficacy, safety, tolerability and feasibility considerations.ResultsThe guideline covers 10 clinical sections in a question-and-answer format that maps onto the patient care journey: case identification; organization and delivery of care; non-pharmacological (lifestyle, psychosocial, psychological), pharmacological, neuromodulation and complementary and alternative medicine interventions; high-risk clinical situations; and mental health of the father or co-parent. Equity, diversity and inclusion considerations are provided.ConclusionsThis guideline's detailed evidence-based recommendations provide clinicians with key information to promote the delivery of effective and safe perinatal mental healthcare. It is hoped that the guideline will serve as a valuable tool for clinicians in Canada and around the world to help optimize clinical outcomes in the area of perinatal mental health.

Adverse childhood experiences in firstborns and mental health risk and health-care use in siblings: a population-based birth cohort study of half a million children in England

BACKGROUND

Adverse childhood experiences (ACEs) often affect multiple children within families, yet studies tend to focus on the health outcomes of individual children, underestimating the needs of affected families. We aimed to examine the association between firstborns exposed to ACEs between 1 year before and 2 years after birth (the first 1000 days) and the risks of mental health problems, mental health-related health-care contacts, and all-cause hospital admissions in multiple children from the same mother, compared to firstborns without ACEs.

METHODS

We derived a population-based birth cohort in England using linked electronic health records for first-time mothers (aged 14-55 years) with their children (born 2002-18). We followed up the cohort from 1 year before birth up to 18 years after birth across the Clinical Practice Research Datalink GOLD and Aurum databases (primary care), Hospital Episode Statistics (secondary care), and the Office of National Statistics (death registrations) between April 1, 2001, and March 31, 2020. We included six different ACE domains, including child maltreatment, intimate partner violence, maternal substance misuse, maternal mental health problems, adverse family environments, and high-risk presentations of child maltreatment, in the records of the mother or the firstborn in the first 1000 days. The primary outcome was the number of children (aged 5-18 years) with recorded mental health problems per mother. We used adjusted and weighted negative binomial regression models to estimate incidence rate ratios.

FINDINGS

Of 333 048 firstborns and their mothers, 123 573 (37·1%) had any ACEs between 1 year before and 2 years after birth, and 65 941 (19·8%) of all mothers had at least one child with a mental health problem between ages 5 years and 18 years (median follow-up 11·4 years [IQR 9·2-14·1]). Mothers with firstborns with ACEs had 1·71 (95% CI 1·68-1·73) times as many children in total with mental health problems (mean 29·8 children per 100 mothers, 29·4-30·1) compared with mothers without firstborns with ACEs (mean 17·4 children per 100 mothers, 17·3-17·6), translating into a mean difference of 12·3 (95% CI 11·9-12·7) additional children with mental health problems per 100 mothers. These mothers also had increased incidence rates of children with all-cause emergency admissions and mental health-related contacts. There was no significant difference in the risk of mental health problems between firstborn and later-born children.

INTERPRETATION

ACEs in firstborns during the first 1000 days were associated with increased mental health problems and health-care needs in multiple children in the same family. The findings highlight the importance of early identification of vulnerable first-time parents and firstborns and increased policy focus on sustained support beyond the first 1000 days to promote healthier long-term family outcomes. Future evaluations of interventions should include the health outcomes of multiple children within families.

FUNDING

NIHR Policy Research Programme.

A systematic review of the clinical practice guidelines for the assessment, management and treatment of eating disorders during the perinatal period

BACKGROUND

Eating disorders during the perinatal period can pose significant risks to both the mother and the baby. Clinical practice guidelines include statements of expected practice intending to improve effectiveness and quality of care within health care services. This systematic review aimed to identify and synthesise current clinical practice guideline recommendations on the assessment, management and treatment of eating disorders during the perinatal period.

METHODS

Three bibliographic databases and five guideline repository databases were searched alongside the grey literature. Guidelines were screened against eligibility criteria and recommendations for the assessment, management or treatment of eating disorders during the perinatal period were extracted. All included guidelines were assessed for quality using the AGREE-II tool. Recommendations were analysed and summarised using narrative synthesis.

RESULTS

From the 242 records screened, 17 met inclusion criteria. Guideline quality ranged from three out of seven to seven out of seven. Six overall recommendations were formed from the narrative synthesis of data: 1) Early detection: recognising the signs and symptoms, 2) Assessment and screening: a three-pronged approach, 3) Educating and supporting the mother: the importance of knowledge, 4) Cross-system collaboration, 5) Psychological, pharmacological and medical treatment, and 6) Continued monitoring.

CONCLUSION

Perinatal eating disorder guideline recommendations were fairly consistent but showed considerable variability in quality and depth of recommendations. Recommendations require further contextualisation, to allow them to be operationalised and implemented within services. The review findings provide an initial framework for health care professionals responsible for supporting women with eating disorders during the perinatal period, and have several implications for policy, service delivery and health outcomes for women and their families.

Prevalence of fear of childbirth, its risk factors and birth outcomes in Australian multiparous women

BACKGROUND

Fear of childbirth (FoC) is a widespread issue that impacts the health and well-being of mothers and newborns. However, there is inconsistency regarding the prevalence of FoC in the and there is limited research on the prevalence of FoC among Australian pregnant women.

AIM

To investigate the prevalence of FoC, its risk factors and birth outcomes in Australian multiparous women.

METHODS

In this prospective cohort quantitative study, 212 multiparous women were recruited from antenatal clinics at Westmead Hospital in western Sydney from 2019 to 2022. Pregnant women who attended antenatal visits and met the inclusion criteria signed the consent forms and completed several online questionnaires at baseline. After they gave birth, their birth outcomes were collected from the hospital’s medical record database. The data were analyzed using SPSS software and descriptive statistics, χ² test, independent samples t-test, and multivariable logistic regression analysis.

RESULTS

Out of 212 participants, 24% experienced a high level of FoC and 7% experienced severe FoC. The χ² test results revealed that a family income of ≤ $100000, no alcohol intake during pregnancy, pre-existing health problems, previous caesarean section (emergency or planned), and previous neutral/traumatic childbirth experiences were significantly associated with higher levels of FoC (P < 0.05). Other risk factors included being moderately to very worried and fearful about the upcoming birth, having severe to extremely severe anxiety throughout pregnancy, and expressing low relationship satisfaction. According to multivariable logistic regression, the odds of a high level of FoC were higher in women with anxiety, a history of traumatic childbirth experience, a history of sexual assault during childhood, pre-existing health problems, and lower relationship satisfaction (P < 0.05).

CONCLUSION

High-severe levels of FoC are experienced by pregnant multiparous women and are affected by several demographic factors. However, due to the small sample size in the present study, further studies with larger sample sizes are required to draw a firm conclusion on the prevalence of severe FoC among multiparous women and its associated risk factors and birth outcomes.

