A systematic review of ethnic minority women's experiences of perinatal mental health conditions and services in Europe

Multilevel modelling of determinants of perinatal mortality in East Africa: a pooled analysis of National health survey data

BACKGROUND

Perinatal mortality, which includes stillbirths and early neonatal deaths, is a critical indicator of maternal and newborn health, especially in developing countries. It highlights the effectiveness of healthcare systems and socioeconomic inequalities. Despite global efforts, such as the Sustainable Development Goals (SDGs), to reduce perinatal mortality, developing countries continue to experience high rates due to factors like inadequate access to quality healthcare, maternal health issues, and socioeconomic disparities. Since, there is limited evidence in the region, this study investigates perinatal mortality in East Africa, using data from Demographic and Health Surveys (DHS) to identify key determinants and inform policy interventions aimed at improving health outcomes.

METHODS

This study utilized data from the DHS conducted in East Africa. A weighted sample of 101,728 children was included in the analysis using R-4.4.0 software. Descriptive data, including frequencies and texts, were performed. A multilevel modeling analysis was employed to analyze perinatal mortality, considering both individual-level factors and contextual factors. The multilevel model accounts for clustering within countries and allows for the examination of both fixed and random effects that influence perinatal mortality. For the multivariable analysis, variables with a p-value ≤ 0.2 in the univariate analysis were considered. The Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) and a p-value < 0.05 was reported to indicate statistical significance and degree of association in the final model.

RESULTS

The overall pooled effect size of perinatal mortality is 3.67 (2.92, 4.59), with Tanzania having the highest rate and Comoros having the lowest rate. Women aged 25-34 years (AOR = 0.86, 95% CI: 0.81, 0.95), 35-49 years (AOR = 0.89, 95% CI: 0.79, 0.97), and 35-49 years (AOR = 0.89, 95% CI: 0.79, 0.97) compared to women aged 15-24 years, gave birth the first before the age of 20 (AOR = 1.09, 95% CI: 1.03, 1.28), have secondary or higher education (AOR = 0.76, 95% CI: 0.69, 0.81), not being married (AOR = 1.11, 95% CI: 1.05, 1.21), poorer (AOR = 0.94, 95% CI: 0.89, 0.98), and richest women (AOR = 0.95, 95% CI: 0.91, 0.97) compared to the poorest women, mass media exposure (AOR = 1.09, 95% CI: 1.03, 1.15), women with 3-5 children (AOR = 1.16, 95% CI: 1.08, 1.21), and with more than 5 children had even greater odds (AOR = 1.36, 95% CI: 1.29, 1.44), twin births (AOR = 3.62, 95% CI: 3.41, 3.79), modern contraceptive (AOR = 0.82, 95% CI: 0.81, 0.91), had history of abortion (AOR = 8.53, 95% CI: 8.29, 8.79), birth interval of 24-36 (AOR = 0.68, 95% CI: 0.65, 0.73), and 37-59 months (AOR = 0.61, 95% CI: 0.55, 0.67) compared to intervals of < 24 months respectively, having health insurance (AOR = 0.87, 95% CI: 0.82, 0.92), rural residence (AOR = 1.05, 95% CI: 1.02, 1.18), residing in low-income (AOR = 1.33, 95% CI: 1.28, 1.49), and higher literacy rates (AOR = 0.81, 95% CI: 0.79, 0.89) were statistically associated with perinatal mortality respectively.

CONCLUSIONS

The study reveals several significant factors associated with perinatal mortality in East Africa. Factors such as women who gave birth before the age of 20, not married, mass media exposure, having more children, twin births, history of abortion, residing in rural areas, and in low-income countries were linked to higher odds of perinatal mortality, however, being older age, better education, better wealth, modern contraception, longer birth intervals, have health insurance, and high literacy rate countries were linked to lower odds of perinatal mortality. To reduce perinatal mortality in East Africa, targeted interventions should focus on improving educational attainment for women, enhancing access to health insurance, and promoting the use of modern contraceptive methods. Additionally, policies aimed at supporting unmarried mothers, managing multiple births, and addressing rural healthcare disparities are essential.

A phenomenological exploration of non-carrying mothers in same-gender relationships experiences of a psychologically traumatic birth

AIMS/BACKGROUND

Birth trauma is increasingly recognised in policy and practice, yet remains focused on birthing women, also holding the assumption that families involve only one of these. This research explored psychologically traumatic birth experiences in non-carrying mothers in same-gender relationships, and how they made sense of these experiences.

DESIGN/METHODS

Interviews were conducted with eight participants recruited via social media and charities, analysed using Interpretive Phenomenological Analysis. Sample demographics were homogeneous; all self-identified as Black, lesbian, first-time mothers.

RESULTS AND DISCUSSION

Four themes were developed: 'anticipated and realised threats', 'navigating identities and roles in the transition to motherhood', 'importance of feeling understood and accepted by others' and 'adapting to a new normal'. Participants' reported threat often began during pregnancy, influenced through prior experiences of perinatal loss, trauma, and stressors related to holding minoritised identities, specifically concerning sexuality and race. Challenges were experienced related to navigating dual identities as both a partner and mother, with prevalent feelings of resentment, invisibility, shame, and not being 'good enough'. Most experienced stigma and discrimination, from within and outside their families, and valued spaces where they felt accepted, including through connecting with other LGBTQ+ parents. Implications for subsequent reproductive choices were voiced, typically linked to efforts to prevent repeated trauma.

CONCLUSION

Psychologically traumatic birth may be experienced by any parent, bringing significant impacts for individuals and their relationships. Intersectional approaches that recognise diverse routes to parenthood are needed to inform and evaluate family-focused support provision, which may include facilitating couples' navigation of reproductive choices.

Exploring perspectives on how to improve psychological treatment for women from minoritised ethnic communities: qualitative study with psychological therapists

BACKGROUND

Women from minoritised ethnic communities experience inequalities in access, experience and outcomes of psychological therapy. Understanding the factors associated with these inequalities could inform improvements to mental health services.

AIMS

To explore therapists' experiences of providing treatment to women from minoritised ethnic communities, including insights on adaptations made at the delivery, content and wider organisation levels, and to gather suggestions about potential treatment improvements.

METHOD

Semi-structured interviews were conducted with 13 therapists working in two National Health Service Talking Therapies for anxiety and depression services and who had experience of treating women from minoritised ethnic communities. Data were analysed using thematic analysis.

RESULTS

Three high-order themes were identified: incorporating ethnicity and culture in the delivery of psychological therapies, challenges associated with delivering therapeutic interventions to women from minoritised ethnic groups and improvements to services that could support better access, engagement and outcomes for women from minoritised ethnic groups.

CONCLUSIONS

Findings indicate that therapists viewed cultural adaptation and cultural sensitivity as important to the delivery of appropriate care for minoritised ethnic women. Challenges to appropriate care included limited service resources, communication and language barriers, stigma and existing access and engagement inequalities. Therapists suggested that, to deliver high-quality care and optimise outcomes, improvements are required in cultural sensitivity training, flexibility of service delivery, outreach work with communities to encourage uptake and reduce stigma, support for staff and workforce diversity.

Persistent Postpartum Depression During the COVID-19 Pandemic and the Role of Social Supports

Rates of postpartum depression have been higher than typical during the COVID-19 pandemic. This study examines the persistence of depressive symptoms at 12-30 months postpartum and the role of perceived access to social support in depression outcomes. In total, 242 individuals who gave birth in the United States during the COVID-19 pandemic responded to an online survey that assessed depressive symptoms and supports in the postpartum period. A subset of 12 participants completed semi-structured interviews. Over 35% of respondents reported symptoms consistent with clinical depression at 12-30 months postpartum. Lower household income, COVID-related worries during pregnancy, experiences of intimate partner violence, and lack of perceived access to informal supports were predictors of depressive symptoms. Qualitative findings contextualize and highlight the role of supports in postpartum wellbeing. This study adds to the growing research about persistent postpartum depression and highlights the necessity of informal and formal supports in the postpartum period.

Parent's experiences of the impact of ethnicity and skin pigmentation on perinatal care

OBJECTIVES

This study aimed to explore the perceived impact of ethnicity and race on perinatal care among parents from diverse ethnic minority backgrounds or who had a Black, Asian, or ethnic minority child born in the UK within the last five years to better understand areas of ethnic inequality within perinatal care.

DESIGN

This study employed a focused ethnography, recruiting a purposive sample through posters, professional organisations, and social media platforms. Efforts to ensure maximum phenomenon variation included diverse ethnic and geographical representation. Semi-structured interviews using the digital platform, Zoom, explored experiences of accessing and receiving care, with a focus on challenges and perceptions related to ethnicity, race or skin pigmentation. Interview schedules underwent stakeholder validation and pilot testing. NVivo software facilitated qualitative analysis, employing an inductive approach with rigorous coding and thematic analysis.

RESULTS

Ethnic minority parental experiences (n = 24) revealed significant systemic challenges within the healthcare system. Three major themes were observed: Parent's voices not being heard, Systemic factors and Discrimination. Participants expressed feelings of marginalisation and inadequate communication with healthcare providers. Instances where concerns were dismissed or belittled, coupled with issues related to consent, highlighted pervasive systemic shortcomings. Structural barriers such as difficulties in scheduling appointments and perceived organisational neglect further compounded these challenges. Discriminatory attitudes and racial stereotypes also influenced the quality of care received, contributing to disparities in health outcomes and maternal wellbeing. Participants noted feelings of social isolation, exacerbated by pandemic-related restrictions and a lack of tailored support networks.

