Sage Journals: Discover world-class research

Abstract

Introduction

The postpartum period is accompanied by health risks that impact many women. Postpartum depression (PPD) is a mental health problem that has been neglected in maternal healthcare services.

Objective

The purpose of this study was to explore nurses’ perceptions towards health services’ contribution to lowering the incidence of PPD.

Methods

An interpretive phenomenological approach was adopted in a tertiary hospital in Saudi Arabia. A convenience sample of 10 postpartum nurses was interviewed face-to-face. The analysis followed Colaizzi's data analysis method.

Results

Seven main themes emerged on how to improve maternal health services to contribute to reducing the incidence of PPD among women: (1) maternal mental health, (2) follow-up of mental health status, (3) screening mental health status, (4) enhancing health education, (5) reducing stigma toward mental health, (6) updating resources, and (7) empowering nurses.

Conclusion

The integration of mental health services into maternal services that are provided to women needs to be considered in the context of Saudi Arabia. This integration will result in high-quality holistic maternal care.

Keywords

postpartum depression care women

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

Design

This is an interpretive phenomenological qualitative inquiry as this approach dedicated to understanding and uncovering experiences of individuals in constant relation with others (Frechette et al., 2020). In this paper, we attempt to understand the factors that contribute to improving care for postpartum women and reducing depression based on the interpretation of nurses’ experience in caring for postpartum women (Neubauer et al., 2019).

Research Questions

What are nurses’ perceptions towards health services’ contribution to reducing PPD? What are the recommendations for improving women's health services?

Sample

The convenience sampling method was used as there is a greater likelihood of including nurses that are more readily accessible (Suen et al., 2014). To develop a thorough understanding of the phenomenon of interest, a study must be credible, which requires interviewing a sufficient number of nurses to gain a good understanding of the subject (Ellis, 2016). In interpretative phenomenology, an average of 10 phenomenon-rich participants is appropriate (Frechette et al., 2020).

Inclusion Criteria

Nurses who worked in the postpartum department in a tertiary maternal hospital who were involved in caring for postpartum women, and who speak Arabic or English were included.

Exclusion Criteria

Nurses who were not working in postpartum units, non-Arabic or non-English speakers were excluded or who did not want to participate in the study.

Data Collection

An interview protocol was designed to assist the researcher in organizing their thoughts on topics such as headings, how to begin the interview, concluding ideas, how to conclude the interview and thanking the interviewees (Cresswell & Poth, 2016). Additionally, Bevan's (2014) phenomenological interview structure was applied in this study. The utilized interview structure provides researchers with an explicit approach because it enables the use of phenomenology as a comprehensive method of research that contributes to the clarity of the overall study (Bevan, 2014). The data required for this study were collected through individual face-to-face interviews that were conducted over the course of two days. Six participants were interviewed on the first day and four on the second day. The duration of the interviews ranged from 30 to 45 min. Data saturation was recognized by an absence of the emergence of new data, thus indicating suitability of the termination of the session. Credibility was attained by intensive listening during interviews, careful probing to obtain rich and comprehensive data, audio-recording interviews for the purpose of transcription and monitoring the transcription accuracy, all of which are strategies for enhancing the quality of obtained data (Polit & Beck, 2017).

Institutional Review Board Approval

This study was approved by the review board of King Saud University and King Fahad Medical City. The participants were informed about the study, asked to participate on a voluntary basis, and were reminded of their right to withdraw from the study at any time. Prior to the interview, the participants signed informed consent forms and informed that their participation was voluntary, and anonymous and would not affect their employment status.

Data Analysis

The interviews were recorded, transcribed, and stored until they were analyzed. Morrow et al. (2015) was used as a straightforward method and logical procedure for delving into the meanings of nurses’ experiences (Wirihana et al., 2018). Additionally, the findings were sent to the participants via a link for the purpose of validation (Polit & Beck, 2017).

Moreover, dependability was ensured by a member check, which was performed by introducing the data to the participants after the analysis to determine the truthfulness of the results. Confirmability was demonstrated by an audit trail through the digital recording, and field notes assisted with confirmability. Transferability was presented by detailed information allowing for judgements concerning the setting, the participants and their experience.

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.

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

Research Questions Findings

Seven main themes emerged on how to improve maternal health services to reduce the incidence of PPD among women: (1) maternal mental health, (2) follow-up of mental health status, (3) screening mental health status, (4) enhancing health education, (5) reducing stigma toward mental health, (6) updating resources, and (7) empowering nurses.