Who decides to follow the referral advice after a positive postpartum depression screening result? Reflections about the role of sociodemographic, health, and psychological factors from psychological consultations - a cross-sectional study

BACKGROUND/OBJECTIVE

Postpartum depression (PPD), a common and severe mental health problem, affects about 13-20 % of new mothers. Despite the psychological intervention's effectiveness, referral uptake rates among affected women are low. In the article, we aim to characterise those new mothers who adhered to referral advice after a positive PPD screening result.

METHOD

9161 women had taken part in a midwife-led PPD screening. Those who scored equal to or more than ten points on the Edinburgh Postnatal Depression Scale (EPDS) were referred for psychological consultations (12 %, n = 1109). We used data gathered during the realization of a PPD prevention programme. The following measures were used: EPDS, a sociodemographic and health data survey, and psychological consultation cards.

RESULTS

We found that only 85 (8 %) of referred mothers later enrolled in psychological consultations. Those mothers who adhered to the referral advice had higher EPDS (total score) and EPDS - 3A anxiety scores than mothers who did not contact a psychologist. Moreover, they had a higher gestational age at birth and, on average, fewer children. More PPD symptoms, C-section experience, self-assessed good financial situation and a postgraduate higher education degree were predictors of seeking help.

CONCLUSION

A mother's decision to follow the referral advice is crucial in mental health prevention and should be treated as an addition to a separate step 2: referral in a 3-step PDD management process, with identification constituting a step 1, and intervention - a step 3.

Developing Music Therapy in Maternity Care in Ireland: A Qualitative Study

Music therapy can be a form of preventive or early intervention. It strengthens and utilizes women's own resources to build resilience, aids relaxation, reduces symptoms of anxiety and depression, promotes parent-infant attachment, and adapts to physical and psychological challenges during the perinatal period. The inclusion of music therapy in Irish maternity services has the potential to improve the quality of healthcare delivery provided to parents and infants. Recent studies demonstrate that the prospect of music therapy is welcomed by parents and perinatal healthcare professionals in Ireland, but such services are yet to be formally embedded in maternity care. Building on a cross-sectional survey, this qualitative study employed 6 semi-structured interviews with women and perinatal healthcare professionals in Ireland to understand their perspectives on developing music therapy in Irish maternity care services. Four themes were identified from the thematic analysis of these interviews: (1) music has multiple functions during the perinatal period; (2) music programs contribute to holistic perspectives and approachability in perinatal care; (3) music therapy provides specialist support; and (4) further development of music therapy services is challenging. The findings offer important insights and practical considerations on the key components of the music therapy programs and strategies in developing music therapy in Irish maternity settings. This information can directly inform music therapy researchers and practitioners in designing music therapy programs and developing relevant services in collaboration with maternity care professionals and policymakers.

Facilitators and Barriers of Implementing Expanded Sexually Transmitted Infection Screening in California Family Planning Clinics

BACKGROUND

Reportable sexually transmitted infections (STIs) have increased in California, with dramatic rises in prenatal and congenital syphilis. In response, in 2018 Planned Parenthood Northern California implemented 2 opt-out screening protocols: (1) HIV, chlamydia, gonorrhea, and syphilis co-screening for pregnant patients at pregnancy diagnosis and (2) linking HIV and syphilis screening for all patients.

METHODS

Using qualitative analyses, we explored implementation barriers and facilitators that can be addressed by clinical leadership and staff to expand uptake of enhanced screening protocols. Sixteen staff were interviewed across 3 Planned Parenthood Northern California clinics. Primary thematic analysis followed by secondary subanalysis identified themes. Analyses of questions were only included for each interviewee if answered and applicable.

RESULTS

Five themes of commentary emerged, featuring both facilitators and barriers for protocol implementation: patient education/communication, staff education/communication, workflow; patient willingness, and (for protocol 1 only) visit complexity at the time of pregnancy diagnosis. Additional findings included the following: 93% (13 of 14) stated protocols increased syphilis screening and identification; 100% (12 of 12) reported positive impacts on patient care; 42% (5 of 12) noted increases in staff workload, 25% (3 of 12) reported workload improvements over time, and 33% (4 of 12) reported no workload-related impacts; and 86% (13 of 15) reported decreased screening during the COVID-19 pandemic.

CONCLUSION

Addressing patient and staff education during the beginning stages of implementation may have positive impacts on willingness to adopt new protocols. Consideration of workflow and visit complexity at pregnancy diagnosis may also aid in successful implementation of expanded STI screening protocols in family planning clinics.

Exploring the acceptability, feasibility and utility of a digital tool for self-reporting perinatal anxiety and depression in urban obstetric and paediatric clinics in India

Background

Common mental disorders, such as anxiety and depression, affect 13% to 55% of women during the perinatal period in India. However, high-volume obstetric clinics often lack resources for routine mental health assessment. Digital tools could address this gap by facilitating maternal mental health screening.

Aim

This study evaluates the feasibility, acceptability and utilization of digital self-reporting for perinatal anxiety and depression in two urban obstetric and paediatric clinics.

Method

A multilingual digital application was developed for self-assessment using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and psychosocial risk factors. A total of 234 participants (101 pregnant and 133 postpartum women) completed the assessment, receiving immediate results and personalized recommendations. Follow-up calls 24 h later gathered feedback on feasibility and acceptability.

Results

Among the 234 participants, the assessment identified mild anxiety in 15.8%, moderate to severe anxiety in 11.1%, mild depression in 31.6% and moderate to severe depression in 14.1%. Over 83% of women reported at least one psychosocial risk factor, and 10.2% had a history of psychiatric illness. Of 138 participants responding to follow-up, 60.4% preferred digital self-assessment alone for its convenience and non-judgmental nature. In contrast, 22.5% preferred consulting with their obstetrician or a mental health professional. Challenges included application navigation confusion and attempts to modify answers for lower scores, prompting refinements for improved user experience and cultural relevance.

Conclusion

Digital self-reporting is a feasible and acceptable approach for early detection of perinatal mental health concerns in high-volume urban clinics. Further testing is needed in rural and diverse healthcare settings to assess its broader applicability.

Developing a coaching manual to provide human support for the Mothers and Babies Online (eMB) perinatal mental health intervention

Background

Depression that occurs in pregnancy or postpartum (perinatal depression) impacts 1 in 5 mothers, yet access to effective and high-quality preventative interventions remains elusive for most. Digital interventions are a promising solution to this treatment gap because of the ubiquity of mobile devices and internet access. The Mothers and Babies Online Course (eMB) is an online adaptation of Mothers and Babies, an evidence-based preventative program for postpartum depression. Preliminary studies of eMB point to its potential efficacy, but low engagement with eMB was a major limitation. Leveraging home visitors as coaches to guide clients through eMB may be a way to increase uptake and engagement, and ultimately improve outcomes when implemented in home visiting programs.

Objective

The aim of this study was to implement user-centered design methods to develop a coaching manual for home visitors to implement eMB.