CONCLUSION

These findings underscore the urgent need for systemic reforms aimed at ensuring culturally safe and anti-racist practice, addressing communication barriers, and reducing discriminatory practices to enhance healthcare experiences and outcomes for ethnic minority parents. This includes training all healthcare staff around cultural safety.

Understanding the support needs of women with hyperemesis gravidarum

PROBLEM

Hyperemesis Gravidarum (HG) is a severe condition, but little is known about how best to psychologically support those going through this experience.

BACKGROUND

HG, a severe form of nausea and vomiting affects 0.3-3.4 % of pregnancies. It can have significant psychological impacts on sufferers, with increased rates of anxiety, depression and post-traumatic stress. There is a need for interventions tailored to this group that could ameliorate these impacts.

AIM

To explore what women with HG found useful for their mental health, what could and should be targeted in an intervention and optimal features of an intervention.

METHODS

A series of focus groups were run with 22 survivors of HG, analysed using reflexive thematic analysis.

FINDINGS

Four overarching themes were identified: the individual journey of HG; recognition and validation by healthcare professionals; impact on family roles and systems; flexible personalised support. The need for cultural competence in understanding and developing support ran through the themes.

DISCUSSION

HG involves both physical and psychological impacts, some of which are exacerbated by invalidating interactions and lack of knowledge in the healthcare system. Those with HG are simultaneously physically and mentally depleted, leading to multiple impacts on woman and family. A tailored intervention including elements of information, recording and active psychological intervention could support women's physical and mental health during HG, with the potential to prevent or ameliorate negative psychological consequences.

CONCLUSION

Psychological support for women with HG is a current gap. A tailored intervention has promise to mitigate negative impacts of this condition.

Mental health promotion and protection relating to key life events and transitions in adulthood: a rapid systematic review of systematic reviews

BACKGROUND

During the decades representing working-age adulthood, most people will experience one or several significant life events or transitions. These may present a challenge to mental health.

AIM

The primary aim of this rapid systematic review of systematic reviews was to summarise available evidence on the effectiveness of interventions to promote and protect mental health relating to four key life events and transitions: pregnancy and early parenthood, bereavement, unemployment, and housing problems. This review was conducted to inform UK national policy on mental health support.

METHODS

We searched key databases for systematic reviews of interventions for working-age adults (19 to 64 years old) who had experienced or were at risk of experiencing one of four key life events. Titles and abstracts were screened by two reviewers in duplicate, as were full-text manuscripts of relevant records. We assessed the quality of included reviews and extracted data on the characteristics of each literature review. We prioritised high quality, recent systematic reviews for more detailed data extraction and synthesis.

RESULTS

The search and screening of 3997 titles/abstracts and 239 full-text papers resulted in 134 relevant studies, 68 of which were included in a narrative synthesis. Evidence was strongest and of the highest quality for interventions to support women during pregnancy and after childbirth. For example, we found benefits of physical activity and psychological therapy for outcomes relating to mental health after birth. There was high quality evidence of positive effects of online bereavement interventions and psychological interventions on symptoms of grief, post-traumatic stress, and depression. Evidence was inconclusive and of lower quality for a range of other bereavement interventions, unemployment support interventions, and housing interventions.

CONCLUSIONS

Whilst evidence based mental health prevention and promotion is available during pregnancy and early parenthood and for bereavement, it is unclear how best to support adults experiencing job loss, unemployment, and housing problems.

Understanding occupational therapy perinatal mental health practice in mothers from ethnic minorities: A qualitative study of practitioner perceived barriers and enablers

Introduction

In the United Kingdom, ethnic minority mothers experience increased risk of mental illness compared to white women of British heritage. However, there is insufficient research to guide perinatal mental health occupational therapists to develop services that are accessible and meet the diverse needs of service users. This study explored perinatal mental health occupational therapists' perceptions of the barriers and enablers to an inclusive service provision for ethnic minority mothers.

Methods

A qualitative study was undertaken. Recruitment via social media used non-probability sampling. Semi-structured interviews collected data which were then analysed thematically.

Results

Eight occupational therapist participated in the study. Three main themes were identified: observation of caseloads; experience of providing occupational therapy; influence of the therapist's culture. Participants perceived stigma, fear, language and cultural perceptions created barriers for ethnic minority mothers.

Discussion

Limited workforce diversity, ineffective mandatory training and insufficient referral to occupational therapy by other healthcare professionals were believed to negatively impact service delivery. Cultural experience and reflective practice were felt to enable inclusive practice. Recommendations to inform perinatal mental health occupational therapy practice in the United Kingdom and internationally include collaborations to gain a more diverse workforce, improved mandatory training and strategies to increase cultural sensitivity and competence.

Attitudes, experiences, and implications of asking about suicide during the perinatal period: A qualitative study with maternity healthcare practitioners

BACKGROUND

Suicide is a leading cause of maternal death. Maternity healthcare practitioners (HCPs) are uniquely positioned to identify perinatal mental health (PMH) problems and/or suicidality. Research exploring HCPs attitudes towards suicide-related screening items and their experiences of asking about perinatal suicidality is limited.

OBJECTIVES

(i) to explore HCPs attitudes towards 16 suicide-related screening items; and (ii) to explore HCPs broader views, experiences and implications of discussing suicide with perinatal women in maternity care settings.

METHODS

Fifteen semi-structured interviews were conducted with maternity HCPs. The sample included midwives, health visitors, general practitioners, and specialist PMH practitioners working in the United Kingdom (UK). Inductive thematic analysis was used to explore the data and identify themes.

RESULTS

Most HCPs felt uncomfortable with, disliked, or found half of the suicide-related items unhelpful. Reasons included use of ambiguous or emotive terms. HCPs preferred not to use the word 'suicide' with pregnant or postnatal women. In the thematic analysis, four themes were identified: (i) Approaches for discussing and identifying PMH problems and suicidality; (ii) Competing demands and continuity of carer; (iii) PMH and suicidality training and support; and (iv) Availability of PMH services and referral pathways. These factors affected HCPs capacity, willingness, and confidence to ask women suicide-related questions.

CONCLUSIONS

HCPs need targeted PMH and suicidality training and support in maternity care contexts to enable them to feel more equipped, comfortable, and available to have conversations with women about PMH and suicide. Timely detection and intervention may help to improve care for women experiencing perinatal suicidality.

A group psychological intervention for postnatal depression in British mothers of South Asian origin - the ROSHNI-2 RCT

Background

Postnatal depression is more common in British South Asian women than white women in the United Kingdom. Despite empirical evidence suggesting the effectiveness of cognitive-behavioural therapy as a first line of treatment, little evidence is available regarding its applicability to different minority ethnic groups.

Objectives

Determining the clinical and cost-effectiveness of a culturally adapted group psychological intervention (Positive Health Programme) in primary care for British South Asian women with postnatal depression compared with treatment as usual.

Setting

General practices and children's centres in the North West, East Midlands, Yorkshire, Glasgow and London.

Participants

British South Asian women meeting the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) depression criteria, aged 16 years or above, with infants up to 12 months.

Design

A multicentre randomised controlled trial with an internal pilot and partially nested design to compare treatment as usual plus the Positive Health Programme with treatment as usual in British South Asian women with postnatal depression, with a qualitative study to examine the acceptability and feasibility of the intervention.

Intervention

The Positive Health Programme, a culturally adapted group intervention based on the principles of cognitive-behavioural therapy delivered by facilitators over 12 sessions.

Outcomes measures

The primary outcome was recovery from depression (Hamilton Depression Rating Scale ≤ 7) at end of intervention (approximately 4-6 months). Analysis of the primary outcome and the long-term follow-up (at 12 months) used a logistic random-effects model to estimate the odds ratio of caseness between treatments, adjusting for centre, severity of depression and education at baseline. Cost data were collected using an Economic Patient Questionnaire.

Results

Seven hundred and thirty-two participants across four study centres were randomised by the Manchester Clinical Trials Unit. At 4 months, almost half of patients in the treatment (Positive Health Programme) group were recovered (138 or 49%), whereas 105 (37%) were recovered in the control (treatment as usual) group. By 12 months, the control (treatment as usual) and treatment (Positive Health Programme) group had over 50% recovery at 140 (54%) and 141 (54%), respectively. For the primary outcome, recovery from postnatal depression at end of intervention, we found a significant effect such that the odds of achieving recovery in the treatment group were almost twice as high compared to the treatment as usual group (odds ratio 1.97, 95% confidence interval 1.26 to 3.10). Between the two groups, there was no significant difference in the odds of recovery at 12 months (odds ratio 1.02, 95% confidence interval 0.62 to 1.66), highlighting a need for more intensive therapies and/or longer-term care plans for this group of patients.

Qualitative results

The intervention was considered feasible and acceptable from the perspectives of Positive Health Programme participants, facilitators, and general practitioners. The findings suggest improved emotional and social support and an enhanced sense of well-being.

Economic evaluation

Positive Health Programme implementation was estimated to cost an average of £408 per participant. The intention-to-treat analysis shows that the Positive Health Programme intervention costs £22,198 per quality-adjusted life-year gain. Positive Health Programme was cost-effective on average but with a substantial uncertainty: the probability that Positive Health Programme was cost-effective was 44% (65%) at the willingness to pay £20,000 (£30,000) per quality-adjusted life-year. The Positive Health Programme was highly cost-effective for those who attended 5-8 sessions, costing £9040 per quality-adjusted life-year.

Limitations

The study sample limits generalisability with other ethnic minority groups, and the cost-effectiveness analysis did not explore recall bias.

Conclusions

The results of this study provide robust evidence that the culturally adapted psychological intervention for postnatal depression in South Asian women is effective at the primary end point and acceptable to women.