Theme 1: Maternal Mental Health

The nurses explained that there are specialized clinics to which postpartum women can be referred when required, for example, obesity clinics or diabetic clinics. For postpartum mental health, it is vital to introduce a similarly specialized clinic for addressing PPD. This was expressed by two of the participants:

They have to concentrate on postpartum women's mental health, like how we have obesity clinics and other clinics to refer women to.

The only suggestion is to provide a clinic for women that focuses on mental health.

Furthermore, it was suggested that maternal mental health services need to be available from the pregnancy period so that any problems can be detected as early as possible as expressed by one of the participants:

During the antenatal period, a clinic could ask if a postpartum woman has any psychiatric problems or is taking any medication.

Theme 2: Follow-Up of Mental Health Status

The majority of nurses recognized that postpartum women who are at risk of or have depression need to be followed up and monitored. They pondered on how postpartum women with depression are followed up. In addition, home visits were established by some healthcare institutions for specific groups in the community such as elderly people. However, providing care through home visits for postpartum women and addressing depression is not yet established. This was expressed by one of the participants:

If diagnosed with postpartum depression, how will they be followed up? The healthcare system, I think, relies on home visits, but how they will set that up or provide support.

In addition, nurses suggested introducing home visits or creating community institutions that primarily focus on postpartum women's health needs and address maternal mental health. It was indicated that due to the risk of PPD developing at any time, home care should be considered a solution for following up on the mental health status of postpartum women. This was expressed by one of the participants:

Home care follow-up for postpartum women because there is a chance of developing PPD. Maybe we could do follow-up care every two to three weeks.

The nurses also commented on the fact that postpartum women are sometimes discharged early, for example, if they undergo a normal spontaneous vaginal delivery or, if they do not have any obvious health problems that may increase their length of stay in the hospital, they may be discharged within 24 h. At this point, health personnel may not be able to recognize the risk of developing PPD, among postpartum women. Therefore, it was recommended that postpartum women be followed up a few days after discharge. This was expressed by one of the participants:

Postpartum women who deliver normally will be sent home quickly and won’t mind. I think we need someone to monitor them right after, like checking how they are feeling after a certain number of days. Is the woman okay? What is her status at home?

Moreover, postpartum women can be followed virtually, at least by telephone, to check on postpartum woman's mental health status and direct them towards any help that is required. It was expressed by one of the participants:

The best way after discharge that we can follow up is maybe we can ask by phone or offer home care to identify how a postpartum woman is and if she has any signs or symptoms [of PPD].

Moreover, it was suggested to activate the role of primary healthcare centers in maternal mental health care so that postpartum women can access healthcare where they live. This was expressed by one of the participants:

I think the support from the community health care services and the primary health centre should also follow up with a postpartum woman so we can track her status.

Theme 3: Screening Mental Health Status

The nurses indicated that screening should be performed to detect any mental health issues and allow for early management before postpartum women reach the chronic stage and become more complicated to treat. Several screening programs are currently applied by healthcare services in relation to women's health, such as breast cancer and cervical cancer screening. Yet, when it comes to PPD, screening for depression among postpartum women is rare and needs to be enhanced to include maternal mental health. This was expressed by one of the participants:

Depression screening is very rare, so we have to improve that one and concentrate more on women's mental health, especially postpartum.

In addition, it was recommended that screening for depression should be performed from the beginning of pregnancy to help reveal the risk of depression earlier and allow for interventions that can be carried out throughout the postpartum period. This was expressed by one of the participants:

In my view screening will help, because from the beginning of the antenatal period, if they are already screening for depression, it could be carried on during the postpartum period.

In contrast, it was claimed that postpartum women know themselves and so are best placed to identify changes in their mental health, suggesting that they should be educated in conducting self-assessments for PPD. This was expressed by one of the participants:

Postpartum women can also do self-assessment by asking “How was I before?” And now, if there are any changes in their behaviour or mood swings, a postpartum woman can do a self-assessment if she has received an appropriate education.

Interestingly, a recommendation was provided to include husbands in any screening for depression because their depression could be a source of postpartum women's depression. This was expressed by one of the participants:

Even the husband, I think, needs to be assessed, because if the husband has depression, it may contribute to the depression of a postpartum woman.

