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A qualitative inquiry on pregnant women’s preferences for mental health screening Bayrampour, Hamideh; McNeil, Deborah A; Benzies, Karen; Salmon, Charleen; Gelb, Karen; Tough, Suzanne Oct 3, 2017

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RESEARCH ARTICLE Open AccessA qualitative inquiry on pregnant women’spreferences for mental health screeningHamideh Bayrampour1* , Deborah A. McNeil2, Karen Benzies3, Charleen Salmon4, Karen Gelb5and Suzanne Tough6AbstractBackground: Approaches to screening can influence the acceptance of and comfort with mental health screening.Qualitative evidence on pregnant women’s comfort with different screening approaches and disclosure of mentalhealth concerns is scant. The purpose of this study was to understand women’s perspectives of different mentalhealth screening approaches and the perceived barriers to the communication and disclosure of their mental healthconcerns during pregnancy.Methods: A qualitative descriptive study was undertaken. Fifteen women, with a singleton pregnancy, were recruitedfrom a community maternity clinic and a mental health clinic in Calgary, Canada. Semi-structured interviewswere conducted during both the 2nd and 3rd trimesters. Data were analyzed using thematic analysis.Results: Preferences for mental health screening approaches varied. Most women with a known mental health issuepreferred a communicative approach, while women without a known mental health history who struggledwith emotional problems were inclined towards less interactive approaches and reported a reluctance toshare their concerns. Barriers to communicating mental health concerns included a lack of emotional literacy(i.e., not recognizing the symptoms, not understanding the emotions), fear of disclosure outcomes (i.e., fearof being judged, fear of the consequences), feeling uncomfortable to be seen vulnerable, perception aboutthe role of prenatal care provider (internal barriers); the lack of continuity of care, depersonalized care, lackof feedback, and unfamiliarity with/uncertainty about the availability of support (structural barriers).Conclusions: The overlaps between some themes identified for the reasons behind a preferred screeningapproach and barriers reported by women to communicate mental health concerns suggest that havingoptions may help women overcome some of the current disclosure barriers and enable them to engagein the process. Furthermore, the continuity of care, clarity around the outcomes of disclosing mental healthconcerns, and availability of immediate support can help women move from providing “the best answer”to providing an authentic answer.Keywords: Pregnancy, Mental health screening, Depression, Anxiety, Prenatal careBackgroundDepression and anxiety are common during pregnancy.Prevalence estimates of 6% and 17% have been reportedfor major and minor depression [1], respectively. The ratesof anxiety symptoms and anxiety disorders during theantenatal period are 23% [2] and 15% [3], respectively.Poor maternal mental health is linked to several adverseoutcomes including preterm birth [4, 5], postpartum de-pression [6, 7], difficulty in attachment and bonding, cog-nitive and developmental delays and mental healthproblems in children [8–12]. Perinatal depression andanxiety carry significant long-term costs to society relatedto adverse impacts on child behavioral and developmentaloutcomes and women’s quality of life [13].Women with perinatal mental health problems oftendo not seek help [14]. The benefits of perinatal mentalhealth screening include early detection and manage-ment that can reduce symptoms and their severity [15].* Correspondence: hamideh.bayrampour@ubc.ca1Department of Family Practice, Midwifery Program, University of BritishColumbia, 3rd Floor David Strangway Building, 320–5950 UniversityBoulevard, Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Bayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 DOI 10.1186/s12884-017-1512-4Professional organizations recognize the risk of poormental health during perinatal period and the potentialbenefits of screening [16, 17]. The National Institute forHealth and Care Excellence (NICE) clinical guideline onantenatal and postnatal mental health recommendsscreening for both anxiety and depression during preg-nancy [16]. The American College of Obstetricians andGynecologists recommends that clinicians screen womenat least once during the perinatal period for depressionand anxiety symptoms [18].Screening acceptability is individuals’ willingness tocomplete a questionnaire or conduct a procedure [19].Quantitative data show that most women are comfort-able with perinatal mental health screening. However,some women are not able to confide in their prenatalcare providers about mental health issues and are un-willing to disclose and share how they feel [20, 21]. Onein five pregnant women reports being somewhat honestor not at all honest during mental health screenings[22]. Additionally, the women who