Future work

Further development of the Positive Health Programme intervention and evaluation, with longer-term outcome follow-ups and exploration of cost-effectiveness of remote delivery of the Positive Health Programme.

Study registration

Current Controlled Trials ISRCTN10697380.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/68/08) and is published in full in Health Technology Assessment; Vol. 29, No. 6. See the NIHR Funding and Awards website for further award information.

Exploring perspectives on how to improve psychological treatment for women from minoritised ethnic communities: A qualitative study with service users

BACKGROUND

Women are disproportionately impacted by depression and anxiety disorders and in particular, women from minoritised ethnic communities experience inequalities in access to outcomes of psychological treatment for these disorders. Better understanding from the views of service users about the factors that impact their access to, and experiences of care could help to optimise treatment for these groups.

METHOD

This study explored experiences of treatment and gathered suggestions about treatment improvement, from the perspectives of women currently using psychological therapy services. Semi-structured interviews were conducted with 12 female NHS Talking Therapies for anxiety and depression (NHSTTad) service users from minoritised ethnic communities. Data were analysed using thematic analysis.

RESULTS

Four high-order themes were identified: (1) cultural identity and experiences of mental health and treatment, (2) challenges associated with treatment, (3) facilitators of good treatment experiences and outcomes and (4) improvements for women from minoritised ethnic communities.

CONCLUSIONS

Findings showed that cultural sensitivity and awareness are important to minoritised ethnic women receiving therapy. Challenges included access difficulties and limitations of treatment options offered, alongside personal challenges of engaging in therapy. Facilitators of good treatment experiences and outcomes included flexibility on the part of the service, as well as therapist-related factors such as identity characteristics (age, gender and culture of therapist), a good therapeutic relationship and the therapist's ability to deliver person-centred care. Improvements included ensuring care is culturally sensitive, reducing waiting times or providing better support for people on waiting lists, providing a flexible service that takes individual needs into account, increasing workforce diversity and reaching out to underserved communities. Many of the suggested improvements are generalisable to underserved minoritised ethnic groups, regardless of gender and could be applied to other psychological therapies services other than NHSTTad.

Language use in depressed and non-depressed mothers and their adolescent offspring

BACKGROUND

Approximately 10% of mothers experience depression each year, which increases risk for depression in offspring. Currently no research has analysed the linguistic features of depressed mothers and their adolescent offspring during dyadic interactions. We examined the extent to which linguistic features of mothers' and adolescents' speech during dyadic interactional tasks could discriminate depressed from non-depressed mothers.

METHODS

Computer-assisted linguistic analysis (Linguistic Inquiry and Word Count; LIWC) was applied to transcripts of low-income mother-adolescent dyads (N = 151) performing a lab-based problem-solving interaction task. One-way multivariate analyses were conducted to determine linguistic features hypothesized to be related to maternal depressive status that significantly differed in frequency between depressed and non-depressed mothers and higher and lower risk offspring. Logistic regression analyses were performed to classify between dyads belonging to the two groups.

RESULTS

The results showed that linguistic features in mothers' and their adolescent offsprings' speech during problem-solving interactions discriminated between maternal depression status. Many, but not all effects, were consistent with those identified in previous research using primarily written text, highlighting the validity and reliability of language behaviour associated with depressive symptomatology across lab-based and natural environmental contexts.

LIMITATIONS

Our analyses do not enable to ascertain how mothers' language behaviour may have influenced their offspring's communication patterns. We also cannot say how or whether these findings generalize to other contexts or populations.

CONCLUSION

The findings extend the existing literature on linguistic features of depression by indicating that mothers' depression is associated with linguistic behaviour during mother-adolescent interaction.

Socioeconomic deprivation and perinatal anxiety: an observational cohort study

BACKGROUND

Women from areas of social deprivation and minority ethnic groups are more likely to experience poor physical health and have higher rates of mental health problems relative to women from less socially disadvantaged groups. However, very little research has examined this in relation to perinatal anxiety. The current study aims to determine prevalence, risk factors and desire for treatment for perinatal anxiety in three regions of the UK with diverse regional characteristics.

METHODS

Women completed measures of anxiety in early, mid-, late-pregnancy and postpartum. Participants were included from three regions of the UK: Region 1 = North East England & North Cumbria n = 512; Region 2 = London North Thames n = 665; Region 3 = West Midlands n = 705.

RESULTS

Prevalence of perinatal anxiety was lower in Region 1 (OR 0.63 95% CI 0.45 to 0.89) and Region 2 (OR 0.72 95% CI 0.52 to 0.98) relative to Region 3. Analysis showed the effect of neighbourhood socioeconomic deprivation on perinatal anxiety differed by region. In more affluent regions, living in a deprived neighbourhood had a greater impact on perinatal anxiety than living in a deprived neighbourhood in a deprived region. Other factors associated with risk of anxiety in the perinatal period included physical health problems and identifying as being from 'mixed or multiple' ethnic groups.

CONCLUSIONS

Neighbourhood deprivation relative to regional deprivation is a better predictor of perinatal anxiety than either regional deprivation or neighbourhood deprivation alone. Women of mixed ethnic backgrounds and women with physical health problems may warrant more attention in terms of screening and support for perinatal anxiety. Self-reported desire for treatment was found to be low.

Social determinants in prenatal antidepressant use and continuation: Systematic review and meta-analysis

INTRODUCTION

Depression is one of the most common co-morbidities during pregnancy; with severe symptoms, antidepressants are sometimes recommended. Social determinants are often linked with antidepressant use in the general population, and it is not known if this is the case for pregnant populations. Our objective was to determine if social determinants are associated with prenatal antidepressant intake via a systematic review and meta-analysis.

METHODS

A systematic search of five databases was conducted to identify publications from inception to October 2022 that reported associations with prenatal antidepressant intake (use/continuation) and one or more social determinants: education, race, immigration status, relationship, income, or employment. Eligible studies were included in random effects meta-analyses.

RESULTS

A total of 23 articles describing 22 studies were included. Education was significantly and positively associated with prenatal antidepressant continuation and heterogeneity was moderate. (Odds ratio = 0.83; 95% CI, 0.78 to 0.89; p < 0.00001; I2 = 53%). Meta-analyses of antidepressant use and education, race, and relationship status, and antidepressant continuation and income were not significant with high levels of heterogeneity.

DISCUSSION

While most social determinants in this review were not linked with prenatal antidepressant intake, lower maternal education level does seem to be associated with lower rates of prenatal antidepressant continuation.

CONCLUSIONS

Education appears to be linked with prenatal antidepressant intake. The low number of included studies precludes conclusive evidence for other social determinants.

Pathways to specialist community perinatal mental health services: a two-site longitudinal retrospective service evaluation

Background

During pregnancy and the postpartum period, women's mental health can deteriorate quickly. Timely and easy access to services is critically important; however, little is known about the pathways women take to access services. Previous research has shown that women from ethnic minority groups in the United Kingdom experience more access issues compared to the White British women.

Aim

To describe pathways taken to specialist community perinatal mental health services and explore how they vary across services and ethnic groups.

Methods

This is a two-site, longitudinal retrospective service evaluation conducted in Birmingham and London during 6 months (1 July-31 December 2019). Electronic records of 228 women were accessed and data were extracted on help-seeking behaviour, referral process and the type of pathway (i.e. simple or complex). Data were collected using the adapted World Health Organization encounter form and analysed using uni- and multivariable analyses.

Results

The median time from the start of perinatal mental illness to contact with perinatal mental health services was 20 weeks. The majority of patients accessed perinatal mental health services through primary care (69%) and their pathway was simple, that is they saw one service before perinatal mental health services (63%). The simple pathway was used as a proxy for accessible services. In Birmingham, compared to London, more referrals came from secondary care, more women were experiencing current deterioration in mental health, and more women followed a complex pathway. Despite differences between ethnic groups regarding type of pathway and duration of patient journey, there was no evidence of difference when models controlled for confounders such as clinical presentation, general characteristics and location. The service's location was the strongest predictor of the type of pathway and duration of patient journey.

Limitations

The heterogeneity among categorised ethnic groups; data extracted from available electronic records and not validated with patient's own accounts of their pathways to care; unanalysed declined referrals; the study was conducted before the COVID-19 pandemic and pathways may be different in the post-COVID-19 period.

Conclusion

The study provides important insights into how patients find their way to community perinatal mental health services. It shows that there is a great degree of variability in the time taken to get into these services, and the pathway taken. This variation does not come from different needs of patients or different clinical presentations but rather from service-level factors.

Future work

The studied community perinatal mental health services in the United Kingdom operate with a significant degree of variability in the types and characteristics of patient pathways. Future research should explore these issues on the national and international levels. Additionally, future research should explore the reasons for the different pathways taken and the outcomes and risks associated with them.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/105/14.

Efficacy of a culturally adapted, cognitive behavioural therapy-based intervention for postnatal depression in British south Asian women (ROSHNI-2): a multicentre, randomised controlled trial

BACKGROUND

Postnatal depression necessitates timely and effective interventions to mitigate adverse maternal and child outcomes in the short term and over the life course. British south Asian women with depression are often underserved and undertreated due to stigma, language barriers, and cultural barriers. This trial aimed to test the clinical efficacy of a culturally adapted, group cognitive behavioural therapy (CBT)-based intervention, the Positive Health Programme (PHP), delivered by non-specialist health workers for postnatal depression in British south Asian women.