Theme 4: Enhancing Health Education

The nurses believed that women could be prepared for the postpartum period through effective health education. Such education should empower a woman to care for herself and her baby, identify the normal process of the maternal journey, and differentiate between normal and abnormal signs both physically and mentally during the postpartum period. Educating a postpartum woman every time she visits the clinic from the start of her pregnancy would enable her to maintain her mental health after delivery. This was expressed by one of the participants:

Antenatally, if she already has an education, the anxiety at least will be less for a postpartum woman because she will know what to do after delivery.

Additionally, nurses suggested including family members in women's health education content so they understand PPD and can be supportive. This was expressed by one of the participants:

We need better education for postpartum women and their family members. Maybe we can provide education and explain to the family that there is a condition occurring due to hormonal changes that are associated with depression and mood swings, and make them aware of the signs and symptoms.

Theme 5: Reducing Stigma Toward Mental Health Problems

The feelings of guilt and stigma that postpartum women who are experiencing depression could prevent them from seeking help. Nurses highlighted that the negative attitude toward mental health issues needs to be considered and awareness is needed to overcome this misconception to enable postpartum women to attend the required health care whenever she needs it. This was expressed by two of the participants:

Some feel guilty because I am like this, so they feel bad about it. That is the main thing I felt personally.

Postpartum women are afraid to verbalise what they think is a taboo, especially for their cultures.

Theme 6: Updating Resources

Policies and procedures are commonly applied to guide healthcare services within health organizations, and the nurses noted that such policies and procedures must be updated on a regular basis so as to reflect the latest evidence-based practice. Updating the current policies should include the screening and management of PPD. This was expressed by one of the participants:

They should also update the policies. We’re already upgrading nowadays, so they should upgrade that one as well.

Additionally, there is a stressed need to develop assessments to assist with screening for maternal mental problems as expressed by one of the participants:

We need to have a postpartum risk assessment tool that will guide us every time after delivery so that we can assess everyone.

Relatedly, it was mused on the possibility of a screening tool being developed based on specific criteria to assist nurses in identifying postpartum women who are at risk of developing PPD, assessing the severity of their risk and monitoring them carefully. This was expressed by one of the participants:

Maybe, in the future, we can develop one tool to help with it. Now, as such a tool is not available, it may help if we work on one assessment tool and educate people about the criteria so we can determine the severity of the condition.

Theme 7: Empowering Nurses

The nurses considered themselves to be in the best position to care for postpartum women and assess their psychological status. The nurses suggested that nurses should address the mental care of a postpartum woman and be there every time she needs them. This was expressed by one of the participants:

We should assess postpartum woman not only physically but also mentally, psychologically, and determine how she feels after delivery, and we should be there with a postpartum woman through this journey.

In addition, it was indicated that nurses should be prepared by continuous education regarding PPD to provide mental care to postpartum women based on their needs and intervene to prevent further deterioration. This was expressed by one of the participants:

We can educate the staff also, then if you have any doubt about symptoms, immediately report it, don’t wait until tomorrow, then we can do immediate management.

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.

Footnotes

Acknowledgments

The authors thank the Deanship of Scientific Research, College of Nursing Research Centre at King Saud University for funding this research. Also, the findings of the current study emphasized the important role of primary care settings in addressing maternal mental health.

Author Contributions

H.M. and S.Y. conceived the study and collected the data. S.H. determined the methodology and wrote the background section, S.Y. and D.M. wrote the discussion. All authors reviewed and amended the manuscript before submitting for publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Considerations

The research and interview process commenced after the ethics committee of the University approved (Institutional Review Board—King Saud University—Kingdom of Saudi Arabia) with log No.KSU-HE-21-617.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Seham Mansour Alyousef

Sami Abdulrahman Alhamidi

References

Adjorlolo

Aziato

Akorli

V. V.

(2019). Promoting maternal mental health in Ghana: An examination of the involvement and professional development needs of nurses and midwives. Nurse Education in Practice, 39, 105–110. https://doi.org/10.1016/j.nepr.2019.08.008

Al Nasr

R. S.

Altharwi

Derbah

M. S.

Gharibo

S. O.

Fallatah

S. A.

Alotaibi

S. G.

Almutairi

K. A.

Asdaq

S. M. B.

(2020). Prevalence and predictors of postpartum depression in Riyadh, Saudi Arabia: A cross sectional study. PLOS ONE, 15(2), e0228666. https://doi.org/10.1371/journal.pone.0228666