Methods

10 parents and 10 home visitors were interviewed individually. Measures included a "think aloud" activity and a semi-structured interview focused on gaining insight into parent and home visitor needs and preferences regarding eMB coaching in the context of home visiting. Thematic analysis was used to derive themes and sub-themes from interview transcripts.

Results

Parents were enthusiastic about eMB, but noted barriers including limited time and forgetfulness. Parents also thought that their home visitor would be the ideal eMB coach because of the existing close relationship. Home visitors shared that eMB would fit seamlessly into their home visiting workflow. They also thought that home visitors could address challenges that parents encounter in using eMB and leverage their relationship with parents to crystalize learning. Home visitors also noted that a coaching manual would be a key part of successful eMB implementation. Thus, valuable insights from parents and home visitors were used to create a coaching manual.

Conclusions

Parents and home visitors were both enthusiastic about eMB with adjunctive coaching, and home visitors agreed that a coaching manual would be vital in guiding them to help parents through eMB. Results highlight the importance of engaging end-users in all aspects of online intervention design, including the coaching manual. The effectiveness of the intervention and utility of the coaching protocol will be evaluated in a future pilot trial.

Implementing universal maternal depression screening in Head Start: A convergent mixed methods study

Aims

Implementing maternal depression screening in child-serving programs can help ensure that more mothers receive mental health services. This study examined the implementation of universal maternal depression screening in community-based Head Start programs.

Methods

Quantitative and qualitative data were merged in a convergent mixed method design to assess four domains from the RE-AIM implementation science framework (Reach, Adoption, Implementation, and Maintenance). Qualitative data included interviews with stakeholders and meeting minutes from the implementation period. Quantitative data included intervention outcomes and administrative data.

Results

In terms of reach, 85% of eligible Head Start mothers were screened for depression, and English-speaking mothers were more likely to refuse screening than Spanish-speaking or bilingual mothers. Barriers to screening included lack of availability, stigma, privacy concerns, lack of interest, and lack of trust. In terms of adoption, all sites and staff adopted screening due to organizational mandates. In terms of implementation, there was wide variation in rates of positive screenings across staff completing the screening (ranging from 0% to 46%), and barriers included concerns about staff role and lack of training. In terms of maintenance, screening was not sustained after the study period due to organizational priorities and lack of buy-in from staff.

Conclusion

Universal maternal depression screening has the potential to reach low-income Head Start mothers, but additional efforts should be made to build staff capacity to engage mothers in screening.

Women's experiences and views of routine assessment for anxiety in pregnancy and after birth: A qualitative study

BACKGROUND

Anxiety in pregnancy and postnatally is highly prevalent but under-recognized. To identify perinatal anxiety, assessment tools must be acceptable to women who are pregnant or postnatal.

METHODS

A qualitative study of women's experiences of anxiety and mental health assessment during pregnancy and after birth and views on the acceptability of perinatal anxiety assessment. Semi-structured interviews were conducted with 41 pregnant or postnatal women. Results were analysed using Sekhon et al.'s acceptability framework, as well as inductive coding of new or emergent themes.

RESULTS

Women's perceptions of routine assessment for perinatal anxiety were generally favourable. Most participants thought assessment was needed and that the benefits outweighed potential negative impacts, such as unnecessary referrals to specialist services. Six themes were identified of: (1) Raising awareness; (2) Improving support; (3) Surveillance and stigma; (4) Gatekeeping; (5) Personalized care and (6) Trust. Assessment was seen as a tool for raising awareness about mental health during the perinatal period and a mechanism for normalizing discussions about mental health more generally. However, views on questionnaire assessments themselves were mixed, with some participants feeling they could become an administrative 'tick box' exercise that depersonalizes care and does not provide a space to discuss mental health problems.

CONCLUSION

Routine assessment of perinatal anxiety was generally viewed as positive and acceptable; however, this was qualified by the extent to which it was informed and personalized as a process. Approaches to assessment should ideally be flexible, tailored across the perinatal period and embedded in continuity of care.

New treatments: Opportunities and challenges

Across the spectrum of perinatal mental illness, there exist a variety of effective treatments. However, the available treatments are not always matched to the presentation, resources, constraints, or values of each patient. Furthermore, provider, local, and systemic factors complicate access to current treatment options. New and emerging approaches offer the potential of more effective treatment for specific perinatal psychiatric disorders. From neuroactive steroid medications to accelerated psychotherapy interventions, recent innovations have demonstrated enhanced efficacy on a faster timeline. Optimally, these developments will also lower barriers to care but this is not necessarily true. We review novel and upcoming interventions across perinatal mental illness and place them in the context of existing treatments and common challenges.

Guideline No. 454: Identification and Treatment of Perinatal Mood and Anxiety Disorders

OBJECTIVE

To help perinatal health care providers identify and assist pregnant and postpartum patients with perinatal mental illness, specifically perinatal mood and anxiety disorders. Areas of focus include risk factors and identification, screening, treatment, and referral.

TARGET POPULATION

All individuals who are pregnant or in the first year postpartum.

OUTCOMES

Open dialogue and evidence-informed care for perinatal mood and anxiety disorders, including competency for identification, screening, treatment, and referral, which will lead to improvements in patient care.

BENEFITS, HARMS, AND COSTS

Pregnant and postpartum individuals with untreated perinatal mental illness, including mood and anxiety disorders, may suffer devastating effects and their family may experience short- and long-term adverse outcomes.

EVIDENCE

A literature search was conducted using Medline (Ovid), PubMed, Embase and the Cochrane library from inception to June 2024. Additional articles were identified from article bibliographies and grey literature published by reputable societies and organizations (see online Appendix A).

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All heath care providers who provide preconception counselling and/or care during pregnancy and the postpartum period. The term "perinatal" will be used throughout this guideline to refer to these health care providers.

SOCIAL MEDIA ABSTRACT

New SOGC Guideline! Identify, support, and treat perinatal mood and anxiety disorders. Focused on risk factors, screening, treatment and referrals during pregnancy and the postpartum period. Let's open dialogue and provide evidence-informed care for improved patient outcomes.

SUMMARY STATEMENTS

RECOMMENDATIONS: IDENTIFICATION AND RISKSCREENINGTREATMENT.