METHODS

This study was a randomised controlled trial, with culturally adapted recruitment and an internal pilot, comparing the PHP (intervention group) with treatment as usual (control group) in British south Asian women with postnatal depression. The study was conducted at five centres across the UK. Participants were aged 16 years or older, met the DSM-5 criteria for depression, and had infants aged 0-12 months. Randomisation (1:1) was stratified by centre, with a block size of 18, and was done through an independent remote telephone service. The PHP was delivered over 12 group sessions in 4 months. The primary outcome was recovery from depression (defined as a Hamilton Depression Rating Scale [HDRS] score ≤7) at 4 months after randomisation, and an assessment was also done at 12 months. Analysis was on an intention-to-treat basis including only participants with non-missing outcome data; we used a random-effects logistic regression model including fixed covariates for study site, baseline depression severity (HDRS score), parity, and years in education and a random coefficient for therapy group. This trial is registered with the ISRCTN (ISRCTN10697380).

FINDINGS

Of the 9136 individuals approached for recruitment between Feb 8, 2017, and March 29, 2020, 4296 women were eligible for and consented to screening, among whom 732 screened positive and were randomly allocated: 368 (50%) to the PHP group and 364 (50%) to the control group. Participants were mostly of Pakistani (397 [55%] of 719 with available data), Indian (176 [24%]), or Bangladeshi ethnicity (127 [18%]), with an overall mean age of 31·4 years (SD 5·2), with their youngest infants having a mean age of 23·6 weeks (14·2). At 4 months from randomisation, the proportion of participants who showed recovery from depression on the HDRS was significantly higher in the PHP group (138 [49%] of 281) than in the control group (105 [37%] of 281; adjusted odds ratio 1·97 [95% CI 1·26-3·10]). At the 12-month follow-up, this difference was no longer significant (1·02 [95% CI 0·62-1·66]).

INTERPRETATION

In British south Asian women with postnatal depression, a culturally adapted group CBT-based intervention could aid in quicker recovery from depression compared with treatment as usual. Further research is needed to identify how to sustain the treatment effect and establish strategies for scale-up.

FUNDING

UK National Institute for Health and Care Research.

Barriers to accessing perinatal mental health services and suggestions for improvement: qualitative study of women of Black and south Asian backgrounds

BACKGROUND

Maternity outcomes for women from certain ethnic groups are notably poor, partly owing to their not receiving treatment from services.

AIMS

To explore barriers to access among Black and south Asian women with perinatal mental health problems who did not access perinatal mental health services and suggestions for improvements, and to map findings on to the perinatal care pathway.

METHOD

Semi-structured interviews were conducted in 2020 and 2021 in the UK. Data were analysed using the framework method.

RESULTS

Twenty-three women were interviewed, and various barriers were identified, including limited awareness of services, fear of child removal, stigma and unresponsiveness of perinatal mental health services. Whereas most barriers were related to access, fear of child removal, remote appointments and mask-wearing during COVID-19 affected the whole pathway. Recommendations include service promotion, screening and enhanced cultural understanding.

CONCLUSIONS

Women in this study, an underrepresented population in published literature, face societal, cultural, organisational and individual barriers that affect different aspects of the perinatal pathway.

Disparities in spatiotemporal clustering of maternal mental health conditions before and during the COVID-19 pandemic

Mounting evidence indicates the worsening of maternal mental health conditions during the COVID-19 pandemic. Mental health conditions are the leading cause of preventable death during the perinatal and postpartum periods. Our study sought to detect space-time patterns in the distribution of maternal mental health conditions in pregnant women before (2016-2019) and during (2020-2021) the COVID-19 pandemic in North Carolina, USA. Using the space-time Poisson model in SaTScan, we performed univariate and multivariate cluster analysis of emergency department (ED) visits for perinatal mood and anxiety disorders (PMAD), severe mental illness (SMI), maternal mental disorders of pregnancy (MDP), suicidal thoughts, and suicide attempts during the pre-pandemic and pandemic periods. Clusters were adjusted for age, race, and insurance type. Significant multivariate and univariate PMAD, SMI, and MDP clustering persisted across both periods in North Carolina, while univariate clustering for both suicide outcomes decreased during the pandemic. Local relative risk (RR) for all conditions increased drastically in select locations. The number of zip code tabulation areas (ZCTAs) included in clusters decreased, while the proportion of urban locations included in clusters increased for non-suicide outcomes. Average yearly case counts for all maternal mental health outcomes increased during the pandemic. Results provide contextual and spatial information concerning at-risk maternal populations with a high burden of perinatal mental health disorders before and during the pandemic and emphasize the necessity of urgent and targeted expansion of mental health resources in select communities.

Indian immigrants' constructions of mental health and mental illness in the perinatal period: A qualitative study

AIM

The aim of this study is to explore how immigrant women and men from India construct mental health and mental illness in the perinatal period.

DESIGN

Qualitative interpretive design.

METHODS

Data were collected by conducting in-depth interviews with 19 participants. Photo elicitation, free listing and pile sorting were used during the interviews. Purposive sampling was used, and data were collected in 2018 and 2019. Data were analysed using thematic analysis.

FINDING/RESULTS

One major theme and three subthemes were identified. 'We do not talk about it' was the major theme and the subthemes: (1) 'living peacefully and feeling happy' described the views on mental health; (2) 'that's the elephant in the room still' captures how participants felt when talking about mental illness; and (3) 'why don't we talk about it' offers reasons why the Indian community does not talk about mental health and illness.

CONCLUSION

The findings of this study have highlighted the importance of understanding the impact of immigration and being culturally sensitive when assessing mental health in the perinatal period.

IMPACT

The findings of this study identify some of the reasons for non-disclosure of mental health issues by immigrants. Incorporating these findings during psychosocial assessment by health professionals in the perinatal period will help translate the cultural aspects into more effective communication.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public contribution to the study was provided by the Community Stakeholders Group; these were members of the immigrant community from India who had expertise in mental health. They contributed to the study design and the key terms and phrases for the free list used in interviews.

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.

Experiences and impacts of psychological support following adverse neonatal experiences or perinatal loss: a qualitative analysis

BACKGROUND

Poor parental mental health in the perinatal period has detrimental impacts on the lives and relationships of parents and their babies. Parents whose babies are born premature and/or sick and require neonatal care or those who experience perinatal loss are at increased risk of adverse mental health outcomes. In 2021 a North-West charity received funding to offer psychological support to service users of infants admitted to neonatal care or those who had experienced perinatal loss, named the Family Well-being Service (FWS). The FWS offered three different types of support - ad hoc support at the neonatal units or specialist clinics; one-to-one person-centred therapy; or group counselling. Here we report the qualitative findings from an independent evaluation of the FWS.

METHODS

Thirty-seven interviews took place online or over the phone with 16 service users (of whom two took part in a follow-up interview), eight FWS providers and 11 healthcare professionals. Interviews were coded and analysed using thematic analysis.

RESULTS

The analysis revealed two themes. 'Creating time and space for support' detailed the informational, contextual, and relational basis of the service. This theme describes the importance of tailoring communications and having a flexible and proactive approach to service user engagement. Service users valued being listened to without judgement and having the space to discuss their own needs with a therapist who was independent of healthcare. Communication, access, and service delivery barriers are also highlighted. The second theme - 'making a difference' - describes the cognitive, emotional, and interpersonal benefits for service users. These included service users being provided with tools for positive coping, and how the support had led to enhanced well-being, improved relationships, and confidence in returning to work.

CONCLUSION

The findings complement and extend the existing literature by offering new insights into therapeutic support for service users experiencing adverse neonatal experiences or perinatal loss. Key mechanisms of effective support, irrespective of whether it is provided on a one-to-one or group basis were identified. These mechanisms include clear information, flexibility (in access or delivery), being independent of statutory provision, focused on individual needs, active listening, the use of therapeutic tools, and positive relationships with the therapist. Further opportunities to engage with those less willing to take up mental health support should be developed.

Mental health stigma and health-seeking behaviors amongst pregnant women in Vietnam: a mixed-method realist study

BACKGROUND

Approximately 15% of women in low-and middle-income countries experience common perinatal mental disorders. Yet, many women, even if diagnosed with mental health conditions, are untreated due to poor quality care, limited accessibility, limited knowledge, and stigma. This paper describes how mental health-related stigma influences pregnant women's decisions not to disclose their conditions and to seek treatment in Vietnam, all of which exacerbate inequitable access to maternal mental healthcare.

METHODS

A mixed-method realist study was conducted, comprising 22 in-depth interviews, four focus group discussions (total participants n = 44), and a self-administered questionnaire completed by 639 pregnant women. A parallel convergent model for mixed methods analysis was employed. Data were analyzed using the realist logic of analysis, an iterative process aimed at refining identified theories. Survey data underwent analysis using SPSS 22 and descriptive analysis. Qualitative data were analyzed using configurations of context, mechanisms, and outcomes to elucidate causal links and provide explanations for complexity.

RESULTS

Nearly half of pregnant women (43.5%) would try to hide their mental health issues and 38.3% avoid having help from a mental health professional, highlighting the substantial extent of stigma affecting health-seeking and accessing care. Four key areas highlight the role of stigma in maternal mental health: fear and stigmatizing language contribute to the concealment of mental illness, rendering it unnoticed; unconsciousness, normalization, and low literacy of maternal mental health; shame, household structure and gender roles during pregnancy; and the interplay of regulations, referral pathways, and access to mental health support services further compounds the challenges.

CONCLUSION

Addressing mental health-related stigma could influence the decision of disclosure and health-seeking behaviors, which could in turn improve responsiveness of the local health system to the needs of pregnant women with mental health needs, by offering prompt attention, a wide range of choices, and improved communication. Potential interventions to decrease stigma and improve access to mental healthcare for pregnant women in Vietnam should target structural and organizational levels and may include improvements in screening and referrals for perinatal mental care screening, thus preventing complications.

