Exploring the Healthcare Services’ Contribution to Reducing Postpartum Depression

Introduction

The field of maternal health concerns the health of women during pregnancy, birth, and the postpartum period (Hogan, 2022), which combine to form a period associated with significant health risks for women. Regarding maternal mental health, the World Health Organization (WHO) has estimated that 10% of pregnant women and 13% of postpartum women worldwide experience mental health problems, most commonly depression (WHO, 2019a).

Postpartum depression (PPD) can have severe consequences for postpartum women and their newborns, including impaired relationships, poor child development, behavioral problems, and a higher risk of developing recurrent depression (Mattson & Smith, 2015). Moreover, depressed postpartum women have been found to exhibit poor engagement during their infants’ early lives, decreased interaction activities, reduced breastfeeding, altered sleep patterns, reduced childcare visits, and a greater incidence of harming their infants and meting out punishment (Field, 2010).

Review of Literature

Unfortunately, the mental health of postpartum women has traditionally been neglected in maternal health programs, particularly in low- and middle-income nations (Atif et al., 2015). Moreover, PPD remains underdiagnosed because women may not show any signs of depression or may fail to initiate a discussion about their mood with their healthcare providers (Falana & Carrington, 2019). As mental health problems are considered particularly challenging to address, the WHO initiative stressed the need to integrate related mental health services into maternal and child health services (WHO, 2019b). In addition, guidelines have been published to help non-specialized healthcare providers to identify and manage mental health problems as part of a holistic healthcare approach that covers patients’ physical and psychological needs in all healthcare settings (WHO, 2017).

By 2020, PPD was expected to be among the top three general health problems worldwide (Buist et al., 2007).

In Saudi Arabia, the prevalence of PPD has been reported in several studies. Al Nasr et al. (2020) assessed the prevalence of PPD among 174 women in Riyadh and compared it with potential predictors using a self-administered version of the Edinburgh Postpartum Depression Scale (EPDS). They reported the prevalence of PPD to be 38.5% among the women. In addition, an unsupportive partner, recent stressful life experiences, and caesarean delivery were identified as significant predictors of PPD (Al Nasr et al., 2020). Similarly, Alasoom and Koura (2014) used the EPDS to test for PPD among women attending Dammam's primary healthcare centers and found that 17.8% of the participating women had depression. A family history of depression was the leading indicator of PPD, followed by an unsupportive spouse, a lifelong history of depression, an unintended pregnancy, and traumatic life events (Alasoom & Koura, 2014).

As a consequence of the Saudi Vision 2030, the Ministry of Health (MOH) new model of care is designed to achieve physical, mental, and social well-being (MOH, 2017). In addition, one of the model of care system's focuses is on safe birth for women (MOH, 2017). However, there are currently no national guidelines for depression screening, either during pregnancy or after birth (Saleh et al., 2020). It should also be recognized that the actual prevalence of PPD may be higher than reported postpartum complications due to the lack of screening and follow-up available to women post-delivery. Currently, the primary goal of maternity care services in Saudi Arabia is the safe delivery of a healthy baby. Thus, postpartum women's physiological health aspects are covered to a far greater extent than their mental health aspects.

In light of this, action should be taken to develop a care pathway that focuses on maternal mental health in Saudi Arabia.

Swanson (1991) developed the theory of caring, which has subsequently been validated for utilization in research, education, and practice. The theory of caring involves five steps: knowing, being with, acting for, enabling and maintaining belief, and each of these five steps both enhances the caregiver's attitude and promotes the patient's total well-being when used in nursing practice (Lillykutty & Samson, 2018). Under the lens of this theory, this study's aim was to explore nurses’ perceptions towards health services’ contribution to reducing PPD and develop recommendations for improving women's health services in Saudi Arabia.

Methods

Results

Sample Characteristics

In total, 10 nurses, who were all female, their ages ranged from 27 to 52 years, and their experience was from 3 to 19 years participated. Table 1 presents the characteristics of the participants.

OPEN IN VIEWER

Table 1.

Participant Characteristics.

No.	Age	Sex	Nationality	Education	Experience	Position
1	50 years	Female	Indian	Diploma	10 years	Staff nurse
2	50 years	Female	Filipino	Bachelor	15 years	Staff nurse
3	37 years	Female	Filipino	Bachelor	12 years	Staff nurse
4	44 years	Female	Filipino	Bachelor	19 years	Charge nurse
5	28 years	Female	Filipino	Bachelor	7 years	Staff nurse
6	40 years	Female	Filipino	Diploma	9 years	Staff nurse
7	37 years	Female	Indian	Diploma	15 years	Staff nurse
8	52 years	Female	Indian	Diploma	10 years	Staff nurse
9	38 years	Female	Indian	Diploma	13 years	Staff nurse
10	27 years	Female	Filipino	Bachelor	7 years	Staff nurse