Enablers of and Barriers to Perinatal Mental Healthcare Access and Healthcare Provision for Refugee and Asylum-Seeking Women in the WHO European Region: A Scoping Review

Perinatal mental health is a growing public health concern. Refugee and asylum-seeking women are particularly susceptible to experiencing perinatal mental illness and may encounter a range of challenges in accessing healthcare. This scoping review sought to identify the enablers of and barriers to healthcare access and healthcare provision for refugee and asylum-seeking women experiencing perinatal mental illness in the WHO European Region. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was applied. Nine databases and six grey literature sources were initially searched in April 2022, and an updated search was completed in July 2023. The search identified 16,130 records, and after the removal of duplicates and the screening process, 18 sources of evidence were included in this review. A data extraction table was used to extract significant information from each individual source of evidence, which was then mapped to the seven dimensions of the candidacy framework. Empirical (n = 14; 77.8%) and non-empirical (n = 4; 22.2%) sources of evidence were included. The literature originated from seven countries within the WHO European Region, including the United Kingdom (n = 9; 50%), Germany (n = 3; 16.7%), Denmark (n = 2; 11.2%), Norway (n = 1; 5.6%), Greece (n = 1; 5.6%), Sweden (n = 1; 5.6%), and Switzerland (n = 1; 5.6%). The results indicate that, although enablers and barriers were apparent throughout the seven dimensions of candidacy, barriers and impeding factors were more frequently reported. There was also a notable overall lack of reported enablers at the system level. Unaddressed language barriers and lack of attention to the diversity in culturally informed perceptions of perinatal mental illness were the main barriers at the individual level (micro-level) to identifying candidacy, navigating healthcare systems, and asserting the need for care. The lack of culturally appropriate alignment of healthcare services was the key organizational (meso-level) barrier identified. The wider structural and political contexts (macro-level factors), such as lack of funding for consultation time, focus on Western diagnostic and management criteria, and lack of services that adequately respond to the needs of refugee and asylum-seeking women, negatively influenced the operating conditions and wider production of candidacy. It can be concluded that there are multilevel and interconnected complexities influencing access to and provision of perinatal mental healthcare for refugee and asylum-seeking women.

Comparing the effect of two systems-level interventions on perinatal generalized anxiety disorder and posttraumatic stress disorder symptoms

BACKGROUND

The Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms are designed to help obstetric practices address perinatal depression. The PRogram in Support of Moms includes the statewide Massachusetts Child Psychiatry Access Program for Moms program, plus proactive implementation support.

OBJECTIVE

The goal of this study was to understand the impact of these programs on perinatal generalized anxiety disorder and posttraumatic stress disorder symptoms among individuals screening positive for depression.

STUDY DESIGN

We conducted a secondary analysis of 2017-2022 data from a cluster randomized controlled trial of Massachusetts Child Psychiatry Access Program for Moms vs PRogram In Support of Moms. We included participants completing a generalized anxiety disorder or posttraumatic stress disorder screen at baseline (n=254) with antenatal Edinburgh Postnatal Depression Scale scores ≥10. We assessed changes in generalized anxiety disorder and posttraumatic stress disorder symptoms from pregnancy (4-25 weeks of gestational age or 32-40 weeks of gestational age), 4-12 weeks postpartum, and 11-13 months postpartum. We conducted a difference-in-difference analysis to compare symptom change from pregnancy to postpartum. We used adjusted linear mixed models with repeated measures to examine the impact of the Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms on changes in the Generalized Anxiety Disorder 7 and the Posttraumatic Stress Disorder Checklist.

RESULTS

Mean Generalized Anxiety Disorder 7 scores decreased by 3.6 (Massachusetts Child Psychiatry Access Program for Moms) and 6.3 (PRogram In Support of Moms) points from pregnancy to 4-12 weeks postpartum. Mean Posttraumatic Stress Disorder Checklist scores decreased by 6.2 and 10.0 points, respectively, at 4-12 weeks postpartum among individuals scree ning positive on the Generalized Anxiety Disorder 7 (n=83) or Posttraumatic Stress Disorder Checklist (n=58) in pregnancy. Generalized Anxiety Disorder 7 and Posttraumatic Stress Disorder Checklist scores decreased among both groups at 11-13 months postpartum. These changes were clinically meaningful. PRogram In Support of Moms conferred a statistically significant greater decrease (2.7 points) on the Generalized Anxiety Disorder 7 than the Massachusetts Child Psychiatry Access Program for Moms at 4-12 weeks postpartum. No differences were found between the Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms in Posttraumatic Stress Disorder Checklist or Generalized Anxiety Disorder 7 change at 11-13 months, although both were associated with a reduction in generalized anxiety disorder and posttraumatic stress disorder symptoms at 4-12 weeks and 11-13 months postpartum.

CONCLUSION

Both the Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms could help to improve symptoms for individuals experiencing co-occurring symptoms of depression, generalized anxiety disorder, or posttraumatic stress disorder. PRogram In Support of Moms may confer additional benefits in the early postpartum period, although this difference was not clinically significant.

World Psychiatric Association-Asian Journal of Psychiatry Commission on Public Mental Health

Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health remains overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative overview of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.

Evaluation of perinatal anxiety assessment measures: a cognitive interview study

BACKGROUND

Anxiety in pregnancy and postpartum is highly prevalent but under-recognised. To identify perinatal anxiety, assessment tools must be acceptable, relevant, and easy to use for women in the perinatal period.

METHODS

To determine the acceptability and ease of use of anxiety measures to pregnant or postpartum women (n = 41) we examined five versions of four measures: the Generalised Anxiety Disorder scale (GAD) 2-item and 7-item versions; Whooley questions; Clinical Outcomes in Routine Evaluation (CORE-10); and Stirling Antenatal Anxiety Scale (SAAS). Cognitive interviews were used to examine ease of comprehension, judgement, retrieval and responding.

RESULTS

All measures were acceptable. Some items were deemed less relevant to the perinatal period e.g., difficulties sleeping. Ease of comprehension, judgement, retrieval and responding varied, with all measures having strengths and weaknesses. The SAAS and CORE-10 had the lowest mean number of problematic components. The GAD had the highest mean number of problematic components​. Non-binary response options were preferred. Preferences for time frames (e.g. one week, one month) varied. Qualitative data provides in-depth information on responses to each measure.

CONCLUSIONS

Findings can be used to inform clinical guidelines and research on acceptable anxiety assessment in pregnancy and after birth.

Substance use during pregnancy: the role of mindfulness in reducing stigma

Stigmatization is a significant healthcare barrier among individuals who utilize substances during pregnancy. Of the 3.6 million U.S. births each year, approximately 10% are affected by perinatal substance use, an estimate which is likely underestimated due to fear of stigma and prosecution. Of those experiencing perinatal substance use, less than 11% receive treatment, while maternal deaths due to overdose during the postpartum period have increased by 81% from 2017 to 2020. Societal perception of non-pregnant individuals experiencing substance use disorders recognizes the biological basis of addiction, whereas for pregnant individuals, societal perception slides into moral failing as the basis of addiction. Many recommendations and guidelines for decreasing substance use stigmatization among non-pregnant and pregnant individuals exist. We focus on the use of mindfulness in recognizing and addressing structural and social stigma within healthcare systems. Mindfulness has been extracted from its roots as an essential element of the Eightfold Path in Buddhism, which largely centers on living ethically to reduce suffering of self and others. By acknowledging the roots of mindfulness, providers can engage mindfully in practices that help identify one's overarching personal values and encourage one to lead healthcare encounters compassion and willingness to support help-seeking community members who are experiencing suffering. A deeper awareness of mindfulness practices within the context of ethical conduct can support healthcare shifts away from criminalization toward more patient- and family-centered approaches.