Culturally Sensitive Perinatal Mental Health Care: Experiences of Women From Minority Ethnic Groups

BACKGROUND

Current research has identified how ethnic minority women experience poorer health outcomes during the perinatal period. In the United Kingdom, specialist perinatal mental health services provide mental health treatment for women throughout the perinatal period. Service users have previously highlighted that perinatal services are hard to access and lack cultural sensitivity, whereas healthcare professionals have described limited opportunities and resources for developing cultural competency.

OBJECTIVES

We explored the experiences of ethnic minority women with National Health Service (NHS) specialist perinatal teams and identified what culturally sensitive perinatal mental health care means to this group.

DESIGN

Individual semi-structured interviews were conducted, and an interpretative phenomenological analysis framework was used to analyse the interview transcripts.

SETTING AND PARTICIPANTS

Participants were recruited from NHS specialist perinatal teams and online via social media.

RESULTS

Six women were interviewed. Four group experiential themes central to the experiences of participants emerged: (1) strengthening community networks and peer support; (2) valuing cultural curiosity; (3) making sense of how culture, ethnicity, race and racism impact mental health; and (4) tailoring interventions to ethnic minority women and their families.

DISCUSSION AND CONCLUSIONS

The findings capture how ethnic minority women experience specialist perinatal teams and offer insights into practising culturally sensitive care. Perinatal mental health professionals can support ethnic minority women by strengthening their access to community resources and peer support; being curious about their culture; helping them to make sense of how culture, ethnicity, race and mental health interact; and applying cultural and practical adaptations to interventions.

PATIENT OR PUBLIC CONTRIBUTION

A Lived Experience Advisory Group (LEAG) of women from ethnic minority groups contributed to the design and conduct of this study. The LEAG had lived experience of perinatal mental health conditions and accessing specialist perinatal teams. The LEAG chose to co-produce specific aspects of the research they felt fit with their skills and available time throughout five group sessions. These aspects included developing the interview topic guide, a structure for debriefing participants and advising on the social media recruitment strategy.

Stigma in functional neurological disorder (FND) - A systematic review

OBJECTIVE

The purpose of this systematic review was to evaluate stigma and Functional Neurological Disorder (FND) regarding: 1) prevalence and associated factors, 2) the nature and context of stigma in FND, and 3) stigma-reduction interventions.

METHODS

We searched four relevant databases from inception to December 2023, using search terms relevant to FND and stigma themes. We employed the method of synthesis by "aggregation and configuration" to synthesise and analyse the data into emergent themes.

RESULTS

We found 127 studies, spanning 148 countries, involving 18,886 participants. Of these, 4889 were patients, 13,123 were healthcare professionals, and 526 were caregivers. Quantitatively, stigma has been mainly studied in patients with functional seizures, and was higher than patients with epilepsy in three studies. Stigma experienced by patients is associated with poorer quality of life and caregiver burden. We found 10 themes and 29 subthemes revealing stigma as a systemic process, with intrapersonal, interpersonal and structural aspects. Few studies examined the perspective of caregivers, the public or online community. We identified six anti-stigma interventions.

CONCLUSION

Stigma in FND is a layered process, and affects patient quality of life and provision of care. Stigma needs to be addressed from the top structures, at governmental level, so that appropriate care pathways can be created, giving patients with FND parity of esteem with other medical conditions.

A meta-analytic examination of sensitive responsiveness as a mediator between depression in mothers and psychopathology in children

The current meta-analysis examined the mediating role of sensitive-responsive parenting in the relationship between depression in mothers and internalizing and externalizing behavior in children. A systematic review of the path of maternal sensitive responsiveness to child psychopathology identified eligible studies. Meta-analytic structural equation modelling (MASEM) allowed for the systematic examination of the magnitude of the indirect effect across 68 studies (N = 15,579) for internalizing and 92 studies (N = 26,218) for externalizing psychopathology. The synthesized sample included predominantly White, English-speaking children (age range = 1 to 205 months; Mage = 66 months; 47% female) from Western, industrialized countries. The indirect pathway was small in magnitude and similar for externalizing (b = .02) and internalizing psychopathology (b = .01). Moderator analyses found that the indirect pathway for externalizing problems was stronger when mother-child interactions were observed during naturalistic and free-play tasks rather than structured tasks. Other tested moderators were not significant.

Lesbian, gay, bisexual, and transgender clinical competence of physiotherapy students in Israel

BACKGROUND

Clinical competence encompasses attitudes, skills, and knowledge regarding diverse client groups. Appropriate clinical competence requires an understanding of the cultural context in which healthcare is delivered. In conservative countries such as Israel, there is a noticeable scarcity of information regarding the clinical competency of physiotherapy students (PTSs) in effectively treating lesbian, gay, bisexual and transgender (LGBT) individuals. The objective of this study was to assess the level of LGBT clinical competence among PTSs in Israel.

METHODS

Conducted through an anonymous online self-report survey, this study gathered personal and academic background information and self-reported data on previous LGBT education during undergraduate studies of PTSs. It utilized the Hebrew version of the Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS) questionnaire. Descriptive statistics were computed for all outcome measures. The internal reliability of the LGBT-DOCSS was assessed. Total scores of the LGBT-DOCSS, along with scores in each of the three subscales (clinical preparedness, knowledge, and attitudes), were compared across different levels of religiosity and gender.

RESULTS

The sample comprised of 251 PTSs, with an average age of 25.57 ± 3.07 years (34.7% men, 65.3% women). All students reported a lack of LGBT community-related courses during their undergraduate studies. The translated Hebrew version demonstrated good internal consistency, with Cronbach's alpha ranging from 0.65 to 0.83. The LGBT-DOCSS total score was 4.55 ± 0.61 out of 7, indicating a low level of clinical competency. The highest mean score was in the attitudes subscale (6.55 ± 0.87), which was significantly higher than the scores for the knowledge subscale (3.14 ± 1.46) and clinical preparedness subscale (3.36 ± 0.86). Religiousness was significantly associated with clinical preparedness and attitudes. Men exhibited higher self-reported levels of knowledge and clinical preparedness, albeit with more negative attitudes compare to women. Sexual orientation was significantly associated with clinical competency, with PTSs who identified as heterosexual demonstrating a lower level of clinical competency compared to participants who identified as non-heterosexual.

CONCLUSIONS

In Israel, PTSs demonstrated a low level of clinical competency in terms of self-reported knowledge and self-reported clinical preparedness but contrasting positive attitudes toward the LGBT community. Religiousness, gender and sexual orientation had a significant influence on competency levels.These preliminary findings highlight the urgent necessity to enhance the knowledge of PTSs regarding the LGBT community to improve their clinical competence.

TRIAL REGISTRATION NR

Not applicable.

Examining Indirect and Direct Effects of Risk and Resilience on the Relation Between Perceived Discrimination and Eating Disorder Symptoms in Ethnic Minority American Women

Direct relationships between perceived discrimination and eating pathology in ethnic minorities are well-documented. However, theoretical work examining unique risk and resilience factors that strengthen or weaken the relation between these constructs in ethnic minorities is lacking. The current study aims to address this gap by incorporating stress-process and tripartite frameworks to examine social and personal resources as they relate to perceived discrimination and eating pathology. In a sample of Black, Asian, and Latine women (N = 296, M age = 30.82), social support did not mediate the relationship between perceived discrimination and eating pathology. A significant interaction effect was observed for thin-ideal internalization strengthening the relation between perceived discrimination and negative emotional eating. Thin-ideal internalization moderated the relation between perceived discrimination and negative emotional eating in Latine Women, and disordered eating in Black Women. Overall, findings suggest ethnic minority Women have both personal and social resources that may influence the strength of effect on the relation between perceived discrimination on eating pathology.

Barriers to help-seeking for postpartum depression mapped onto the socio-ecological model and recommendations to address barriers

Postpartum depression affects nearly a quarter of women up to a year after childbirth. Although it is treatable, significant barriers to help-seeking prevent women from being treated. This paper assesses key literature on the barriers for help-seeking among women with postpartum depression. The barriers identified have been mapped onto the socio-ecological model in addition to potential recommendations that professionals can use to address barriers on individual, interpersonal, organizational, community and societal levels. The recommendations provided are meant to serve as leverage points for professionals in efforts to create appropriate support and interventions. As such, this paper serves as a mapping tool for healthcare and public health professionals to assess obstacles to women's help-seeking and to guide multi-pronged interventions on various levels of the socio-ecological model that may increase help-seeking among women with postpartum depression. Holistically and comprehensively providing support to women will require significant effort throughout all sectors of society as opposed to isolated, siloed interventions.

Impact of maternal risk factors on ethnic disparities in maternal mortality: a national population-based cohort study

Background

Ethnic disparities in maternal mortality are consistently reported. This study aimed to investigate the contribution of known risk factors including age, socioeconomic status, and medical comorbidities to observed ethnic disparities in the United Kingdom (UK).

Methods

A cohort of all women who died during or up to six weeks after pregnancy in the UK 2009-2019 were identified through national surveillance. No single denominator population included data on all risk factors, therefore we used logistic regression modelling to compare to 1) routine population birth and demographic data (2015-19) (routine data comparator) and 2) combined control groups of four UK Obstetric Surveillance System studies (UKOSS) control comparator)).