Alasoom

L. I.

Koura

M. R.

(2014). Predictors of postpartum depression in the eastern province capital of Saudi Arabia. Journal of Family Medicine and Primary Care, 3(2), 146–150. https://doi.org/10.4103/2249-4863.137654

Alexandrou

Sakellari

Kourakos

Sapountzi-Krepia

(2018). Health visitors’ perceptions on their role to assess and manage postpartum depression cases in the community. Health and Social Care in the Community, 26(6), 995–1000. https://doi.org/10.1111/hsc.12638

Almutairi

Alyousef

Lalithabai

(2022). Interfering barriers to postpartum depression screening among women in Saudi Arabia: A phenomenological study. World Family Medicine, 21(1), 31–39. https://doi.org/10.5742/MEWFM.2023.95256018

Atif

Lovell

Rahman

(2015). Maternal mental health: The missing ‘m’ in the global maternal and child health agenda. Seminars in Perinatology, 39(5), 345–352. https://doi.org/10.1053/j.semperi.2015.06.007

Bevan

M. T.

(2014). A method of phenomenological interviewing. Qualitative Health Research, 24(1), 136–144. https://doi.org/10.1177/1049732313519710

Buist

A. E.

Barnett

B. E. W.

Milgrom

Pope

Condon

J. T.

Ellwood

D. A.

Boyce

P. M.

Austin

M. P. V.

Hayes

B. A.

(2007). To screen or not to screen: That is the question in perinatal depression. Medical Journal of Australia, 177(7 SUPPL.), 101–105. https://doi.org/10.5694/j.1326-5377.2002.tb04866.x

Creswell

J. W.

Poth

C. N.

(2016). Qualitative inquiry and research design: Choosing among five approaches. Sage publications.

10.

Ellis

(2016). This present darkness: A history of Nigerian organized crime. Oxford University Press, USA.

11.

Engle

P. L.

(2009). Maternal mental health: Program and policy implications. The American Journal of Clinical Nutrition, 89(3), 963S–966S. https://doi.org/10.3945/ajcn.2008.26692G

12.

Epifanio

M. S.

Genna

De Luca

Roccella

La Grutta

(2015). Paternal and maternal transition to parenthood: The risk of postpartum depression and parenting stress. Pediatric Reports, 7(2), 5872. https://doi.org/10.4081/pr.2015.5872

13.

Falana

S. D.

Carrington

J. M.

(2019). Postpartum depression: Are you listening? The Nursing Clinics of North America, 54(4), 561–567. https://doi.org/10.1016/j.cnur.2019.07.006

14.

Field

(2010). Postpartum depression effects on early interactions, parenting, and safety practices: A review. Infant Behavior & Development, 33(1), 1–6. https://doi.org/10.1016/j.infbeh.2009.10.005

15.

Frechette

Bitzas

Aubry

Kilpatrick

Lavoie-Tremblay

(2020). Capturing lived experience: Methodological considerations for interpretive phenomenological inquiry. International Journal of Qualitative Methods, 19, 1609406920907254.

16.

Ganann

Sword

Newbold

K. B.

Thabane

Armour

Kint

(2019). Provider perspectives on facilitators and barriers to accessible service provision for immigrant women with postpartum depression: A qualitative study. The Canadian Journal of Nursing Research = Revue Canadienne de Recherche En Sciences Infirmieres, 51(3), 191–201. https://doi.org/10.1177/0844562119852868

17.

Harvey

S. T.

Fisher

L. J.

Green

V. M.

(2012). Evaluating the clinical efficacy of a primary care-focused, nurse-led, consultation-liaison model for perinatal mental health. International Journal of Mental Health Nursing, 21(1), 75–81. https://doi.org/10.1111/j.1447-0349.2011.00766.x

18.

Henderson

Dixon

Bauer

Knapp

Morrell

Slade

Walters

S. J.

Brugha

(2019). Cost-effectiveness of PoNDER health visitor training for mothers at lower risk of depression: Findings on prevention of postnatal depression from a cluster-randomised controlled trial. Psychological Medicine, 49(8), 1324–1334. https://doi.org/10.1017/S0033291718001940

19.

Higgins

Amos

Pfau

Racaniere

Matthey

Rezende

Lerchner

(2018). Towards a definition of disentangled representations. arXiv preprint arXiv, 1812.02230.

20.