Improved Screening for Depression in Patients Initiating Fertility Treatment

OBJECTIVE

To improve screening for depression in patients who are initiating fertility treatment at a reproductive endocrinology and infertility (REI) center by screening all patients at their initial visit using the Patient Health Questionnaire-9 (PHQ-9).

DESIGN

This quality improvement project was conducted using a plan-do-study-act cycle implemented with a postintervention study design.

SETTING/LOCAL PROBLEM

A medium-size REI center in a mid-Atlantic U.S. metropolitan area where screening for mental health status in patients initiating fertility treatments was not occurring.

PARTICIPANTS

Patients who were scheduled in person with REI providers for a new patient consult regarding fertility were declared eligible.

INTERVENTION/MEASUREMENTS

The PHQ-9 was administered by providers at initial consults for patients seeking fertility treatments from October 2022 to February 2023. Three cycles of the plan-do-study-act model were used to execute change. For all patients who scored 5 to 9 (mild depression), conversations regarding counseling referrals occurred. For all patients who scored ≥10 (moderate to severe depression), a referral for counseling and medication management was generated. Data were analyzed via descriptive statistics.

RESULTS

A total of 115 participants were included. A screening rate of 84.3% (n = 97) was achieved for patients initiating treatment. Of the 97 screened, 21 patients had a score of ≥5; 19 were given a referral for counseling. However, none of the patients attended a counseling session or started medication prescribed by their primary care provider during the 2-month follow-up period. Barriers identified included costs, personal preferences, and access to services.

CONCLUSION

The PHQ-9 screening tool was implemented at an REI clinic to improve the frequency of mental health screenings and provide necessary referrals. However, additional follow-up is needed to ensure patients are receiving appropriate mental health care.

Current perspectives on perinatal mental health and neurobehavioral development: focus on regulation, coregulation and self-regulation

PURPOSE OF REVIEW

Perinatal mental health research provides an important perspective on neurobehavioral development. Here, we aim to review the association of maternal perinatal health with offspring neurodevelopment, providing an update on (self-)regulation problems, hypothesized mechanistic pathways, progress and challenges, and implications for mental health.

RECENT FINDINGS

(1) Meta-analyses confirm that maternal perinatal mental distress is associated with (self-)regulation problems which constitute cognitive, behavioral, and affective social-emotional problems, while exposure to positive parental mental health has a positive impact. However, effect sizes are small. (2) Hypothesized mechanistic pathways underlying this association are complex. Interactive and compensatory mechanisms across developmental time are neglected topics. (3) Progress has been made in multiexposure studies. However, challenges remain and these are shared by clinical, translational and public health sciences. (4) From a mental healthcare perspective, a multidisciplinary and system level approach employing developmentally-sensitive measures and timely treatment of (self-)regulation and coregulation problems in a dyadic caregiver-child and family level approach seems needed. The existing evidence-base is sparse.

SUMMARY

During the perinatal period, addressing vulnerable contexts and building resilient systems may promote neurobehavioral development. A pluralistic approach to research, taking a multidisciplinary approach to theoretical models and empirical investigation needs to be fostered.

Increasing Access To Perinatal Mental Health Care: The Perinatal Psychiatry Access Program Model

Perinatal psychiatry access programs offer a scalable approach to building the capacity of perinatal professionals to identify, assess, and treat mental health conditions. Little is known about access programs' implementation and the relative merits of differing approaches. We conducted surveys and semistructured interviews with access program staff and reviewed policy and procedure documents from the fifteen access programs that had been implemented in the United States as of March 2021, when the study was conducted. Since then, the number of access programs has grown to thirty state, regional, or national programs. Access programs implemented up to five program components, including telephone consultation with a perinatal psychiatry expert, one-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, trainings for perinatal professionals, and practice-level technical assistance. Characterizing population-based intervention models, such as perinatal psychiatry access programs, that address perinatal mental health conditions is a needed step toward evaluating and improving programs' implementation, reach, and effectiveness.

Implementing a National Navigation Service for Perinatal and Infant Mental Health: Early Learnings from the ForWhen Model

ForWhen is an Australia-based national navigation service aimed at helping parents and carers navigate the perinatal mental health service landscape and connect them with appropriate support and clinical services. The current study forms part of a mixed-methods evaluation of the ForWhen program. Semi-structured interviews were conducted with ForWhen navigators during the early design and implementation phases of the service. Results were used to characterise the ForWhen navigator activities and responsibilities, identify navigator core competencies, and examine facilitators and barriers to successful implementation of a large-scale navigation program for perinatal and infant mental health. Further research will be crucial for evidencing the utility and potential of navigation models in addressing identified issues with access to treatment for perinatal and infant mental health issues.

The Pressing Need to Integrate Mental Health into Obstetric Care

Mental health and substance use conditions are prevalent among perinatal individuals. These conditions have a negative impact on the health of perinatal individuals, their infants, and families, yet are underdiagnosed and undertreated. Populations that have been marginalized disproportionately face barriers to accessing care. Integrating mental health into obstetric care could address the perinatal mental health crisis. We review perinatal mental health conditions and substance use, outline the impact associated with these conditions, and describe the promise and potential of integrating mental health into obstetric settings to improve outcomes for patients receiving obstetric and gynecologic care.

Behavioral Health Integration on Inpatient Obstetric Units: Program Development, Strategies for Implementation, and Lessons Learned

Perinatal mood and anxiety disorders and substance use disorders are the primary causes of maternal mortality in the postpartum period and represent major public health concerns. Despite this, these conditions remain undertreated. Behavioral health integration in outpatient obstetric settings is necessary but insufficient to meet the needs of all patients. Inpatient behavioral health integration represents a promising avenue for addressing gaps in care. Results from recent program development indicate that needs assessment, stakeholder backing, collaboration with existing programs, and adaptability are key factors in successful implementation.

Longitudinal impact of an online interdisciplinary perinatal mental health module on Healthcare Professionals' knowledge, skills, attitudes and confidence: A qualitative evaluation

AIM/OBJECTIVE

The current study aimed to explore the following research question; 'What is the longitudinal impact, if any, of an online interdisciplinary perinatal mental health module on HCP knowledge, skills, attitudes and confidence'.

BACKGROUND

Research suggests that one in five women/people will experience a mental health issue during the perinatal period. Healthcare Professionals (HCPs) play a critical role in identifying, supporting and referring those who disclose health or psychosocial concerns in pregnancy or after birth and consistent research findings highlight the need for appropriate targeted perinatal mental health education among this cohort. To address this need, a thirteen-week (Masters Level) interdisciplinary online module in perinatal mental health was collaboratively developed between one Irish Higher Education Institution and national mental healthcare specialists. The module aims to develop HCP knowledge, skills, attitude and confidence in sustainably supporting women/people and families experiencing perinatal mental health issues. However, a recent scoping review concluded that there was insufficient evidence with respect to the longitudinal impact of such courses on HCP practice.

