Engagement with perinatal mental health services: a cross-sectional questionnaire survey

The study was conducted at a 270-bed public outer metropolitan hospital (OMH) serving a socio-economically disadvantaged region in Queensland, Australia [25]. On the outskirts of the capital city, in a ‘growth corridor’, the catchment population of ~ 151,000 has relatively higher rates of hospital utilisation than Queensland residents generally [26].

Pregnant women residing in the OMH catchment can access free obstetrician-led outpatient antenatal care, regardless of their pregnancy risk profile. At the initial visit (7–14 weeks), service midwives routinely screen patients for symptoms of depression and anxiety, using the Edinburgh Postnatal Depression Scale (EPDS). As part of this process, women are provided written and verbal information about PD/A. Women who score ≥ 13, and/or have a positive response to the item (ten) regarding thoughts of self-harm, are offered a referral to the local PMHS. When a referral is received, the PMHS arranges outreach assessment or appointments at the OMH. Engagement with PMHS is voluntary. Practice-based evidence (Mackle 2016, personal communication, 5th June) indicates that one-third of women who are referred to the local PMHS agree to make an initial appointment, and of these women, only one-third attend.

The study was approved by the authorised certified Human Research Ethics Committee (HREC/16/QPCH/237) and the site Research Governance office of the hospital. Before accessing the questionnaire, potential participants were provided verbal and written information by the study investigators and advised that completion of the questionnaire would imply consent for the use of the data for research purposes.

A cross-sectional survey was conducted using a questionnaire designed specifically for this study. The questionnaire (additional file 1) was iteratively developed in several stages. Initially, a pool of items was generated based on a review of the literature (summarised in Table 1) and consultation with obstetricians, midwives, mental health clinicians, and psychiatrists with expert knowledge of the population of interest. The first section of the questionnaire contained items concerning participant demographic data, and their obstetric and mental health histories, specifically addressing depression and anxiety. The second section of the questionnaire invited participants to rate their self-reported mental health knowledge on a 5-point Likert scale and enquired as to their PMHS referral status and level of engagement. The third section of the questionnaire included items identifying potential barriers and facilitators to PMHS engagement. There were 22 items (11 items each for barriers and facilitators) and women were asked to rate, on a 3-point Likert scale, the extent to which these factors had influenced or would have influenced their engagement with PMHS. There was no free text option available and the questionnaire took a maximum of 5 minutes to complete.

A tree algorithm was utilised for the questionnaire, as depicted in Fig. 1. The three primary branches of the questionnaire were tailored for (1) women not offered referral to the PMHS (WNOR); (2) women offered referral to the PMHS who did not attend (WDNA); and (3) women who were offered a referral to the PMHS and attended (WA).

The questionnaire was piloted with ten women to assess face and content validity. Cognitive interviewing was used to explore interpretation and comprehensibility of each item. Adjustments were made to the general structure of the questionnaire, and the wording and sequence of items based on the feedback of this pilot group. The women on whom the questionnaire was piloted, appreciated the anonymous nature of the questionnaire and found the Google Forms format user-friendly.

Women receiving antenatal care at the hospital were eligible for participation if they were aged 18 years or older, attending their first medical antenatal appointment, and sufficiently fluent in English to complete the consent processes and questionnaire.

Recruitment for the study was time limited and occurred from February 2017 to July 2017. Convenience sampling of consecutive, unselected women attending their first medical appointment (generally ≥20 weeks gestation) were approached individually in the antenatal clinic waiting room by one of the researchers (Author 2). To prevent the perception of coercion, this researcher was not involved in the provision of healthcare to the individual, and women were advised their health care would not be influenced regardless of their decision to participate. Prior to the medical appointment women would typically have been reviewed by a midwife, completed the EPDS, provided education about PD/A and referred to PMHS if appropriate. After being provided patient-oriented verbal and written information about the study by the approaching researcher, women who met eligibility criteria and agreed to participate were provided with a portable electronic device with access to the questionnaire in Google Forms. The researcher was readily available if women had clarification questions.

Statistical analysis was performed using STATA version 13 [27], which involved the calculation of descriptive statistics and comparisons of women by referral status.

For analysis, the Likert scale was collapsed into dichotomous categories for the 2 items related to knowledge of mental health: Not knowledgeable = 1, 2, 3 and Knowledgeable = 4, 5. For the items related to barriers and facilitators, responses were also collapsed into dichotomous categories of “Not at all” and “A little”/“A lot”. The “Not applicable” response was converted to missing. The frequencies of responses for these items were concentrated at the extremes of the 3-point scale. Dichotomous categorisation of the responses for these items focused on improving the interpretability of the data.

Responses to each question were summarised by frequency and percentage. Categorical variables were examined using the Pearson Chi-squared test, or Fisher’s Exact test when more than 20% of the expected values were less than five.