Hogan

(2022). Maternal health. Salem Press Encyclopedia.

21.

Layton

Bendo

Amani

Bieling

P. J.

Van Lieshout

R. J.

(2020). Public health nurses’ experiences learning and delivering a group cognitive behavioral therapy intervention for postpartum depression. Public Health Nursing, 37(6), 863–870. https://doi.org/10.1111/phn.12807

22.

Lillykutty

M. J.

Samson

(2018). Insights from Kristen M Swanson’s theory of caring. Asian Journal of Nursing Education and Research, 8(1), 173–177. https://doi.org/10.5958/2349-2996.2018.00036.8

23.

Mattson

Smith

J. E.

(2015). Core curriculum for maternal–newborn nursing. Elsevier Health Sciences.

24.

Ministry of Health (2017). Health sector transformation strategy. https://www.moh.gov.sa/en/Ministry/vro/Documents/Healthcare-Transformation-Strategy.pdf

25.

Missler

van Straten

Denissen

Donker

Beijers

(2020). Effectiveness of a psycho-educational intervention for expecting parents to prevent postpartum parenting stress, depression and anxiety: A randomized controlled trial. BMC Pregnancy and Childbirth, 20(1), 658. https://doi.org/10.1186/s12884-020-03341-9

26.

Modula

M. J.

Ramukumba

M. M.

(2018). Nurses’ implementation of mental health screening among HIV infected guidelines. International Journal of Africa Nursing Sciences, 8, 8–13. https://doi.org/10.1016/j.ijans.2018.02.001

27.

Morrow

Rodriguez

King

(2015). Colaizzi's descriptive phenomenological method. The psychologist 28(8), 643–644.

28.

Musser

A. K.

Ahmed

A. H.

Foli

K. J.

Coddington

J. A.

(2013). Paternal postpartum depression: What health care providers should know. Journal of Pediatric Health Care: Official Publication of National Association of Pediatric Nurse Associates & Practitioners, 27(6), 479–485. https://doi.org/10.1016/j.pedhc.2012.10.001

29.

Neubauer

B. E.

Witkop

C. T.

Varpio

(2019). How phenomenology can help us learn from the experiences of others. Perspectives on medical education, 8, 90–97.

30.

Olin

S. C. S.

Kerker

Stein

R. E. K.

Weiss

Whitmyre

E. D.

Hoagwood

Horwitz

S. M.

(2016). Can postpartum depression be managed in pediatric primary care? Journal of Women’s Health, 25(4), 381–390. https://doi.org/10.1089/jwh.2015.5438

31.

Philpott

L. F.

Corcoran

(2018). Paternal postnatal depression in Ireland: Prevalence and associated factors. Midwifery, 56, 121–127. https://doi.org/10.1016/j.midw.2017.10.009

32.

Place

J. M. S.

Billings

D. L.

Blake

C. E.

Frongillo

E. A.

Mann

J. R.

deCastro

(2015). Conceptualizations of postpartum depression by public-sector health care providers in Mexico. Qualitative Health Research, 25(4), 551–568. https://doi.org/10.1177/1049732314552812

33.

Polit

D. F.

Beck

C. T.

(2017). Nursing research: Generating and assessing evidence for nursing practice. Lippincott Williams & Wilkins.

34.

Poreddi

Sai Nikhil Reddy

Gandhi

Marimuthu

BadaMath

(2021). ‘Unheard voices’: Perceptions of women with mental illness on nurses screening routinely for domestic violence: A qualitative analysis. Investigacion y Educacion en Enfermeria, 39(3), e03. https://doi.org/10.17533/udea.iee.v39n3e03

35.

Rahman

Surkan

P. J.

Cayetano

C. E.

Rwagatare

Dickson

K. E.

(2013). Grand challenges: Integrating maternal mental health into maternal and child health programmes. PLOS Medicine, 10(5), e1001442. https://doi-org.sdl.idm.oclc.org/10.1371/journal.pmed.1001442

36.

Saad

Chan

Nguyen

Srivastava

Appireddy

(2021). Patient perceptions of the benefits and barriers of virtual postnatal care: A qualitative study. BMC Pregnancy and Childbirth, 21(1), 543. https://doi.org/10.1186/s12884-021-03999-9

37.

