Elsevier

Midwifery

Volume 59, April 2018, Pages 47-58
Midwifery

Barriers to addressing perinatal mental health issues in midwifery settings

https://doi.org/10.1016/j.midw.2017.12.020Get rights and content

Highlights

  • Midwives may not adopt a role in addressing mental health issues due to several obstacles.

  • The process of screening/management may be overwhelming due to cumulative stress of disclosures.

  • Training, expansion of practice scope and collaboration are central for care integration.

Abstract

Background

poor perinatal mental health is linked to various adverse pregnancy and child outcomes. Despite having a holistic philosophy of care, similar to other maternity care settings, perinatal mental health issues often remain under-diagnosed and untreated in midwifery settings.

Aim

to determine midwives’ perceived barriers to the screening, referral, and management of perinatal mental health issues.

Methods

the following databases were searched: MEDLINE, CINAHL, EMBASE, and PsycINFO. We included qualitative, quantitative, and mixed methods studies published in a peer-reviewed journal in English. Two reviewers independently extracted data and subsequently integrated the extracted data into a single data matrix. The data matrix was compared iteratively across primary data sources to identify themes and sub-themes. The identified barriers to screening, management and referrals were subsequently categorized into provider-level and system-level barriers. The relevance and methodological quality of the included studies were evaluated using appropriate checklists.

Findings

three hundreds and fifty six articles were retrieved. Twenty studies met the inclusion criteria and were included. Insufficient/lack of training, lack of clarity regarding the scope of practice and time constraints were common provider level barriers across various stages of addressing mental health issues from identification to management. The system-level barriers were more complex and diverse and included unclear pathways and unlinked services, lack of local guidelines or policies, continuity of care, structured office procedures, clinical support and supervision and accessible educational resources, scarcity of available referral resources, complex bureaucratic processes and challenges related to expansion of the scope of practice.

Conclusions and implications for practice

training, expansion of the scope of practice and collaborative care are central for successful screening, management and appropriate and timely referrals of perinatal mental health issues. An integrative model of care may address fragmentation in perinatal mental health services and enable a holistic midwifery care.

Introduction

Mental health issues, such as depression and anxiety, are prevalent during the perinatal period and affect one in five women (, , , , , ). Poor maternal mental health is related to several adverse pregnancy outcomes, including preterm birth and low birth weight (, ). Mental health issues interfere with parent–infant interactions and attachment and are related to subsequent cognitive, behavioral, and psychomotor developmental delays and mental health disorders in children (, Davis and Sandman, 2012, , , ). Several professional organizations recognize the risk of poor perinatal mental health and recommend screening (, ). However, mental health issues commonly remain under-diagnosed and untreated in maternity care settings; women with mental health issues often do not communicate their concerns (Fonseca et al., 2015) for various reasons, such as low mental health literacy and failure to recognize the symptoms, lack of clarity regarding the role of the maternity care provider, stigma and fear of consequences of disclosure (Bayrampour McNeil et al., 2017). One in five health care providers may screen for potential perinatal mental health issues (Coleman et al., 2008). Even in settings where universal screening programs have been introduced, screening goals are not often achieved. For example, in a study by Kim et al. (2009), 67% of the providers inaccurately thought they had reached universal screening, and 95% overestimated their screening rates with an average overestimation twofold greater than the actual screening.

Barriers to perinatal mental health screening and management are complex. In the literature, these barriers have been vastly investigated from women's standpoints with some studies exploring provider perspectives. Evidence indicates that the screening patterns and uptake of screening programs may differ among various health care providers. For example, a review of physician screening patterns for postpartum depression indicated that screening rates were particularly low among pediatricians (Goldin Evans et al., 2015). A recent review on attitudes towards mental health screening highlighted that midwives repeatedly recognize the provision of mental health care as an important part of their role (Noonan et al., 2017); however, a gap remains in understanding the barriers that hinder addressing perinatal mental health issues in midwifery settings. A specific focus on midwifery is important because there is evidence that midwives may be less prepared to address perinatal mental health issues compared with other maternity care providers. For example, Buist et al. (2006) compared the knowledge and awareness of perinatal depression among various maternity care providers in Australia and found that compared with general practitioners and maternal child health nurses, midwives were less likely to detect a mental health problem, determine the need for further evaluation or assistance, and recommend appropriate management and treatment. They also determined that midwives were more likely to report being slightly/very uncomfortable completing the Edinburgh Postnatal Depression Scale (EPDS) or to perceive the EPDS as a non-useful tool (Buist et al., 2006). In another study that consisted of more than 800 midwives, the majority of respondents underestimated the rate of suicidal attempts among pregnant women and approximately half did not correctly identify the incidence, onset of depressive symptoms during the postpartum period, treatment options, and use of antidepressant medications (Jones et al., 2011).

As a client-centered care approach, the psychological and mental well-being of women is an integral part of the provision of midwifery care. The International Confederation of Midwives’ statement of the philosophy of care emphasizes that “midwifery care is holistic and continuous in nature, grounded in an understanding of the social, emotional, cultural, spiritual, psychological and physical experiences of women” (International Confederation of Midwives, 2014). Improvements in the assessment and management of perinatal mental health issues are fundamental to achieve holistic care. To contribute to this vision and identify the areas in which midwifery practice may benefit most, we conducted this review to determine midwives’ perceived barriers to the screening, referral, and management of perinatal mental health issues.

Section snippets

Methods

To address the review objective, we conducted an integrative review using the framework developed by Whittemore and Knafl (2005). Integrative reviews incorporate diverse methodologies and enable the inclusion and synthesis of various perspectives. Thus, they provide a comprehensive understanding of a particular phenomenon or healthcare problem to inform practice and policies (Whittemore and Knafl, 2005).

Results

Twenty studies met the inclusion criteria and were included in the review. Fig. 1 illustrates the selection process using a PRISMA flow diagram (Moher et al., 2009). The main exclusion reasons included focus on women's perspectives rather than providers’ perspectives, screening for issues other than mental health, application of a specific tool, or focus on providers’ own mental health.

Of the included studies, seven studies were conducted in the United Kingdom, six studies in Australia, three

Discussion

Midwives recognize their role in addressing perinatal mental health issues (, , , , ); however, they may not adopt this role because of several obstacles. Similar to a review on physician screening patterns (Goldin Evans et al., 2015), in this review of the midwifery literature, a lack of formal education (, ; Psaros, 2010) and insufficient training (, , ) regarding perinatal mental health issues immensely hindered addressing perinatal mental health issues. However, we found that among studies

Acknowledgements

Ayu Pinky Hapsari and Jelena Pavlovic contributed equally to this work.

Conflict of Interest

None declared.

Ethical Approval

Not applicable.

Funding Sources

Not applicable.

Clinical Trial Registry

Not applicable.

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