The Public’s views of mental health in pregnant and postpartum women: a population-based study

At a prevalence of 13 to 25%, stress, depression, and anxiety are the most common complications experienced by women during the prenatal and postnatal periods [1, 2]. Poor mental health during the perinatal period is identified as a major public health concern and “the biggest unaddressed health challenge of our age” [3]. Without treatment, over one-third of women with prenatal mental health problems will experience unremitting symptoms that persist into their child’s preschool years [4]. However, despite frequent contact with healthcare professionals during pregnancy and post-delivery, the vast majority of women do not seek help for symptoms of stress, depression, or anxiety, or voluntarily disclose their symptoms [5, 6].

Women cite significant deterrents to disclosure and help-seeking during the perinatal period [5‐8]. While some barriers that women describe are clearly system-related (e.g., not obtaining a referral in a timely manner) [7], many reflect deeply held views regarding mental health problems in the prenatal and postnatal periods, including the expectation of being constantly happy to be pregnant or have a new infant, the association of mental health problems with maternal incompetency and being a failure as a mother, the fear that others would think less of them if they admitted to experiencing symptoms, the need to be a ‘super-mother’, the concern that their infant would be apprehended, and the belief that symptoms would improve spontaneously [8‐10].

Views regarding mental health and healthcare are poignant determinants of patient behavior with regard to the access, uptake, and adherence to mental health treatment. Among pregnant and postpartum women, negative or inaccurate views of mental health are impediments to early detection and treatment, in that they are associated with delay in seeking mental healthcare [5] and reduced disclosure of mental health problems [6]. Understanding views towards mental health is also foundational to delivering effective intervention. Evidence rooted in the field of implementation science suggests that effective implementation of interventions must incorporate knowledge of the context that influences the impact of the intervention and its transference into clinical care - with patient views being a central component of the context [11, 12]. Thus, effective and sustainable intervention utilizes patient views to optimize its impact and utilization [11].

While the public’s views surrounding mental health have been well studied with respect to general anxiety and depression, very little research has explored its views related to perinatal mental health. Three key observations highlight the importance of the investigation of the public’s views of perinatal mental health:

1) Only one study to date has explored the public’s views of perinatal mental health [13]; however, it is unclear whether these Australian findings are generalizable to other contexts in that they reflect the public’s awareness of perinatal mental health within a healthcare system that supports the National Perinatal Depression Initiative [14, 15] and espouses highly visible, definitive perinatal mental health awareness strategies (http://​www.​beyondblue.​org.​au/​);

2) Only a few, small studies have explored the views of mental health and healthcare among pregnant and postpartum women and their care providers [6, 7, 16‐18]. Findings of these studies suggest that the most prominent attitudes toward mental health differ from studies conducted in the general population, and warrant a separate investigation. For example, surveys of public attitudes of mental health in the general population have identified social distance (e.g., not wanting to employ or befriend individuals with mental health problems) and stereotyping (e.g., as dangerous, to be blamed, unpredictable) as prominent concerns [19, 20]. In the perinatal literature, attitudes toward mental health are uniquely embedded in concerns related to pregnancy or transitioning to motherhood, such as the belief that women with perinatal depression or anxiety are incompetent or bad mothers, and the guilt that originates from not feeling happy or being able to cope [6, 7]; and

3) The views of childbearing couples are highly sensitive to societal values and opinions, with family and friends representing dominant influences on their behaviors and decisions [5, 8].

As such, understanding the public’s views regarding depression and anxiety in the prenatal and postnatal periods provides a valuable foundation for gaining insight into decision-making, help-seeking, and healthcare utilization patterns of childbearing families.

The purpose of this study was to use a large, population-based sample to describe the public’s views of perinatal mental health on topics related to knowledge of pre-conception, prenatal, and postnatal mental health and their influence on maternal and child outcomes, and to identify factors associated with perinatal mental health knowledge.

This study provides the first Canadian data related to public views of perinatal mental health and adds to the limited body of evidence on this topic. Only one other study in Australia has described the public’s views of perinatal mental health at a population-level [13]. Overall, we found that levels of knowledge of postnatal mental health were high, while knowledge regarding prenatal mental health was significantly lower. Understanding the contributions of past mental health problems and prenatal mental health on the risk of development of depression/anxiety during and after pregnancy was also quite low. The least understood topic was the influence of prenatal mental health on child development, where only one in four participants responded accurately, and over 40% reported that they were unsure or did not know. Finally, our multivariable analyses revealed that the main determinants of both prenatal and postnatal mental health were personal experience with PPD and possessing high levels of knowledge of mental health across the perinatal period. Whereas most demographic variables were not significant, we found that older participants and those with no post-secondary education had significantly lower levels of prenatal and postnatal mental health knowledge, respectively.