Saleh

Z. T.

Elshatarat

R. A.

Ebeid

I. A.

Aljohani

M. S.

Al-Za’areer

M. S.

Alhujaili

A. D.

Al Tarawneh

N. S.

Abu Raddaha

A. H.

(2020). Caring for women with postpartum depression in Saudi Arabia: Nurses’ and midwives’ opinions about their roles. Journal of Psychosocial Nursing & Mental Health Services, 58(7), 42–51. https://doi-org.sdl.idm.oclc.org/10.3928/02793695-20200506-05

38.

Segre

L. S.

O’Hara

M. W.

Arndt

Beck

C. T.

(2010). Screening and counseling for postpartum depression by nurses: The women’s views. MCN. The American Journal of Maternal Child Nursing, 35(5), 280–285. https://doi.org/10.1097/NMC.0b013e3181e62679

39.

Sofronas

Feeley

Zelkowitz

Sabbagh

(2011). Obstetric and neonatology nurses’ attitudes, beliefs, and practices related to the management of symptoms of maternal depression. Issues in Mental Health Nursing, 32(12), 735–744. https://doi-org.sdl.idm.oclc.org/10.3109/01612840.2011.609635

40.

Suen

L. J.

Huang

H. M.

Lee

H. H.

(2014). A comparison of convenience sampling and purposive sampling. The Journal of Nursing, 61(3), 105–111. https://doi.org/10.6224/JN.61.3.105

41.

Swanson

K. M.

(1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161–166. https://doi.org/10.1891/9780826171122.0013

42.

Tel

Ertekin Pinar

Daglar

(2018). Effects of home visits and planned education on mothers’ postpartum depression and quality of life. Journal of Clinical and Experimental Investigations, 9(3), 119–125. https://doi.org/10.5799/jcei.458759

43.

Ukatu

Clare

C. A.

Brulja

(2018). Postpartum depression screening tools: A review. Psychosomatics, 59(3), 211–219. https://doi.org/10.1016/j.psym.2017.11.005

44.

Wirihana

Welch

Williamson

Christensen

Bakon

Craft

(2018). Using Colaizzi’s method of data analysis to explore the experiences of nurse academics teaching on satellite campuses. Nurse Researcher, 25(4), 30. https://doi.org/.sdl.idm.oclc.org/10.7748/nr.2018.e1516

45.

World Health Organization (2016). mhGAP intervention guide mental health gap action programme version 2.0 for mental, neurological and substance use disorders in non-specialized health settings. World Health Organization.

46.

World Health Organization (2017). mhGAP training manuals for the mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings (No. WHO/MSD/MER/17.6). World Health Organization.

47.

World Health Organization (2019a). Maternal mental health. https://www.who.int/teams/mental-health-and-substance-use/maternal-mental-health.

48.

World Health Organization (2019b). The WHO special initiative for mental health (2019-2023): universal health coverage for mental health (No. WHO/MSD/19.1). World Health Organization.

49.

Young

C. A.

Burnett

Ballinger

Castro

Steinberg

Nau

Bakken

E. H.

Thomas

Beck

A. L.

(2019). Embedded maternal mental health care in a pediatric primary care clinic: A qualitative exploration of mothers’ experiences. Academic Pediatrics, 19(8), 934–941. https://doi.org/10.1016/j.acap.2019.08.004

50.

Zubaran

Schumacher

Roxo

M. R.

Foresti

(2010). Screening tools for postpartum depression: Validity and cultural dimensions. African Journal of Psychiatry, 13(5), 357–365. https://doi.org/10.4314/ajpsy.v13i5.63101

Exploring the Healthcare Services’ Contribution to Reducing Postpartum Depression

Abstract

Introduction

Objective

Methods

Results

Conclusion

Keywords

Introduction

Review of Literature

Methods

Design

Research Questions

Sample

Inclusion Criteria

Exclusion Criteria

Data Collection

Institutional Review Board Approval

Data Analysis

Results

Sample Characteristics

Research Questions Findings

Theme 1: Maternal Mental Health

Theme 2: Follow-Up of Mental Health Status

Theme 3: Screening Mental Health Status

Theme 4: Enhancing Health Education

Theme 5: Reducing Stigma Toward Mental Health Problems

Theme 6: Updating Resources

Theme 7: Empowering Nurses

Discussion

Strengths and Limitations

Implications for Practice

Conclusions

Footnotes

Acknowledgments

Author Contributions

Declaration of Conflicting Interests

Ethical Considerations

Funding

ORCID iDs

References