Addressing perinatal depression in a group of underserved urban women: a focus group study

Perinatal depression is widely reported to be the leading complication of childbirth [1]. Prevalence rates of depression in pregnant women have been estimated at between 6.5% to 12.9% [2]. As many as 19.2% of women have a depressive episode during the first 3 months postpartum [2]. Despite this level of need, the utilization of perinatal mental health services is low in terms of both accessing treatment and continuing treatment [3]. Untreated depression during pregnancy can lead to poor self-care, increased substance abuse [4], poor obstetrical outcomes [5], developmental delay in children [6, 7], and increased risk of postpartum depression [8]. Despite its widespread prevalence, perinatal depression frequently goes undetected and disproportionately impacts disadvantaged women and their children. Access to help for perinatal conditions is also influenced by socioeconomic factors, with disparities negatively impacting perinatal mental health [9].

Despite the extent of perinatal mental health problems, much can be done to address mental health needs for women in the perinatal period. Cognitive behavioral therapy (CBT) has been shown to improve depression [10]. Additionally, there is evidence that CBT depression treatments can be culturally adapted to improve their effectiveness with cultural minorities and low socioeconomic groups [11, 12]. CBT and pharmacological interventions may offer effective treatment, but can increase costs of services [13], which may be a barrier for providing care [4‐8]. Other approaches have also been explored, such as interpersonal psychotherapy [14, 15], mindfulness [16] and the use of postpartum doulas [17]. The location of treatment delivery has also been researched, and shows that the delivery of evidence-based treatments by home visiting nurses can also be effective at addressing postpartum depression [18‐21].

While the evidence base for effective treatment is growing, women are still not consistently accessing services for perinatal mental health problems. Research indicates that only a minority of women who are at risk for perinatal depression will receive referrals to address mental health issues, and fewer yet will ultimately engage in treatment [22]. The literature reports barriers to accessing help including a lack of knowledge or understanding about perinatal mental health issues [23], along with previous negative experiences with health care providers or a fear of being judged by health care providers [23]. Women have described how they value being able to talk with peers about their experiences [24]. Some studies indicate that accessing peer support was also potentially seen as the only acceptable option, due to negative views or experiences with more formal services [24, 25]. Stigma related to accessing mental health services has also been identified as an important barrier for accessing help [26].

Despite existing research, there is a need to further our understanding of what kind of mental health needs women think they have, and what kind of support or help they would be likely to access to address those perceived needs. Integrating women’s views and experiences into the development of services may help to overcome some of the barriers such as lack of trust and negative perceptions about accessing help [25]. This research focused on the geographic area of Minneapolis, Minnesota, a racially and culturally diverse large urban center with a population of over 380,000 [27]. Almost one-quarter of Minneapolis families with children under age five live in poverty.

The investigators conducted a needs assessment to inform future development of public health systems approaches to reduce negative outcomes due to perinatal depression, which we defined as the time a woman conceives through the first year post-partum. Here we report on the findings from the focus groups conducted with women in the Minneapolis area as part of that needs assessment. The focus groups were specifically interested in exploring the following research objectives:

Women who were pregnant, or who delivered within the past year, were recruited to participate in focus groups intended to gain information on the mental health needs of women during the perinatal period. Women were recruited from three health care clinics, which were located in disadvantaged parts of the city and serving traditionally underserved populations. Staff in the clinic recruited women into the study from the population of women receiving prenatal or postnatal care in their clinic. Focus groups were conducted at the clinics from which the women were recruited. Groups were combined discussions of women receiving both prenatal and postnatal care, and focused on exploring a breadth of experiences.

The themes which emerged from the analysis are presented in relation to each of the research questions, namely a description of perinatal health needs, the current perception of available mental health resources, and women’s desire for greater mental health supportive services. Here we discuss each of these main areas and their associated sub-themes, which are summarized in Table 1.

This study was designed to talk with women about what mental health needs they feel they have, what help they currently access and what help they would like to address their mental health needs. These needs include those that address emotional needs and ways to alleviate social and economic stressors that have a negative impact on their mental health. Women in the focus groups were asked to describe what they currently do to address their mental health needs. They primarily described relying on support from friends or family or their own strengths, although some acknowledged the usefulness of medication or therapy. This is consistent with other studies that have indicated women may turn to informal supports to meet their needs [24]. However the literature is mixed on the effectiveness of some forms of peer support for postpartum depression [31], although there is some growing indication that it may be an effective approach [17]. Women in this study were quite adamant that peer support would be a preferred option for mental health support. This may indicate that further work needs to be done to review the quality and nature of the peer support interventions offered in the perinatal field, as research on the use of peer support in general mental health indicates it can both be effective and very well received by those seeking mental health improvement [32, 33].

Some women talked about the use of formal treatments, and this remains an important option. However our findings echoed other literature in highlighting the need for service providers to be cognizant of the fact that many women may have had negative experiences previously, and thus have negative perceptions of services [24, 25]. Yet there remains a strong field of research about the usefulness of formal treatments [10], including their ability to be culturally adapted for use [11, 12], and more work needs to be done to address the barriers women face in accessing services.

A clear implication of this work is that the women want those helping them to address their mental health by using an empowerment orientated approach. They also preferred the use of an educational format. These findings highlight that a barrier to engaging women with current services might originate in the approach to services themselves, which use a medical model instead of an empowerment oriented approach to address mental health needs.

One particularly notable finding in this research was how strongly women believed that social and economic challenges, such as difficult relationships, lack of adequate housing, financial issues or unemployment, contribute to mental health problems. Yet when women talked about what they currently do to address mental health needs, all actions focused on addressing emotional needs. Equally, the literature reflects this, as most interventions also focus on emotional needs [10‐13, 16, 17]. There are some exceptions in the literature, with some interventions focusing on multiple risk factors [34], but these approaches appear to be primarily focused on improving health outcomes, rather than overall needs which may contribute to poor mental well-being. This signals the potential importance of addressing social and economic needs into services as one potential way to increase the perception of relevance and accessibility for women.

Women in our study stated that they wanted access to a greater range of different kinds of support for mental health problems, such as educational groups or peer support. They also described significant social and economic needs which were rarely addressed in current services. These findings offer a challenge to further broaden the types of services offered to women to include peer support, resilience focused programming, and educational programming. Also, in order to increase relevance and accessibility for diverse women, mental health services should more clearly address social and economic challenges.