could benefit mostfrom screening frequently are those who are hesitant orskeptical towards screening. In a Canadian survey, 17%of pregnant women identified at least one harm pertain-ing to screening, such as feeling embarrassed, feelingworried about what would happen with the information,not knowing why certain questions were asked, finding theexperience to be negative, and finding the questions or theway questions were asked uncomfortable. A previous diag-nosis of a mental health issue was more common amongwomen who identified harms associated with screeningthan among those who did not (38% vs. 22%) [23].The screening method is part of screening acceptability[19]. Quantitative evidence suggests that approaches toperinatal mental health screening may influence women’scomfort with screening [19]. However, associations be-tween comfort with screening and the ability to be honesthave been reported only for certain screening approachessuch as telephone-based screening [22]. Qualitativeevidence on women’s comfort with different screeningapproaches and disclosure of mental health concerns dur-ing pregnancy is scant. Because the ultimate goal ofscreening programs is to identify those with poor mentalhealth, an in-depth inquiry is needed to understand thereasons for preferring a certain approach and how theseapproaches affect women’s comfort and ability to be hon-est and disclose mental health concerns. Given the accu-mulating evidence on the significance of maternal mentalhealth [4, 5, 8–12] and the recognition of importance ofimplementing screening programs within primary caresettings [17], gaining an understanding about the accept-ability of various screening approaches is essential. Thisevidence can inform design and implementation of screen-ing programs for those most in need of assistance, particu-larly considering the stigma around mental health [14]. Thepurpose of this study was to understand women’s perspec-tives of different mental health screening approaches andthe perceived barriers to the communication and disclosureof their mental health concerns during pregnancy.MethodsA qualitative descriptive study [24] was conducted. Usingpurposeful sampling [25], participants were recruited froma community maternity clinic, and a mental health clinicin Calgary, Canada to ensure diversity of women’s mentalhealth condition. Inclusion criteria included women being20 years or older, having a singleton pregnancy at the sec-ond trimester of pregnancy (20–24 weeks), and ability toread, write, and speak in English. Each woman partici-pated in a semi-structured interview at 2nd trimester ofpregnancy and was invited to a second interview at 3rdtrimester. Interviews were conducted by two female inter-viewers (HB; a postdoctoral fellow with prior qualitativeresearch experience and an interest in maternal mentalhealth and CS; an undergraduate student with no prior re-search experience; CS conducted two interviews that werefollowed by a supplementary interview by HB). The inter-viewers did not know the participants prior to the firstinterview. Semi-structured interviews were conductedusing an interview guide adapted from a previous study[26]. The adopted interview guide was pilot tested and thepilot interview data were not included in data analysis.The clinics’ staff identified potential participants. Face-to-face interviews were conducted at the clinics between No-vember 2012 and July 2013. Data collection continued tothe point of data saturation [27] when no new informationor themes were identified. At the first interview, a briefquestionnaire was used to collect socio-demographic in-formation. Interviews were audio-recorded and tran-scribed verbatim. The study was approved by the ConjointHealth Research Ethics Board (E-24854) and participantssigned a written informed consent form.Data analysisData analysis was carried out concurrently with data col-lection using thematic analysis [28]. Each interview wasread in full by researchers independently and then ana-lysis proceeded with open coding in the margins of thetranscripts. A definition of each code was developed andcodes were clustered into categories, and finally the cat-egories were grouped into themes. The research teammet regularly to discuss and reach consensus on coding,coding scheme, and themes. Data analysis was managedusing NVivo. Descriptive statistics were used to describethe characteristics of the participants using IBM SPSSStatistics version [29].The essences of rigor in qualitative inquiry are the visi-bility of research practices and accountability of the dataanalysis [30, 31]. In the current study, credibility wasBayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 Page 2 of 11established by member checking, independent analysisof data by three researchers (HB, DM, KB), peer reviewand debriefing through regular meetings with the re-search team to achieve a jointly developed interpretationof the data, and reporting verbatim quotes. Dependabil-ity and confirmability were obtained through the use ofan