Discussion

The “maternal mental healthcare” theme suggests integrating mental healthcare with maternity services and establishing clinics for maternal mental health. Harvey et al. (2012) evaluated the clinical effectiveness of a nurse-led, consultation-liaison model for perinatal mental health in primary care. Successful implementation of this model has demonstrated the effectiveness of filling current service gaps and improving the mental health of women. However, Rahman et al. (2013) found that misconceptions about PPD limited the incorporation of mental health efforts into maternal–child programs. The myths regarding maternal mental health include the notions that maternal depression is uncommon, irrelevant to maternal–child health programs, treatable exclusively by professionals and difficult to incorporate into maternal–child health programs. Moreover, Ganann et al. (2019) identified gaps in the mental health services available for women with PPD in terms of the local availability and accessibility of treatment. It has been suggested that the inclusion of a psychiatrist in the multidisciplinary team could help improve some community services and cross-agency efforts to manage PPD. Here, the current priority is to make policymakers, planners, and legislators aware of missed opportunities to integrate mental health treatments into mainstream women's health programs as well as to direct research and implementation funds toward addressing the challenges of scaling up promising approaches (Atif et al., 2015; Rahman et al., 2013).

In terms of the “follow-up maternal mental health status” theme, indicated that follow-up could be performed by phone or via home visits to ensure the continuity of maternal care during the postpartum period and detect any maternal mental health problems.

It has previously been reported that health visits based on protocols and evidence-based practice can play a significant role in enhancing both women's health and the community's understanding of PPD (Alexandrou et al., 2018). Attempts to determine the impacts of home visits and planned training on PPD and the quality of life of postpartum women have revealed a substantial negative correlation between women's depression levels and quality of life, with their depression scores decreasing as their quality-of-life scores increased (Tel et al., 2018). Even when further psychological care proves unnecessary, it is cost-effective for health visitors to be trained in assessing PPD symptoms and providing psychologically informed interventions (Henderson et al., 2019). Moreover, virtual care has the potential to fundamentally alter the landscape of healthcare delivery. Indeed, virtual visits are now recognized as an appropriate delivery model for postnatal follow-up (Saad et al., 2021).

In this study, the “screening mental health status” theme highlighted that a screening tool for maternal mental health issues such as PPD should be adopted or developed. They were dissatisfied that no single tool was available for assessing postpartum women's psychological status. Zubaran et al. (2010) reviewed four screening instruments and found that the EPDS and Postpartum Depression Scale demonstrated the highest sensitivity and specificity. However, when assessed in relation to various cultural situations, none of the available instruments could be deemed perfect. According to Ukatu et al. (2018), no advice regarding the most effective PPD detection method could be offered because the diagnostic performance of the various PPD screening techniques was found to vary based on numerous variables, including the period assessed by the tools, the scheduling of the screening and the populations studied. In a study conducted by Modula and Ramukumba (2018), a significant weakness in the detection of mental illness in healthcare settings, due to a lack of skills and insufficient screening resources was reported.

Moreover, this study showed that screening should begin at the first visit to a maternity clinic and continue throughout the postpartum period. According to Ukatu et al. (2018), there is no specific time to conduct PPD screening, although screening during the first 2 weeks of the postpartum period may result in greater misclassification due to failure to distinguish between PPD and the “baby blues.”

Interestingly, this study showed that husbands should also be screened for depression because they could be a source of women's depression. There is evidence to suggest that the transition to parenthood can be difficult and taxing for both parents, leading to sadness, anxiety, and increased risk of depression (Epifanio et al., 2015). The prevalence of paternal postnatal depression has been determined to be 12% based on a cut-off score of 12 or higher on the EPDS; however, when the cut-off score was lowered to 9 or above, the prevalence increased to 28%. The likelihood of paternal postnatal depression has been found to be increased by having an infant with sleep issues, a history of depression, a lack of social support, bad economic circumstances, and a lack of paternity leave (Philpott & Corcoran, 2018). Of course, nurses may only be able to work with postpartum women without their husbands being present for prenatal exams or well-child visits, which would allow them to assess for anticipatory maternal PPD but not paternal PPD (Musser et al., 2013). Thus, it is crucial for nurses to speak to women about the signs and symptoms of paternal PPD so that they will be able to obtain assistance or additional screening for their husbands if signs are present (Musser et al., 2013).

Also, the findings of the current study emphasized the important role of primary care settings in addressing maternal mental health. Ganann et al. (2019) highlighted how emergency support is available for women in the event of an immediate crisis, although it can prove difficult to refer women in need of psychiatric support who are not in immediate distress. Additionally, Olin et al. (2016) reported that PPD can be managed effectively in primary health care. Primary care clinicians must be provided with critical support in order for them to be able to provide timely, non-stigmatizing care.

The “enhance health education” theme revealed that providing education to women during the antenatal period could decrease their anxiety after delivery and reduce the stigma that is considered a barrier for depressed postpartum women to seek help (Almutairi et al., 2022). To maximize the possibility of detecting PPD symptoms early, nurses and midwives should begin educating new mothers and other relatives about the characteristics and clinical manifestations of depression, as well as how to detect depression symptoms, as early as possible (Saleh et al., 2020). It is necessary to ascertain how aware postpartum women are of PPD. In fact, nursing providers must proactively work to improve knowledge of PPD among perinatal women and their families (Poreddi et al., 2021). Moreover, Buist et al. (2007) found educating perinatal women to have the following positive effects: increased awareness of depression, enhanced ability to appraise their emotional state, decreased use of the health system by those who are unlikely to be depressed and increased satisfaction with health services when they are depressed. On the other hand, Missler et al. (2020) reported that there is currently no evidence to suggest that a universal prevention program implemented during pregnancy is useful in terms of avoiding parenting stress, depression, or anxiety during the first 10 weeks after birth (Missler et al., 2020).