Findings

There were 801 maternal deaths in the UK between 2009 and 2019 (White: 70%, Asian: 13%, Black: 12%, Chinese/Other: 3%, Mixed: 2%). Using the routine data comparator (n = 3,519,931 maternities) to adjust for demographics, including social deprivation, women of Black ethnicity remained at significantly increased risk of maternal death compared with women of white ethnicity (adjusted OR 2.43 (95% Confidence Interval 1.92-3.08)). The risk was greatest in women of Caribbean ethnicity (aOR 3.55 (2.30-5.48)). Among women of White ethnicity, risk of mortality increased as deprivation increased, but women of Black ethnicity had greater risk irrespective of deprivation. Using the UKOSS control comparator (n = 2210), after multiple adjustments including smoking, body mass index, and comorbidities, women of Black and Asian ethnicity remained at increased risk (aOR 3.13 (2.21-4.43) and 1.57 (1.16-2.12) respectively).

Interpretation

Known risk factors do not fully explain ethnic disparities in maternal mortality. The impact of socioeconomic deprivation appears to differ between ethnic groups.

Funding

This research is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-127-21202.

Postnatal depression in British mothers of African and Caribbean origin: a randomised controlled trial of learning through play plus culturally adapted cognitive behaviour therapy compared with psychoeducation

Background

One in every three women worldwide experiences postnatal depression after childbirth, with long-term negative consequences on their children. The mainstream mental healthcare provision for British mothers of African/Caribbean origin is mostly unsuccessful due to a lack of culturally appropriate care.

Methods

The study adopts a mixed-methods randomised controlled trial (RCT) design. A 12-session (60 minutes each) of online Learning Through Play plus Culturally adapted Cognitive Behaviour Therapy (LTP+CaCBT) intervention was employed for treating postnatal depression in comparison with psychoeducation (PE). Participants aged 19-53 were screened for depression using the Patient Health Questionnaire (PHQ-9). N=130 participants who scored >5 on PHQ-9 were randomised into LTP+CaCBT (n=65) or PE (n=65) groups. N=12 focus groups (LTP+CaCBT, n=6; PE, n=6) and n=15 individual interviews (LTP+CaCBT, n=8; PE, n=7) were conducted, transcribed verbatim and analysed.

Results

Satisfaction with intervention (LTP+CaCBT, 72.9%; PE, 65.2%); retention rates (LTP+CaCBT, 91%; PE, 71%); reduction in postnatal depression was higher in LTP+CaCBT on PHQ-9 Md=1.00 with z= -4.046; compared to PE, Md=1.00 with z= -1.504. Both groups showed reduced levels of anxiety on GAD-7 with no significant difference. Emerging themes from the qualitative findings showed increased positive moods, reduced worries about parenting difficulties and the facilitative role of remote intervention.

Conclusions

LTP+CaCBT intervention is culturally appropriate and acceptable and reduces postnatal depression in British mothers of African/Caribbean origin. A fully powered RCT is recommended to evaluate the clinical and cost-effectiveness of LTP+CaCBT, including the child's outcomes compared with routine treatment as usual.

Clinical trial registration

www.ClinicalTrials.gov, identifier NCT04820920.

Equity in prenatal healthcare services globally: an umbrella review

BACKGROUND

Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics.

METHODS

For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews.

RESULTS

The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors.

CONCLUSIONS

This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.

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.

The Impact of Covid-19 on Women's Mental Health and Wellbeing During Pregnancy and the Perinatal Period: A Mixed-Methods Systematic Review

REVIEW QUESTION

What is the impact of Covid-19 upon the mental health and well-being of women during pregnancy and during the perinatal period?

INCLUSION CRITERIA

empirical primary research; maternal mental health and wellbeing; perinatal period; Covid-19; English or Thai language; studies from December 2019-September 2021, updated March 2024.

EXCLUSION CRITERIA

secondary research, commentary, grey literature. Databases searched: CINAHL, Cochrane, JBI, Medline, PsycINFO, Clinical Key and Web of Science. Studies were assessed for bias using tools aligned with study design. A convergent integrated approach was taken whereby quantitative data was combined with qualitative data, synthesised simultaneously using Braun and Clarke Six Steps to Thematical Analysis and presented as narrative. Forty-two studies were included. Overall level of methodological quality of studies was 14 rated good, 28 fair. Overarching themes: "Impact" and "Emotional Impact." Themes: demographic impact; mental health and socio-economic factors; obstetric factors; pre-morbidity; maternity service delivery; relationships; fear and worry, grief and loss. Commonality suggested some evidence for increased risk and prevalence for perinatal mental illness to pre-pandemic levels.

RISK FACTORS

lack/perceived lack of social support; high-risk pregnancy, complex obstetric history; prior mental illness; maternity service delivery, quality and safety; fear and worry. Results confer perinatal mental illness prominent during the pandemic though many did not suggest prevalence higher than pre-pandemic levels, or directly associated. Several factors compound risk. A small number of protective factors are identified. The dynamic processes of risk and protection need to be understood within the specific context in which they operate. The authors received no financial support for the research, authorship, and/or publication of this article. The study was not registered.

Mapping high-risk clusters and identifying place-based risk factors of mental health burden in pregnancy

Purpose

Despite affecting up to 20% of women and being the leading cause of preventable deaths during the perinatal and postpartum period, maternal mental health conditions are chronically understudied. This study is the first to identify spatial patterns in perinatal mental health conditions, and relate these patterns to place-based social and environmental factors that drive cluster development.

Methods

We performed spatial clustering analysis of emergency department (ED) visits for perinatal mood and anxiety disorders (PMAD), severe mental illness (SMI), and maternal mental disorders of pregnancy (MDP) using the Poisson model in SatScan from 2016 to 2019 in North Carolina. Logistic regression was used to examine the association between patient and community-level factors and high-risk clusters.

Results

The most significant spatial clustering for all three outcomes was concentrated in smaller urban areas in the western, central piedmont, and coastal plains regions of the state, with odds ratios greater than 3 for some cluster locations. Individual factors (e.g., age, race, ethnicity) and contextual factors (e.g., racial and socioeconomic segregation, urbanity) were associated with high risk clusters.

Conclusions

Results provide important contextual and spatial information concerning at-risk populations with a high burden of maternal mental health disorders and can better inform targeted locations for the expansion of maternal mental health services.

The Role of Peer Providers to Scale Up Psychological Treatments for Perinatal Populations Worldwide

PURPOSE OF REVIEW

Psychological treatments remain largely inaccessible to perinatal populations despite their robust effectiveness. This gap is partly due to the limited number of available treatment providers. In this review, we critically evaluate recent literature on task-sharing to peer providers and propose future directions.

RECENT FINDINGS

There is a growing evidence base demonstrating that peer providers can effectively deliver psychological treatments for perinatal populations, as well as engage in processes critical to quality assurance, such as measurement-based peer supervision. Findings have also highlighted some benefits of peers over licensed healthcare providers, such as enhanced collaborative relationships, reduced stigma, provision of social comparisons, and increased accessibility. Peer providers may be one solution to improve access to psychological treatments for perinatal populations. However, there is a need to address clinical, professional, and health-system level barriers to effectively leverage this cadre of treatment providers.

Healthcare professionals' views on the accessibility and acceptability of perinatal mental health services for South Asian and Black women: a qualitative study

BACKGROUND

Perinatal mental illness affects one third of new and expectant mothers. Individuals from ethnic minority groups experience higher rates of mental health problems and higher suicide rates. Despite this, women from ethnic minorities-Black and South Asian women in particular-are less likely to receive support from mental health services in the perinatal period. Healthcare professionals (HCPs) who have contact with women during this period have a unique perspective, and their views may provide insights to understand and remedy this health inequality. This study aimed to identify healthcare professionals' views on the current accessibility and acceptability of perinatal mental health services, and ways of improving services by addressing the barriers for these women.

METHODS

Semi-structured interviews were conducted with twenty-four healthcare professionals who work with patients in the perinatal period. Purposive sampling was used to select HCPs from a range of different professions (including mental health staff, midwifery, primary care, social care). The data were analysed using Framework Analysis.

RESULTS

Three main themes were identified from the data: (1) lack of awareness and understanding of perinatal mental illness and service structure in both healthcare professionals and patients; (2) patients' relationships with family, friends and healthcare professionals can both hinder and facilitate access to services; (3) healthcare professionals encourage raising awareness, flexibility, developing shared understandings and questioning assumptions to improve the accessibility and acceptability of services.

CONCLUSION

Key insights into explaining and remedying the health inequalities observed between ethnic groups were proposed by healthcare professionals. Recommendations included sharing information; taking steps to ensure each woman was considered as an individual in her relationship with her culture, ethnicity and childrearing practices; and healthcare professionals addressing their possible unconscious biases through engaging in personal reflexive practices. Reasons these are currently not being implemented deserve further research, and the potential of novel roles such as peer support workers in bridging the space between ideals and practice needs further investigation.

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.

First-generation Nigerian mothers living in the UK and their experience of postnatal depression: an interpretative phenomenological analysis

OBJECTIVE

Previous studies emphasise the negative psychological and physical consequences of Postnatal Depression (PND) on mothers and children's health. In the UK, around 10-20% of women can be affected by perinatal mental health problems. Minority ethnic groups such as Black African mothers are considered to be at greater risk of developing PND and data estimates that immigrant mothers are twice more likely to develop PND than native mothers. The unique experiences and needs of this culturally diverse group remain little explored in the UK. To address this gap in the literature, this study aimed to explore the lived experiences of First-Generation Nigerian Mothers (FGNMs) who suffered PND, their coping behaviours and treatment experiences in the UK.

DESIGN

Six FGNMs with a previous diagnosis of PND and treatment experiences were purposefully recruited from GP practices and social groups attended by Nigerian mothers in the UK. Semi-structured interviews were analysed using Interpretative Phenomenological Analysis.