This study illustrates the low levels of engagement with PMHS in a high-risk population with a high incidence of self-reported history of anxiety and depression and emphasises the importance of identifying barriers and facilitators to provide psychiatric assessment and appropriate management. It also expands on previous research by identifying factors influencing antenatal women’s engagement with PMHS in an Australian context. These factors, regardless of women’s PMHS referral status and engagement, were: (1) lack of time; (2) no one to look after their children; and, (3) encouragement by their family and HCP. Notably, stigma was not found to be a significant barrier to engagement.

This study also identified three factors that could influence service engagement: (1) at least one quarter of women did not recall being given any information about PD/A during their pregnancy; (2) nearly 15% of women did not recall being asked about their mental health during their pregnancy; and (3) nearly half of participants did not consider themselves knowledgeable about mental illness in the perinatal period.

Consistent with findings of other studies, encouragement by family members and HCP were both identified as facilitating factors to women’s decision to engage with PMHS regardless of their referral status [13, 29, 30]. As identified by Prevatt et al. [31], some women may choose not to openly disclose their emotional distress, as such HCP should proactively promote engagement with mental health services to all women and their social supports if there are identified risk factors or concerns about mental health/emotional wellbeing in the perinatal period.

In accordance with previous published literature, lack of access to appropriate childcare and a lack of time were identified as barriers to engagement with PMHS [13, 32]. Compared to Kim et al. [8], the rate of PMHS engagement in this study was low (50% vs. 24%). Button et al. [16] demonstrated that women felt they would be more likely to engage with healthcare services if childcare services could be provided. Improving immediacy and accessibility of access to PMHS could address a perceived lack of time. Byatt et al. [9] found that providing resources to women and offering on-site mental health assessments doubled the rates of engagement with PMHS compared to screening alone. Further studies identified that a short period between PMHS referral and assessment increases engagement, as some women lose interest and/or motivation [10, 18]. Therefore, health services should develop a PMHS capable of: providing timely and accessible appointments at the location of the antenatal service; offering informational resources at time of referral; and providing access to childcare for consumers attending PMHS.

The observed absence of concern about judgement as an identified barrier is inconsistent with the literature. Stigma, both from women themselves and others, has frequently been reported [11]. It has been previously established that women may choose not to disclose their distress [32], however it is unclear why stigma was not identified as a factor in this study. The exact reasons for omission are likely multifactorial and require further exploration in future studies.

A significant proportion of the cohort did not consider themselves knowledgeable about common mental illness during and after pregnancy and did not recall being screened for PD/A. Studies have consistently shown that lack of literacy on the topic of mental illness in the perinatal period impairs a woman’s ability to identify symptoms, and therefore impacts on their engagement with PMHS [10, 11, 17]. Austin et al. [14] support active education about PD/A to women, and repeated screening through the perinatal period. Due to the nature of the questionnaire, it is impossible to determine if women were screened for PD/A and/or educated about PD/A. Regardless, the results suggest that women need to be proactively engaged in a meaningful experience during the screening process, and educated on the rationale for further assessment and treatment. Goldin Evans et al. [33] and Long et al. [34] found that screening rates increase if HCP are educated about perinatal mental health, emphasizing the need for health services to increase mental health literacy amongst HCP. This would also improve health literacy amongst women and their social supports, potentially facilitating increased emotional support.

The cross-sectional questionnaire facilitated the concurrent collection of information about PMHS referral rates and engagement levels within the study population. Several strategies were used to engage women that were unlikely to engage with, or had refused to engage with, PMHS. The short questionnaire length and dissemination through personal invitation at the antenatal clinic provided a high response rate of 71%. Positively, women who had declined engagement with the PMHS agreed to complete the questionnaire. The anonymous nature of the questionnaire may have increased women’s willingness to answer questions truthfully.

Notably in the study sample, only 69 women were referred to PMHS and of those only 10 women had engaged with PMHS. Although the numbers were small, no significant difference was found in factors influencing this group compared to women who did not engage and women not referred to PMHS.

Limitations of the study include the inability to generalise the results to all Australian antenatal women due to self-selection of the participants through convenience sampling. There are some differences between the study population and the general population. In comparison to pregnant women in Queensland: there were a higher proportion of pregnant women under the age of 24 in the sample (24.3% vs. 19.9%); a lower rate of employment during pregnancy (56.0% vs. 68%); a higher background incidence of anxiety and depression (37.6%) and a similar proportion of women identifying as Aboriginal or Torres Strait Islander (5.0% vs 6.8%) [35, 36]. Overall, the demographic characteristics of the sample are indicative of greater socio-economic disadvantage compared to the general population, which is consistent with what is expected for the region. However, it is noted that this limits the generalisability of results obtained to a general population of pregnant women in Australia.

Regarding the analysis of results, a limitation of the study was the collapsing of responses into dichotomous categories for some items in the questionnaire. Dichotomisation of data results in the loss of precision, however due to the distribution of results being concentrated at the extremes of the scales for some items, the loss of information from dichotomisation is compensated by the benefit of improving the interpretability of results.

Women were asked to rate pre-determined barriers and facilitators, potentially resulting in loss of key themes. The EPDS was not included in the questionnaire, and therefore it is not possible to correlate the score with the level of engagement. These omissions were consciously made to decrease the length of the questionnaire and for ease of completion.