The findings raised the need for reducing stigma toward mental health problems by establishing awareness regarding mental health in the communities. Ganann et al. (2019) emphasized the importance of awareness about PPD and reducing both the stigma and discrimination surrounding the disorder. In this regard, they highlighted the importance of providing clear information about preventing, identifying, and managing PPD. Also, the integration of mental health services could contribute to reducing stigma toward mental health problems as Young et al. (2019) evaluated the views and experiences of women who received mental health services from psychiatrists that were integrated into a pediatric primary care safety net clinic. This integration enabled access to care for women with PPD who may otherwise not have sought psychological treatment due to the burden of their symptoms, the logistical difficulties of attending appointments, and mental health stigma.

The “update resources” theme was considered to be vital to improving maternal health services. The findings of this study indicated the need for policies, clinical pathways, and guidelines informed by evidence-based practice to be developed in order to address maternal mental health and guide healthcare providers in addressing the psychological aspects of the woman, screening for PPD and providing appropriate management. In this context, guidelines represent the initial stage of transferring research results into practice and expanding the evidence base. Furthermore, Higgins et al. (2018) noted the importance of developing official strategies to address systems- and provider-related barriers, such as the development of services and care pathways and the provision of culturally sensitive maternal mental health education, so as to empower nurses to confidently and competently address psychological issues.

Moreover, the findings highlighted how efforts must be made to design policies that address women's mental health. Such efforts should be based on research and international norms and pronouncements, such as the recent suggestion by the WHO of the need for a comprehensive strategy for preventing and treating maternal depression (WHO, 2016). Moreover, Engle (2009) recommended expanding the availability of maternal mental health programs and developing easy interventions that primary healthcare practitioners can utilize to alleviate maternal discomfort.

The “empower nurses” theme indicated that the nursing role should be expanded to adequately cover psychological care through continuous education to assess women's mental health status, use screening tools, detect PPD, and provide the most appropriate nursing interventions based on women's needs. Sofronas et al. (2011) and Place et al. (2015) noted the importance of expanding nurses’ confidence in assessing and intervening with depression symptoms, in addition to clarifying the referral process through the creation of educational materials designed to improve the quality of care provided to women experiencing any type of distress during the postpartum period. Improving nurses’ and midwives’ mental health knowledge could make a major difference in terms of supporting maternal mental health (Adjorlolo et al., 2019).

Educational programs enable nurses to detect PPD and provide suitable care based on women's needs. Here, training programs such as nurse-delivered counselling and CBT have been found to positively impact nurses’ confidence and ability (Layton et al., 2020; Segre et al., 2010). Case consultations, team-based debriefing sessions, and opportunities to attend in-service training have also been recognized as useful organizational and professional development supports (Ganann et al., 2019). Nurses’ capacity could be further improved through the provision of cross-cultural resources concerning PPD, effective means of recognizing and helping postpartum women with depression, and greater education on cultural competence and system mechanics.

Strengths and Limitations

The use of a qualitative approach proved valuable in exploring the nurses’ perceptions towards health services’ contribution to addressing PPD due to allowing them the opportunity to offer explanations of the care provided to women after delivery in their own words. Moreover, the participants had an exclusive experience of caring for women in this context, which informed the study and confirmed the findings. The small sample size and the setting were considered a limitation of this study. Therefore, expanding the study to include other healthcare professionals involved in caring for postpartum women, such as midwives, community health nurses, and social workers specializing in the maternity field would be beneficial.

Implications for Practice

An evaluation of the current regulations regarding maternal healthcare services should be performed to help maintain the mental health of postpartum women. Maternal mental health needs to be added to the pack of services provided to women in Saudi Arabia, as the ongoing development of the healthcare system forms part of the Saudi Vision 2030. Policies, guidelines, and clinical pathways should be created to help guide healthcare providers in addressing the psychological health of women during pregnancy, labor, and the postpartum period. Moreover, valid assessment tools, referral and follow-up systems, and the use of technology could play a significant role in healthcare programs that focus on maternity care and should be leveraged to allow women to reach their healthcare providers at any time. In addition, models can be created to be used by healthcare providers and postpartum women in screening for psychological status, determining the level of depression and providing appropriate interventions at the right time.

Conclusions

This study reports the importance of improving the maternal health services available in Saudi Arabia by addressing the gaps in such services and ensuring that they address the maternal mental health issues a woman may encounter throughout her maternal journey. The findings indicated the need to improve maternity care in Saudi Arabia by adding a screening program for PPD and integrating mental health services with the maternity care package. More research is needed to uncover the reality of PPD from women's perspectives.