RESULTS

Three master and seven subordinate themes were identified: (i) Socio-cultural factors (Inter-generational transmission; cultural perceptions: shame and stigma; transitions: adjusting to a new culture); (ii) What about me? The neglected nurturer (experiences of treatment; pretending to be OK); and (iii) Loneliness and coping (lack of support from partner; self-reliance).

CONCLUSIONS

The study provides evidence about the difficulties encountered by FGNMs in relation to PND, including socio-cultural factors, neglect from family and healthcare professionals, and self-reliance as a coping strategy. Contrary to reports suggesting that Black ethnic groups do not seek help for their mental health needs, participants' accounts indicated that their attempts to engage with professionals were met with unsatisfactory responses. The findings highlight the need to address barriers affecting access to services by fostering a patient-centred and culturally sensitive approach in healthcare teams to effectively engage mothers at an early stage in the detection pathway.

Understanding self-harm and suicidal behaviours in South Asian communities in the UK: systematic review and meta-synthesis

BACKGROUND

Previous findings have indicated that self-harm and suicide are associated with different rates, and different risk and protective factors in South Asian people compared with White people in the UK. Substantial qualitative research has explored experiences of self-harm and suicide in South Asian people.

AIMS

The study aims to review the existing qualitative evidence on self-harm and suicidal behaviours in South Asian communities in the UK.

METHOD

Systematic searches were conducted on Medline, EMBASE, PsycINFO, CINAHL, Open Dissertations and the British Library Ethos databases. We selected qualitative studies from both journals and grey literature that included South Asian participants who were resident in the UK and presented perceptions or experiences of self-harm and/or suicidal behaviour. Analysis was undertaken based on the meta-ethnographic approach.

RESULTS

Fifteen studies were included in the analysis. Experience of self-harm was discussed based on three aspects: behind self-harm, functions of self-harm and recovery from self-harm. 'Behind self-harm' refers to factors associated with self-harm and suicide. 'Functions of self-harm' captures the meaning attributed to self-harm and suicide. 'Recovery from self-harm' encapsulates personal and professional help, and practical suggestions for the improvement of mental health services.

CONCLUSIONS

Although some similarities with the majority White population were present, there were also crucial differences that need consideration when shaping health policies, improving access to health services and developing culturally sensitive psychosocial interventions for self-harm and suicide specific to South Asian communities in the UK.

Inter-Generational Differences in Perinatal Health Behaviours: A Secondary Analysis of the Born in Bradford Cohort, Disentangling Ethnicity and Migration

OBJECTIVES

There exists a body of research regarding ethnic differences in perinatal health whereas this is not the case concerning the role of migration status and acculturation in attenuating these differences. This study aims to investigate determinants of health during pregnancy up to one-year postpartum by migration status.

METHODS

The study utilises data collected by the Born in Bradford cohort. The focus of analysis was migration status groupings, based on self-reported country of birth of participants and their parents and grandparents. Chi-Square, one-way ANOVA and correlation coefficients examined relationships between variables.

RESULTS

Migrant women were less likely to smoke (native: 34.4%, 1st generation: 2.8%, 2nd generation: 8.6%) or to be obese (native: 25.5%, 1st generation: 17.4%, 2nd generation: 21.3%) compared to native women. Migrants were less physically active at 6 months (Mean (SD) minutes/week: native 265 (245), 1st generation 113 (162), 2nd generation 147 (182)) with larger increases in BMI over time compared to native women. Migrant women were more likely to be suffering psychological distress at baseline and 6 months postpartum and migrant families were more likely to live in areas of high socio-economic deprivation, despite higher levels of educational attainment.

CONCLUSIONS FOR PRACTICE

This study ethnicity and migration identifies some important differences between ethnic groups with different migration histories, therefore indicating that healthcare professionals should consider eliciting full migration histories to improve care. The impact of these differences on perinatal outcomes is a priority for future research.

Association Between Perinatal Mental Health and Pregnancy and Neonatal Complications: A Retrospective Birth Cohort Study

BACKGROUND

Maternal mental health as an important precursor to reproductive and neonatal complications remains understudied in the United States, particularly in the Southeastern region, despite high medical costs, maternal morbidity, and infant burden. This study sought to estimate the incidence of perinatal mental health disorders and the associated increased risk of leading pregnancy and infant complications.

METHODS

A population-based retrospective birth cohort of childbirth hospitalizations and readmissions was constructed for women in South Carolina, 1999 to 2017. Prevalence rates were calculated for perinatal mood and anxiety disorders (PMAD), severe mental illness, and mental disorders of pregnancy (MDP). Poisson regression models using generalized estimating equations were used to estimate adjusted relative risks for the association between mental health conditions and severe maternal morbidity, hypertensive disorders of pregnancy, gestational diabetes, cesarean section, preterm birth, and low birthweight.

RESULTS

The most prevalent maternal mental condition was MDP (3.9%), followed by PMAD (2.7%) and severe mental illness (0.13%). PMAD was associated with a higher risk of severe maternal morbidity, hypertensive disorders of pregnancy, and cesarean section, as well as a higher risk of preterm birth and low birthweight infants. Severe mental illness was associated with low birthweight, hypertensive disorders of pregnancy, and cesarean section. Pregnant populations with MDP were more at risk for severe maternal morbidity, preterm birth, hypertensive disorders of pregnancy, low birthweight, and cesarean section. Each maternal mental health outcome was associated with an increased risk for hospital readmissions up to 45 days after childbirth.

CONCLUSIONS

Results demonstrate the escalating burden of PMAD and MDP for pregnant populations over time, with important consequences related to maternal and infant morbidity.

Disparities in who is asked about their perinatal mental health: an analysis of cross-sectional data from consecutive national maternity surveys

BACKGROUND

The perinatal period is a vulnerable time, with one in five women experiencing mental health problems. Antenatal and postnatal appointments are key contact points for identifying women in need of support. Since 2014, the UK National Institute for Health and Care Excellence (NICE) has recommended that all women be asked about their mental health at their antenatal booking appointment and early in the postnatal period. The aim of this study was to assess the proportions of women who reported being asked about their mental health during the perinatal period across consecutive national maternity surveys (NMS) in England and to evaluate sociodemographic disparities in who was asked.

METHODS

Secondary analysis was performed on cross-sectional data from the NMS in 2014-2020. In each survey, women reported whether they had been asked about their mental health antenatally (during their booking appointment) and postnatally (up to six months after giving birth). The proportions of women in each survey who reported being asked about their mental health were calculated and compared according to key sociodemographic characteristics and across survey years. Logistic regression was conducted to identify disparities in who was asked.

RESULTS

The proportion of women who reported being asked about their mental health antenatally increased from 80.3% (95%CI:79.0-81.5) in 2014 to 83.4% (95%CI:82.1-84.7) in 2020, yet the proportion of women who reported being asked postnatally fell from 88.2% (95%CI:87.1-89.3) in 2014 to 73.7% (95%CI:72.2-75.2) in 2020. Ethnic minority women (aOR range:0.20 ~ 0.67) were less likely to report being asked about their mental health antenatally and postnatally across all surveys compared to White women. Women living in less socioeconomically advantaged areas (aOR range:0.65 ~ 0.75) and women living without or separately from a partner (aOR range:0.61 ~ 0.73) were also less likely to report being asked about their mental health, although there was less consistency in these disparities across the antenatal and postnatal periods and across surveys.

CONCLUSIONS

Despite NICE recommendations, many women are still not asked about their mental health during the perinatal period, particularly after giving birth. Women from ethnic minority backgrounds are less likely to be asked and these disparities have persisted over time.

Non-birthing mothers' experiences of perinatal anxiety and depression: Understanding the perspectives of the non-birthing mothers in female same-sex parented families

OBJECTIVE

Partners of birthing mothers can themselves experience perinatal mental health (PMH) difficulties. Despite birth rates increasing amongst LGBTQIA+ communities and the significant impact of PMH difficulties, this area is under-researched. This study aimed to examine the experiences of perinatal depression and anxiety of non-birthing mothers in female same-sex parented families.

DESIGN

Interpretative Phenomenological Analysis (IPA) was used to explore the experiences of non-birthing mothers who self-identified as having experienced perinatal anxiety and/or depression.

SETTING AND PARTICIPANTS

Sevenparticipants were recruited from online and local voluntary and support networks for LGBTQIA+ communities and for PMH. Interviews were in-person, online or via telephone.

MEASUREMENTS AND FINDINGS

Six themes were generated. Distress was characterised by feelings of "Failure and Inadequacy in Role" (i.e., parent, partner and individual) and "Powerlessness and Intolerable Uncertainty" in their parenting journey. These feelings were reciprocally influenced by perceptions of the "Legitimacy of (Di)stress as a Non-birthing Parent", which impacted help-seeking. Stressors that contributed to these experiences were: "Parenting Without" a parental role template, social recognition and safety, and parental connectedness; and "Changed Relationship Dynamics" with their partner. Finally,participants spoke about "Moving Forward" in their lives.

KEY CONCLUSIONS

Some findings are consistent with the literature on paternal mental health, including parents' emphasis on protecting their family and experiencing services as focusing on the birthing parent. Others appeared distinct or amplified for LGBTQIA+ parents, including the lack of a defined and socially recognised role; stigma concerning both mental health and homophobia; exclusion from heteronormative healthcare systems; and the importance placed on biological connectedness.

IMPLICATIONS FOR PRACTICE

Culturally competent care is needed to tackle minority stress and recognise diverse family forms.