DESIGN/METHODS

The study design adopted a qualitative descriptive design that used online individual interviews for data collection. The evaluation was informed by the Kirkpatrick and Kirkpatrick Evaluation Model. The study group consisted of six voluntarily self-selected perinatal mental health module participants. Longitudinal impacts of the module were explored 8-10 months following module completion. Thematic Analysis was undertaken using Braun and Clarkes Framework. Ethical approval for the study was obtained from the author's Higher Education Institution (HEI).

RESULTS

Findings revealed several interrelated and reinforcing themes that had an impact on the longer-term application of enhanced knowledge, skills, attitude and confidence in practice. These were; pedagogical features of the interdisciplinary perinatal mental health education module, sociocultural and professional influences, persistent enthusiasm and commitment to improve care in spite of systemic obstacles and, ongoing need for perinatal mental health education.

CONCLUSIONS

Provision of targeted, agile and manageable professional education courses on perinatal mental health care will continue to be required. However, despite sustained commitment and enthusiasm to implement enhanced knowledge and skills, systemic obstacles continue to exist and these may have an impact on the efficacy of such courses in the longer term.

Analysis of the access of pregnant women to the first programmatic dental appointment: an ecological study

To plan and evaluate public health policies, it is important to understand the influence of social factors on the quality and access to dental care. This study aimed to verify the potential association between the indicators of pregnant women receiving dental care and the social and health care indicators of cities in the Brazilian state of Minas Gerais. A cross-sectional ecological study was performed with secondary data from the Brazilian Institute of Geography and Statistics and the Health Care Department of the Ministry of Health regarding the cities of Minas Gerais. The study analyzed three health care indicators (such as more than six prenatal, the proportion of syphilis and human immunodeficiency virus tests, and oral health coverage) and four social indicators (average monthly wage, illiteracy rate, proportion of employed population, and rate of adequate sanitary sewerage). Bivariate analysis (Mann-Whitney test) and logistic regression were performed using Jamovi software. All of the indicators analyzed were associated with the access of pregnant women to dental care. However, in the regression models, only health care indicators remained statistically significant. Thus, although social indicators are associated with the access of pregnant women to dental appointments, access to primary health care and the teamwork of primary health care teams may overcome social inequality in the access of pregnant women to dental care.

Psychosocial predictors of post-natal anxiety and depression: Using Structural Equation Modelling to investigate the relationship between pressure to breastfeed, health care professional support, post-natal guilt and shame, and post-natal anxiety and depression within an infant feeding context

High perceived pressure to breastfeed and poor perceived quality of health care professional support have been associated with early breastfeeding cessation, guilt, and shame. This is problematic because guilt and shame significantly predict post-natal anxiety and depression. No previous attempts have been made to provide quantitative evidence for relationships mapped between the post-natal social context, infant feeding method and post-natal emotional well-being. The current study aimed to empirically investigate aforementioned pathways. Structural equation modelling was applied to survey data provided online by 876 mothers. Guilt and shame both significantly predicted anxiety and depression. Poor health care professional support and high pressure to breastfeed increased anxiety and depression, and these effects were explained by indirect pathways through increases in guilt and shame. Formula feeding exclusivity was negatively correlated with post-natal anxiety symptoms. This finding may be explained by feelings of relief associated with observed infant weight gain and being able to share infant feeding responsibilities others e.g., with one's partner. This relationship was counterbalanced by an indirect pathway where greater formula feeding exclusivity positively predicted guilt, which increased post-natal anxiety score. While guilt acted as mediator of infant feeding method to increase post-natal depression and anxiety, shame acted independently of infant feeding method. These identified differences provide empirical support for the transferability of general definitions of guilt (i.e., as remorse for having committed a moral transgression) and shame (i.e., internalisation of transgressive remorse to the self), to an infant feeding context. Recommendations for health care practitioners and the maternal social support network are discussed.

A survey of screening and support systems for socially high-risk pregnancies at obstetric facilities in Japan

AIM

To clarify the state of screening and support systems for socially high-risk pregnant women at obstetric facilities across Japan and identify the characteristics of facilities related to the implementation of screening.

METHODS

This cross-sectional study used a self-administered questionnaire. Participants were managers of hospitals, clinics, and midwifery birth centers handling deliveries in 47 prefectures across Japan. The questionnaire comprised items regarding the characteristics of participants and their facilities, service provision related to socially high-risk women available at the facility, the number of specified pregnant women (tokutei ninpu) per year, methods of screening, and support systems within the obstetric facilities. Descriptive statistics and multivariate logistic regression analysis were performed using IBM-SPSS version 24 for the association between facility characteristics and screening practices for socially high-risk pregnant women.

RESULTS

Valid responses were received from 716 of 2512 obstetric facilities. Rates of specified expectant mothers per annual number of deliveries were identified as follows: perinatal medical centers (2.7%), general hospitals (1.6%), obstetrics and gynecology hospitals (1.0%), and clinics (0.8%). A total of 426 facilities (60.6%) reported screening all expectant mothers to identify socially high-risk pregnant women. Multiple logistic regression analysis revealed that facility characteristics and service/care provision related to screening practices included availability of in-hospital midwife-led care and in-hospital midwifery clinics (adjusted odds ratio 1.61; 95% CI [1.30, 1.47]), one-on-one care by midwife (1.73; 95% CI [1.15, 2.59]), multidisciplinary meetings within the facility (1.70; 95% CI [1.14, 2.56]), follow-up support systems after discharge (1.90; 95% CI [1.17, 3.09]), and participation in the regional council for children in need of protection (2.33; 95% CI [1.13, 4.81]).

CONCLUSIONS

Approximately 60% of surveyed obstetric facilities screen for socially high-risk women. Increasing service provision at facilities may be necessary to implement screening.

Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis

Background

Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care.

Objectives

Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services.

Methods

Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders.

Data sources

Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews.

Review methods

In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway.

Results

Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women's economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels.

Limitations

In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English.

Conclusions

The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services.

Recommendations for health policy and practice

These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it.

Future work

Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries.

Trial registration

This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Developing Specialist Perinatal Mental Health Services: the door of opportunity

The development of Specialist Perinatal Mental Health Services in Ireland in recent years (2018-2021) is described. The paper highlights the role of unexpected opportunity in advancing this much needed service for women, infants and their families. It also emphasises the need for funding combined with an implementation mechanism to ensure that the service emerging is true to the Model of Care designed and is available in a uniform manner to women nationally.

Serial multiple mediation of perceived professional healthcare support and social structural factors in the relationship between care-seeking behavior and perinatal mental health in Chinese mothers

BACKGROUND

In previous studies, it has been observed that mother's perinatal mental health (PMH) problems can be improved by engaging in appropriate health care-seeking behaviors. However, the exact mechanism that influences the relationship between these two factors is still not fully understood. This cross-sectional study aims to examine the serial multiple mediating effects of perceived professional healthcare support (PPHS) and social structural factors on the association between care-seeking behavior and PMH.