audit trail, documenting contextual information, andparticipants’ reflections, and reporting detailed methodo-logical descriptions. Transferability was demonstrated byproviding details of study participants to clarify the char-acteristics of the women to enable readers to identifyapplicability to populations with whom they work.ResultsOf the 18 women invited to participate, 15 agreed totake part in the study. Sample characteristics are pre-sented in Table 1. Of 15 participants, 12 (80%) took partin the second interview conducted at the 3rd trimester.In total, 27 individual interviews, each about one hour,were conducted. The mean gestational age at the firstinterview was 21.8 (±2.2) weeks and at the second inter-view was 34.4 (±1.9) weeks. Four participants had medicalcomplications during the current pregnancy and six expe-rienced mental health problems in the past, of which fourhad received treatments (Table 2). The findings are pre-sented in two sections: (1) screening preferences and (2)barriers for communicating mental health concerns.Screening preferencesDuring the interviews, participants were asked about theirscreening preferences and reasons for favoring certain ap-proaches. Preferences for mental health screening varied,and there was no consensus among participants on a pre-ferred format. All except one participant indicated thesame preferred method at both the 2nd and 3rd trimesterinterviews. The findings for screening preferences andmotives were categorized into two groups: less interactiveapproach and communicative/interactive approach.Less interactive approachLess interactive approaches included any screening con-ducted through a self-reported questionnaire completedin a clinic or online. The reasons for preferring this ap-proach, in addition to convenience, included thinkingthings through, sustaining personal space and not reveal-ing emotional vulnerability.Thinking things throughA need to think about answers emerged from the in-terviews with women who preferred this approach.Most participants explained that this approach wouldgive them time to think and to ensure they answeredquestions accurately, while, others reported that thisapproach would give them time to think about theanswer that they wanted to share. A nulliparouswoman commented:“I can think about what people say to me and I canthink about what I want to say back. Whereas a phoneconversation is you gotta be quicker than that.”(Participant 6)Some women indicated that they were cautiousabout how to respond to the questions and wouldneed extra time to provide “the best answer”. A 32-year-old woman struggling with obsessive thoughtscommented:Table 1 Demographic Characteristics of Participants (N = 15)Variables M (SD)Age (years) 30.93 (4.56)Gestational age at recruitment (weeks) 21.80 (2.15)n (%)Nulliparous 7 (46.7)Multiparous 8 (53.3)Marital StatusMarried 11 (73.3)Common-law or live-in partner 3 (20.0)Single 1 (6.7)EducationHigh school/incomplete university 3 (20.0)Diploma/certificate (e.g. hygienists) 5 (33.3)Bachelor’s degree 7 (46.7)Household incomeUnder $20,000 2 (13.3)$40,000 - $79,000 4 (26.7)$80,000 and above 9 (60.0)Racial/ethnic backgroundOther 4 (26.7)White (Caucasian) 11 (73.3)Family DoctorYes 14 (93.3)No 1 (6.7)Paid work before current pregnancyYes 14 (93.3)No 1 (6.7)Paid work during current pregnancyYes 10 (66.7)No 5 (33.3)Born in CanadaYes 12 (80.0)No 3 (20.0)Bayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 Page 3 of 11“The direct asking the questions I think people mightneed a bit of time. For me, I’m careful how I like toanswer because I’d like to give the best answer kind ofthing so... I need a little bit of time to kind of think ofwhat I need to say. For me, the best way is to say whileyou’re here we need you to fill out this questionnaire.”(Participant 12)Sustaining personal space and not revealing emotionalvulnerabilityWomen, who preferred a less interactive format forscreening, often reported a tendency to conceal their emo-tions for variety of reasons such as not wanting to exposeemotions or be seen vulnerable. Some participants statedthat they would evade the conversation altogether if theythought they might become emotional. A multiparouswoman who was struggling to choose the mode of deliveryafter a caesarean birth and was fearful to make a decisioncommented, “If I don’t show anybody that I’m scared,then no one will know that I’m scared.” She explained:“I’ve always kind of have been viewed as the strongerperson [voice cracks at the words “stronger person”and starts crying] [pause]. I uh yeah really hate beingemotional in front of other people, so I think that’sprobably why. I think, if I feel like I’m going to getemotional, I will avoid a topic, so I uh do not wantpeople to see that weakness cause everybody kind ofjust thinks like someone once called me the MargaretThatcher once.” (Participant 5)Hence, sustaining personal space also emerged asthese women felt that in less interactive approaches, par-ticularly online screening, they would have their ownspace