"We Should Be Working Together, and It Felt like They Disrupted That": Pregnant Women and Partners' Experiences of Maternity Care in the First UK COVID-19 Pandemic Lockdown

Pregnant women were identified as being at elevated risk from COVID-19 early in the pandemic. Certain restrictions were placed upon birth partners accompanying their pregnant partner to in-person maternity consultations and for in-patient maternity care. In the absence of a central directive in England, the nature of restrictions varied across maternity services. Eleven participants (seven pregnant women and four partners), who were expectant parents during the first UK COVID-19 pandemic lockdown, took part in serial interviews in pregnancy and the postnatal period. Data were subject to a reflexive thematic analysis. Four main themes were identified, with sub-themes: uncertainty and anxiety (uncertainty and anxiety about COVID-19, uncertainty and anxiety about maternity services); disruption of partnering and parenting role; complexity around entering hospital spaces (hospitals offering protection while posing threat, individual health professionals in inflexible systems); and attempting to feel in control. Separating couples may result in disruption to their anticipated roles and significant distress to both partners, with potential impacts for mental health and future family relationships. Trauma-informed perspectives are relevant for understanding parents' experiences of maternity care in the pandemic and identifying ways to improve care to promote and protect the mental health of all parents.

Attitudes toward seeking professional psychological help among Chinese pregnant women: A cross-sectional study

BACKGROUND

There exists a gap between the high prevalence of mental health problems and negative attitudes toward seeking professional psychological help among Chinese pregnant women. This study aimed to investigate the attitudes and factors toward seeking professional psychological help among Chinese pregnant women to provide some suggestions for improving pregnant women's psychological help-seeking behaviors.

METHODS

A total of 1024 pregnant women were recruited. The Chinese version of the Attitude Toward Seeking Professional Psychological Help Scale (ATSPPH) was used to assess the attitudes toward professional psychological help-seeking. Demographic and socio-psychological factors were collected by self-developed questionnaire, Perceived Social Support Scale, Simplified Coping Style Questionnaire, and Patient Health Questionnaire-9 Scale.

RESULTS

1006 pregnant women were included in the final analysis. Only 3.7 % of participants chose professionals as their first choice for psychological help-seeking. The attitudes toward seeking professional psychological help were relatively positive, with the highest score of stigma tolerance among four subscales in ATSPPH. Education level, perceived social support, and positive coping style had a positive predictive effect on the four subscales of ATSPPH. Women with prenatal depressive symptoms had a lower score in the subscales of recognition of need for psychotherapeutic help and confidence in mental health practitioner; women with higher scores of negative coping style had a lower score in the subscales of stigma tolerance and interpersonal openness. History of professional psychological help-seeking behaviors was only associated with the subscale of recognition of need for psychotherapeutic help; Maternal age was only associated with the subscale of interpersonal openness.

CONCLUSION

The attitudes toward seeking professional psychological help were relatively positive among Chinese pregnant women, and stigma tolerance was the significant barrier to professional psychological help-seeking. More attention should be paid to those women with older age, negative coping style, and women with prenatal depressive symptoms.

Experiences of Mental Health Care Among Women Treated for Postpartum Psychosis in England: A Qualitative Study

Postpartum psychosis has been found to affect 0.89-2.6 per 1000 women. Onset is typically rapid and severe. Early recognition and appropriate treatment are crucial for a good prognosis. Our aim in this study was to understand women's experiences of mental health care and services for psychosis in the postnatal period. Semi-structured interviews were conducted with 12 women who reported being treated for postpartum psychosis. Findings were analysed thematically. Women reported that healthcare professionals across maternity and mental health services often lacked awareness and knowledge of postpartum psychosis and did not always keep them or their partners/families informed, supported, and involved. Women wanted better collaboration between and within services, and more efficient, appropriate, and timely care. They valued inpatient services that could meet their needs, favouring Mother and Baby Units over general psychiatric wards. Early Intervention in Psychosis services and specialist perinatal community mental health teams were also well liked.

Experiences and needs of women from ethnic minorities in maternity healthcare: A qualitative systematic review and meta-aggregation

OBJECTIVES

To consolidate the available evidence around ethnic minority women's experiences and needs when accessing maternity care.

METHODS

A qualitative systematic review and meta-aggregation of qualitative data were conducted. Nine electronic databases were searched for qualitative or mixed-methods studies from the inception of each database until January 2022. Using the Nested-Knowledge software, meta-aggregation was conducted according to the Joanna Briggs Institute (JBI) data synthesis approach to identify all potential intersections between different themes. Methodological quality of included studies was assessed using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) and the mixed-methods appraisal tool (MMAT) checklists for qualitative and mixed-methods studies, respectively.

RESULTS

Twenty-two studies (nineteen qualitative and three mixed-methods) were included. All studies were of good methodological quality. An overarching theme 'the struggles and fears of ethnic minority women' was identified. The negative experiences with maternity care were attributed to barriers including ineffective communication, cultural and religious insensitivity, inattentiveness and disregard for women's needs, and isolation-related impact due to the COVID pandemic.

CONCLUSIONS

Overall, our review highlighted several significant gaps between the care provided and the expected care among ethnic minority women accessing maternity care services. This mismatch between their expectations and care resulted in negative experiences, as the women reported being discriminated against and disrespected. There is an urgent need to develop and implement maternity care policies that are inclusive of needs of the ethnic minority women to optimize their maternity care experience.

Mothers' accounts of the impact of being in nature on postnatal wellbeing: a focus group study

BACKGROUND

The postnatal period is a vulnerable time for mothers to experience stress and mental health difficulties. There is increasing evidence that spending time in nature is beneficial for wellbeing. Nature-based interventions have been developed to support mental health, but not specifically tailored for mothers during the postnatal period. Understanding mothers' views and experiences of nature would help determine the suitability for and potential impact of such interventions on postnatal wellbeing.

AIMS

To explore mothers' views on the impact of spending time in nature on their postnatal mental wellbeing.

METHODS

Focus groups were held with mothers of young children (under five), including mothers from migrant and refugee communities, mothers living with mental health difficulties, and disabled mothers. Data were analysed using reflexive thematic analysis.

RESULTS

Four focus groups were held, with a total of 30 participants. Six themes were developed: (1) mothers' experiences of what constitutes 'nature'; (2) sensing nature improves wellbeing; (3) natural spaces facilitate human connection; (4) nature provides escape and relief from daily indoor stressors; (5) nature allows new perspectives; and (6) mothers face a variety of environmental, practical, psychological, physical, socioeconomic, and cultural barriers to spending time in nature during the postnatal period.

CONCLUSIONS

Mothers report significant benefits to their postnatal wellbeing when spending time in nature. Further research is warranted to understand whether nature-based interventions have the potential to support postnatal wellbeing, socially, mentally, and physically.

Mapping the contextual mental health interventions for perinatal adolescent mothers with self-reported common mental symptoms (anxiety and depression) in sub-Saharan African countries: a scoping review

Introduction: Early preventive interventions may support adolescent mothers' mental health during the perinatal period. However, adolescent maternal mental health interventions have received little empirical research attention. This scoping review maps the evidence on interventions appropriate for adolescent mothers during the perinatal period in Sub-Saharan African countries.Methods: The process was guided by the Joanna Briggs Institute's methodology for scoping reviews. Five databases, MEDLINE, EMBASE, PsycInfo, CINAHL, Google Scholar, and ProQuest, were searched for citations of studies published from 2000. The reporting is according to Preferred Reporting for Systematic Reviews and Meta-analysis (PRISMA).Results: The initial search of databases resulted in 2 757 records. After duplicates were removed, 311 records were screened, and eight records included. Interventions included five key strategies: cognitive behavioural therapy; group problem-solving; psychoeducation; psychosocial group counselling; and integrated mothers and babies course and early childhood development group-based intervention. None of the interventions specifically targeted adolescent mothers, however.Discussion and conclusion: There is limited evidence of interventions specific to adolescent mothers. There is a need for the development, implementation and evaluation of specific interventions relevant to this population group.

Emotional difficulties, coping strategies, and help-seeking patterns among Czech perinatal women

OBJECTIVE

To understand both, women´s perception of emotional difficulties in perinatal period and their related coping strategies. Further, we mapped and analysed help-seeking patterns utilized by these women to overcome their emotional difficulties. This study serve as an important piece of information for women-centred innovations in perinatal mental health care in Czechia, and more broadly in the region of Central and Eastern Europe.

DESIGN

A qualitative study with an exploratory and descriptive approach using thematic analysis.

SETTING

Online survey consisting of open-ended questions mapping women´s perception of emotional difficulties in perinatal period and their related coping strategies and help-seeking patterns.

PARTICIPANTS

Two hundred women self-reporting emotional difficulties in perinatal period, from whom 108 (54 %) stated that they had sought professional help with their emotional difficulties.

FINDINGS

Two themes were identified in the analysis of women´s perception of emotional difficulties including Experience of symptoms of mental disorders, and Mother-child relationship. Three themes were identified in the analysis of women´s coping with these difficulties (Personal resources, External resources, and No coping strategy used). Four themes were identified in the analysis of help seeking patterns utilized by study participants (Mental health specialists, Physicians of the first line of contact, Midwifes, and Peer consultants).

KEY CONCLUSIONS

Emotional difficulties of perinatal women stemmed in both, general symptoms of mental disorders and specific concerns connected to mother-child relationship. Therefore, the perinatal mental health services should cover both topics, preferably by a multidisciplinary team. Women search information about perinatal mental health, so thus, easy to reach valid resources are needed. Finally, Czech perinatal women experiencing emotional difficulties utilize various help-seeking patterns. Some of them naturalistically utilize integrated stepped care even when it is not systematically established.