METHODS

The cross-sectional study evaluated 1705 Chinese mothers (pregnancy 12 to 41 weeks) through questionnaires from October 2021 to November 2022. These mothers were selected from three hospitals in Wuxi, with an annual delivery volume of at least 5000. We conducted a structural equation model (SEM) analysis to examine the multiple mediating effect of PPHS and social structural factors (social stigma or social trust) between care-seeking behavior and PMH. After analyzing the results of the SEM, we used bootstrapping to further test the mediating effect.

RESULTS

Among the 1705 Chinese mothers surveyed, 636 (37.3%) sought help from professionals. It was observed that more women tended to seek professional help during the early stages of pregnancy (12 to 28 weeks) compared to the later stages (28 to 41 weeks) (t = 1.47, p < 0.05). The results of the SEM analysis indicated that the mother's care-seeking behavior did not have a significant direct effect on PMH. However, it was identified as a crucial distal variable, with its significant effect being fully mediated by PPHS and social structural factors. The mediation effect of PPHS and social stigma on the pathway from care-seeking behavior to PMH was found to be 92.9% (direct effect = 0.002; indirect effect = 0.026). Additionally, the mediating effect of stigma contributed to 21.9% of the association between care-seeking behavior and PPHS (direct effect = 0.405; indirect effect = 0.114). Similarly, the mediation effect of PPHS and social trust on the pathway from care-seeking behavior to PMH was 73.3% (direct effect = 0.008; indirect effect = 0.022). Moreover, the mediating effect of social trust contributed to 22.0% of the association between care-seeking behavior and PPHS (direct effect = 0.407; indirect effect = 0.115). The proposed model showed a good fit with the collected data.

CONCLUSION

This study examines the serial multiple mediation effect, in which PPHS and social structural factors mediate the relationship between PMH and professional care-seeking behavior. We suggest three levels of intervention: implementing mental health in all policies, providing training for healthcare providers, and establishing healthcare channels with easily accessible information.

Treating postpartum affective and/or anxiety disorders in a mother-baby day hospital: preliminary results

INTRODUCTION

Women experiencing perinatal mental-health illness have unique needs. The present study analyzes preliminary data about the effectiveness of MBDH in treating postpartum women with affective and anxiety disorders.

METHODS

We analysed 33 mothers with affective and/or anxiety disorders treated at the MBDH with their babies between March 2018 and December 2019. All women were assessed at admission, discharge and three months after discharge. Outcomes included symptoms of depression (EPDS) and anxiety (STAI-S), mother-infant bonding (PBQ) and functional impairment (HoNOs). We also assessed the clinical significance of changes in patients' scores on these scales and patient satisfaction.

RESULTS

At discharge, no patients still met the full criteria for the main diagnosis. Between admission and discharge, symptoms of depression and anxiety, mother-infant bonding, functional impairment and autonomy in caring for babies improved significantly. These gains were maintained at three months follow-up. Patient satisfaction was high.

CONCLUSIONS

These preliminary results suggest that multidisciplinary intervention for postpartum women with affective or anxiety disorders at the MBDH improves maternal psychopathology, mother-infant bonding and mothers' ability to care for their babies. MBDHs are a promising approach for delivering specialised perinatal mental-health care for mother-baby dyads.

Toward recovery-oriented perinatal healthcare: A participatory qualitative exploration of persons with lived experience and health providers' views and experiences

BACKGROUND

Perinatal mental health disorders (PMHD) remain often undetected, undiagnosed, and untreated with variable access to perinatal mental health care (PMHC). To guide the design of optimal PMHC (i.e., coproduced with persons with lived experience [PLEs]), this qualitative participatory study explored the experiences, views, and expectations of PLEs, obstetric providers (OP), childcare health providers (CHPs), and mental health providers (MHPs) on PMHC and the care of perinatal depression.

METHODS

We conducted nine focus groups and 24 individual interviews between December 2020 and May 2022 for a total number of 84 participants (24 PLEs; 30 OPs; 11 CHPs; and 19 MHPs). The PLEs group included women with serious mental illness (SMI) or autistic women who had contact with perinatal health services. We recruited PLEs through social media and a center for psychiatric rehabilitation, and health providers (HPs) through perinatal health networks. We used the inductive six-step process by Braun and Clarke for the thematic analysis.

RESULTS

We found some degree of difference in the identified priorities between PLEs (e.g., personal recovery, person-centered care) and HPs (e.g., common culture, communication between providers, and risk management). Personal recovery in PMHD corresponded to the CHIME framework, that is, connectedness, hope, identity, meaning, and empowerment. Recovery-supporting relations and peer support contributed to personal recovery. Other factors included changes in the socio-cultural conception of the peripartum, challenging stigma (e.g., integrating PMH into standard perinatal healthcare), and service integration.

DISCUSSION

This analysis generated novel insights into how to improve PMHC for all users including those with SMI or autism.

Meta-review of the barriers and facilitators to women accessing perinatal mental healthcare

Perinatal mental health (PMH) problems are common and can have an adverse impact on women and their families. However, research suggests that a substantial proportion of women with PMH problems do not access care.

OBJECTIVES

To synthesise the results from previous systematic reviews of barriers and facilitators to women to seeking help, accessing help, and engaging in PMH care, and to suggest recommendations for clinical practice and policy.

DESIGN

A meta-review of systematic reviews.

REVIEW METHODS

Seven databases were searched and reviewed using a Preferred Reporting Items for Systematic Reviews and Meta Analyses search strategy. Studies that focused on the views of women seeking help and accessing PMH care were included. Data were analysed using thematic synthesis. Assessing the Methodological Quality of Systematic Reviews-2 was used to assess review methodology. To improve validity of results, a qualitative sensitivity analysis was conducted to assess whether themes remained consistent across all reviews, regardless of their quality rating.

RESULTS

A total of 32 reviews were included. A wide range of barriers and facilitators to women accessing PMH care were identified. These mapped across a multilevel model of influential factors (individual, healthcare professional, interpersonal, organisational, political and societal) and across the care pathway (from decision to consult to receiving care). Evidence-based recommendations to support the design and delivery of PMH care were produced based on identified barriers and facilitators.

CONCLUSION

The identified barriers and facilitators point to a complex interplay of many factors, highlighting the need for an international effort to increase awareness of PMH problems, reduce mental health stigma, and provide woman-centred, flexible care, delivered by well trained and culturally sensitive primary care, maternity, and psychiatric health professionals.

PROSPERO REGISTRATION NUMBER

CRD42019142854.

Women's experiences of specialist perinatal mental health services: a qualitative evidence synthesis

PURPOSE

Specialist perinatal mental health services identify and treat women experiencing mental health conditions during pregnancy and up to one year post birth. There is limited knowledge about women's experiences of care from specialist services. Evaluation and optimisation of service delivery requires knowledge of women's care experiences. This review aimed to systematically identify, appraise, and synthesise qualitative evidence exploring women's experiences of specialist perinatal mental health services.