if they become emotional. A Nulliparous womancommented:“That’s online if I’m emotional and I don’t want otherpeople to know then they don’t have to know and Ikind of be in my own space. And [that is] the nicething about being online.” (Participant 6)Communicative approachCommunicative approaches included any screening per-formed through communication with a health care pro-vider, such as an in-person or telephone-basedscreening. In this category, all but one participant pre-ferred an in-person format. The reasons for preferringthis approach included being a personal interaction,helping to talk it through, and allowing the instant ex-change of feedback.Being a personal interactionThe participants who favored this approach indicated thatthey would prefer a personal interaction to connect withtheir provider in order to communicate mental healthconcerns. A 26-year-old multiparous participant commen-ted, “you can’t really connect with a piece of paper.” Somewomen also explained that despite the discomfort of be-coming emotional during a communicative approach, itwould be easier to explain concerns in-person.Table 2 Health Characteristics of Participants (N = 15)Variables n (%)Thinking back to before you were pregnant, would you say you wanted to be pregnant …Sooner 3 (20.0)Later 6 (40.0)Then 6 (40.0)Not at all 0 (0.0)Problems or complications during pregnancy (at time of recruitment)Yes 4 (26.7)No 11 (73.3)Experienced any previous mental health problems (e.g. depression, generalized anxiety, bipolar disorder, etc.)Yes 6 (40.0)No 9 (60.0)Treatment for mental health problemsYes 5 (33.3)No 1 (6.7)No problems with mental health indicated 9 (60.0)History of mental health problems in familyYes 4 (26.7)No 11 (73.3)Bayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 Page 4 of 11Helping to talk it throughWomen, who preferred this approach, expressed a need toensure that they were communicating their emotionsclearly and “getting their point across” so their care pro-vider was able to evaluate their condition more accurately.They noted that unlike a questionnaire with close-endedquestions, an in-person conversation would provide anopportunity to explain their concerns more thoroughlyand to elaborate for further clarification if necessary. Anulliparous woman commented:“Sometimes it’s just multiple choice and none of themreally feel like they fit and I don’t want to have to findan answer or to write it to explain myself either itbecomes really long or I’m not sure that I’m gettingmy point across. So I think talking to someoneverbally whether it’s on the phone or in person –there’s no difference – at least I feel confident thatthey get my point across and they can properlyevaluate.” (Participant 6)Some participants also indicated that this approachwould help them understand their own feelings. A22 year-old nulliparous woman commented:“I would be an in-person kind of, yeah. Becausewhen you start chatting you realize things that youwouldn’t when you write it down. Umm I feel likeyou … like when the feelings start coming out thatyou don’t realize when you’re talking in person. Sodefinitely I think that it’s important to have thosekind of conversations and make them personal.”(Participant 11)Allowing the instant exchange of feedbackParticipants favoring this approach indicated thatthrough a communicative screening, they would de-rive meaning, gain clarity from sharing their con-cerns, and potentially obtain strategies to addresstheir mental health challenges. Also from some par-ticipants’ quotes, it appeared that this approachwould provide an opportunity for a two-way infor-mation exchange. A nulliparous woman who had ahistory of depression and described herself asskeptical with regard to trusting people reported thatactually talking to a person and receiving non-verbaland social cues would also help her to know theprovider better when discussing her mental healthconcerns. She commented:“I’m kind of old fashioned when it comes to this stuff.I’m about social interaction with an actual person asopposed through a computer. I find that veryimpersonal so for me, its just like, the actual talkingto a person and being able to see social cues andyou know the non-verbals and things along that lineso you get to know a person a little bit better,easier…its just nice to get that feedback.” (Participant 3)Barriers to communicating mental health concernsWe asked participants whether they would share theirmental health concerns with their maternity care pro-viders. Some participants reported that they wouldcommunicate these concerns and would seek supportif they needed it; however, others indicated that theywould not. The reasons for not sharing mental healthconcerns with a health care provider were classifiedinto internal (personal) barriers and external (struc-tural) barriers.Internal barriersInternal barriers included a lack of emotional literacy,fear of disclosure outcomes, feeling uncomfortable to beseen vulnerable, and perception about the role of pre-natal care provider.Lack