Our finding that respondents were more knowledgeable about postnatal than prenatal mental health is similar to the Australian study in which 24.8% of individuals cited PPD as a major health problem, but only 7.0% of participants recognized the health implications of prenatal anxiety or depression [13]. Indeed, in this study 52% of respondents identified prenatal anxiety as ‘normal’ [13]. The limited understanding of determinants of prenatal and postnatal anxiety/depression is also consistent with this study’s report of common, erroneous beliefs regarding the causes of postnatal depression expressed by both the general public and healthcare providers [13]. The lack of knowledge about the influence of pre-conception and prenatal anxiety/depression on the risk of poor perinatal mental health [22‐24] may reflect errant public belief that the primary causes of perinatal mental health problems are biological in nature –a key observation noted in the Australian study [13]. The failure to recognize the role that other factors play may underlie women’s dread regarding a diagnosis of PPD and their reticence in help-seeking in that a deterministic, biological view implies that women are bound to develop PPD and prevention is not possible.

The disparity that we observed in the public’s prenatal and postnatal mental health knowledge is notable in that qualitative studies have cited major deterrents to mental health help-seeking in pregnancy as lack of knowledge regarding symptoms, where to find help, and treatment options [5, 6]. Furthermore, other studies have related low knowledge of mental health among perinatal healthcare providers to sub-optimal mental health screening behavior [18], which has been reported as less than 20% [25]. Thus, a major concern originating from our findings is that limited awareness of prenatal mental health problems may contribute to the serious under-detection and under-treatment [25, 26] of prenatal mental health problems. Improving perinatal mental health knowledge (e.g., symptoms, where to seek help, treatment options) among women, their families, and healthcare providers may have a substantial impact on detection and treatment.

Emerging evidence indicates that early intervention to improve pregnant women’s mental health has enduring benefits for reducing the risk of postpartum mental health problems and poor infant health and development [27‐29]. Thus, although the historical focus has been on diagnosing and treating PPD, the findings of this study highlight the need for a shift toward improving the public’s understanding of the prevalence and sequelae of prenatal anxiety and depression. The strikingly low level of understanding of the impact of prenatal mental health on child development that we found mirrors the findings of other population-based studies that highlight two key points: 1) the public dismisses the importance of the early life influences on long-term child well-being [30]; and 2) knowledge of factors that influence child development is poor [31].

The finding that older age was related to lower prenatal mental knowledge is similar to the Australian study [13] that reported that fewer older adults identified mental health problems as concerns in the postpartum period compared to younger adults. Other studies have demonstrated that low income and education are associated with low mental health literacy [32]; however, we observed that only low education was related to postnatal knowledge and neither was related to prenatal knowledge. Indeed, the most consistent predictor of prenatal and postnatal knowledge was personally knowing a woman who had experienced postpartum anxiety or depression. The positive role of personal experience on the attitudes of perinatal healthcare providers toward mental health has been reported previously [33]. Our results confirm that this is an important determinant of perinatal mental health literacy in the general public.

This study highlights the lack of public awareness about prenatal mental health problems and the impact of poor perinatal mental health on future maternal mental and child development. Recommendations based on the findings include strengthening public awareness of the determinants of poor perinatal mental health and the potential influence of poor perinatal mental health on child development. However, messages regarding the association between prenatal and postnatal mental health and child outcomes need to be constructed with great care and sensitivity to avoid inflicting unnecessary guilt on childbearing women. Future research should examine the impact of perinatal mental health literacy on screening, referral, and treatment patterns.

DK (PhD) is an Assistant Professor in the Faculty of Nursing and an Adjunct Assistant Professor in the Department of Obstetrics and Gynecology at the University of Alberta. She holds an Early Career Transition Award through the Alberta Centre for Child, Family, and Community Research. MPA (MD, FRANZCP, MB) is a perinatal psychiatrist and Professor in the Faculty of Medicine at University of New South Wales. She is also the Chair of the Perinatal and Women’s Mental Health Unit at the University of New South Wales, the Director of the St. John of God Mother-Baby Unit in Sydney, Australia, and the lead developer of the Australian Clinical Guidelines for Perinatal Mental Health (2011) and the International Marce Society Position Statement on Psychosocial Assessment and Depression Screening in the Perinatal Period (2013). KMH (PhD) is a Professor in the Faculty of Nursing and an Adjunct Professor in the Department of Psychiatry at the University of Alberta. She holds a Canada Research Chair in Stress Disorders in Women. GL (PhD) is an Associate Professor in the Faculty of Nursing at the University of Alberta and is a Certified Psychiatric Nurse. SM (PhD) is an epidemiologist with expertise in statistics, life course analysis, and mental health tool development. She is the senior scientist for the All Our Babies birth cohort study. ST is a Professor in the Department of Paediatrics and Community Health Sciences (Medicine) at the University of Calgary and an Adjunct Professor in the School of Public Health and Department of Obstetrics and Gynecology at the University of Alberta. She is a Health Scholar (Alberta Innovates-Health Solutions) and the Scientific Director of the Alberta Centre for Child, Family and Community Research.