METHODS

A systematic literature search of five databases: Medline (OVID), EMBASE (Elsevier), PsycINFO (EBSCO), CINAHL (EBSCO) and Scopus (Elsevier), grey literature searching, and backward citation, identified a total of 1035 papers of which sixteen met inclusion criteria. Methodological quality of the included studies was assessed using the Critical Appraisal Skills Program (CASP) tool.

RESULTS

Thematic synthesis identified three themes: connected relationships; new beginnings; and meaningful service delivery. Findings identified that relationships developed with clinicians were significant to women and their experience of care. Women valued continuity of care from dedicated non-judgemental clinicians. Peer support from other mothers was perceived as meaningful to women. Through service interventions women gained new insights into their infant's needs and grew in confidence as a mother.

CONCLUSIONS

Women require provision of flexible and accessible specialist services with clinicians who are sensitive to their individual psychosocial needs and preferences. Examining discharge practices and continuing care needs is essential to ensure the best outcomes for women and their families.

Understanding the impact of an AI-enabled conversational agent mobile app on users' mental health and wellbeing with a self-reported maternal event: a mixed method real-world data mHealth study

Background

Maternal mental health care is variable and with limited accessibility. Artificial intelligence (AI) conversational agents (CAs) could potentially play an important role in supporting maternal mental health and wellbeing. Our study examined data from real-world users who self-reported a maternal event while engaging with a digital mental health and wellbeing AI-enabled CA app (Wysa) for emotional support. The study evaluated app effectiveness by comparing changes in self-reported depressive symptoms between a higher engaged group of users and a lower engaged group of users and derived qualitative insights into the behaviors exhibited among higher engaged maternal event users based on their conversations with the AI CA.

Methods

Real-world anonymised data from users who reported going through a maternal event during their conversation with the app was analyzed. For the first objective, users who completed two PHQ-9 self-reported assessments (n = 51) were grouped as either higher engaged users (n = 28) or lower engaged users (n = 23) based on their number of active session-days with the CA between two screenings. A non-parametric Mann-Whitney test (M-W) and non-parametric Common Language effect size was used to evaluate group differences in self-reported depressive symptoms. For the second objective, a Braun and Clarke thematic analysis was used to identify engagement behavior with the CA for the top quartile of higher engaged users (n = 10 of 51). Feedback on the app and demographic information was also explored.

Results

Results revealed a significant reduction in self-reported depressive symptoms among the higher engaged user group compared to lower engaged user group (M-W p = .004) with a high effect size (CL = 0.736). Furthermore, the top themes that emerged from the qualitative analysis revealed users expressed concerns, hopes, need for support, reframing their thoughts and expressing their victories and gratitude.

Conclusion

These findings provide preliminary evidence of the effectiveness and engagement and comfort of using this AI-based emotionally intelligent mobile app to support mental health and wellbeing across a range of maternal events and experiences.

Mental health and substance use disorders at delivery hospitalization and readmissions after delivery discharge

BACKGROUND

The objective was to assess mental health and substance use disorders (MSUD) at delivery hospitalization and readmissions after delivery discharge.

METHODS

This is a population-based retrospective cohort study of persons who had a delivery hospitalization during January to September in the 2019 Nationwide Readmissions Database. We calculated 90-day readmission rates for MSUD and non-MSUD, overall and stratified by MSUD status at delivery. We used multivariable logistic regressions to assess the associations of MSUD type, patient, clinical, and hospital factors at delivery with 90-day MSUD readmissions.

RESULTS

An estimated 11.8% of the 2,697,605 weighted delivery hospitalizations recorded MSUD diagnoses. The 90-day MSUD and non-MSUD readmission rates were 0.41% and 2.9% among delivery discharges with MSUD diagnoses, compared to 0.047% and 1.9% among delivery discharges without MSUD diagnoses. In multivariable analysis, schizophrenia, bipolar disorder, stimulant-related disorders, depressive disorders, trauma- and stressor-related disorders, alcohol-related disorders, miscellaneous mental and behavioral disorders, and other specified substance-related disorders were significantly associated with increased odds of MSUD readmissions. Three or more co-occurring MSUDs (vs one MSUD), Medicare or Medicaid (vs private) as the primary expected payer, lowest (vs highest) quartile of median household income at residence zip code level, decreasing age, and longer length of stay at delivery were significantly associated with increased odds of MSUD readmissions.

CONCLUSION

Compared to persons without MSUD at delivery, those with MSUD had higher MSUD and non-MSUD 90-day readmission rates. Strategies to address MSUD readmissions can include improved postpartum MSUD follow-up management, expanded Medicaid postpartum coverage, and addressing social determinants of health.

Inpatient obstetric consultation-liaison services: Meeting unmet needs in perinatal mental health

Obstetric patients are at increased risk for psychological distress and the development or exacerbation of mental illness, particularly in the setting of pregnancy or delivery complications. Inpatient antepartum, labor and delivery, and postpartum hospitalization is an important opportunity for psychiatric support and intervention. The aims of this paper are to review the unmet mental health needs in obstetric inpatient care, examine the current state of obstetric consultation-liaison (OB CL) psychiatry services, present one existing model of such a service at the authors' institution, provide broad recommendations for the structure and implementation of this service, and detail areas of future research within the area of OB CL psychiatry. We argue that the inpatient obstetric setting is a critical space for mental health evaluation, education and intervention, and that dedicated OB CL psychiatry services are a potentially valuable tool in addressing the perinatal mental health crisis.

Barriers and facilitators for referring women with positive perinatal depression screening results in China: a qualitative study

BACKGROUND

Timely screening and referral can improve the outcomes of perinatal depression (PND). However, uptake rates of referral after PND screening are low in China and the reasons are unclear. The aim of this article is to explore the barriers and facilitators for referring women with positive results of PND screening in the Chinese primary maternal health care system.

METHODS

Qualitative data were collected from four primary health centers located in four different provinces of China. Each of the four investigators conducted 30 days of participant observations in the primary health centers from May to August 2020. Data were collected via participant observations and semi-structured in-depth interviews with new mothers who had positive results of PND screening, their family members, and primary health providers. Two investigators analyzed qualitative data independently. A thematic analysis was conducted, and data were framed using the social ecological model.

RESULTS

A total of 870 hours of observation and 46 interviews were carried out. Five themes were identified: individual (new mothers' knowledge of PND, perceived need to seek help), interpersonal (new mothers' attitudes towards providers, family support), institutional (providers' perception of PND, lack of training, time constraints), community (accessibility to mental health services, practical factors), and public policy (policy requirements, stigma).

CONCLUSIONS

The likelihood of new mothers accepting PND referral is related to factors in five areas. Intervention strategies can be developed around these themes and may include educating new mothers and their families about PND, training primary health providers to improve their awareness of condition and indication for referral, building mental health support in routine postpartum home visits, and providing support through mobile technology.