of emotional literacyA lack of emotional literacy that is the knowledgeabout mental health issues and treatments [32] im-peded communicating mental health concerns. Twosub-themes emerged for this theme including notrecognizing the symptoms and not understandingthe emotions.Not recognizing the symptoms According to theinterviews, some women did not realize they hadmental health problems due to unfamiliarity withsymptoms of mental health issues. A participant whowas expecting her third child noted that she was notaware that she was struggling with anxiety until shefilled out a screening form at a vaccination clinic.This 37-years-old woman indicated that it was thefirst time that she could find a word to describe howshe was feeling:“It was the first time that I could find a descriptiveword that could match how I was feeling. It was like‘panicky to take him somewhere or drive himsomewhere’ and just in general checking up aroundhim during the night and things like that… Irecognized that I was panicky versus concernedthen I realized that I had you know my feelingswere coming from a place of fear versus a placethat’s probably more normal.” (Participant 7)Not understanding the emotions Most women reportedthat if they were not able to understand emotions them-selves they would not communicate it. A 22-year-oldBayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 Page 5 of 11single mother with an unplanned pregnancy explainedthat she was not ready to share her feelings because shewanted to keep her emotions inside until she had a bet-ter understanding of them. She commented:“I think I was just so emotional that it was just betterto keep it all inside and figure out and try tounderstand what was going on and try to understand… I just felt that like my emotions were all over theplace, all the time. And I just didn’t understandthem. I’m probably still like that.” (Participant 11)A number of women also reported not communicatingtheir emotional struggles because they were uncertainwhether these concerns were normal and whether otherwomen also experience these struggles.Fear of disclosure outcomesParticipants’ explanations reflected that the fear of dis-closure outcomes hindered communicating their emo-tional concerns with the provider. Two sub-themes wereidentified for this theme including fear of being judgedand fear of the consequences.Fear of being judged Fear of being misunderstood andjudged emerged as reasons for not sharing concerns.These fears were particularly evident when the womendid not know whether their experiences were normal. A32-year-old pregnant woman who was suffering fromobsessive thoughts of harming her toddler explained thatbecause the providers did not know her and her valuesas a person, they might misunderstand this information.She explained:“I’d say that I’m a little bit reserved with anybody thatI don’t know especially well… I would say with myhusband I try to be as honest as possible because weneed to know how we’re feeling and I see him everyday and stuff but someone that I just see once a weekor once every month kind of thing, I don’t know what... how they’ll perceive what I’m saying to them orhow they’ll take it as a misunderstanding you know?Like I’m gonna harm somebody like my baby? What ifthey think I’m gonna you know... they don’t know myyou know... they don’t know my personal values andthey don’t know me” (Participant 12)In response to the question regarding how the prenatalcare provider could address this concern, this participantnoted that presenting some examples would be helpful:“Like the doctor [says something] like ‘this is what Ihear from another person’ and... ‘this is what I wasthinking when this mother said this to me’.”(Participant 12)It also appeared that this presentation of real-worldexamples could be helpful for women with mental healthconcerns in general:“Like it’s normal to have these types of feelings andit’s not different than any other type of pregnancy. Ijust want peace of mind and … be able to sleep atnight.” (Participant 15)Fear of the consequences Being reserved and skepticalabout sharing mental health struggles due to fear of po-tential consequences was a reoccurring concept. A 26-year-old woman with a history of anxiety disorders de-scribed communicating emotional concerns with ahealth care provider as talking to “a complete stranger”.She commented:“…Because you have no idea who this person is. Soyou know it’s different than talking to your mom orsister about something. Um not that I’d talk to themabout this but then talking to a complete strangerwhose job is to just sit there and decide somethingabout you.” (Participant 14)A need to know what the care provider would do withdisclosed information and whether it would involve fur-ther communication to clarify the normality of feelingsor more serious social services interventions alsoemerged. The participant with obsessive thoughtsexpressed that she would not share her concerns due tothe uncertainty about the outcomes of this disclosure:“There is that kind of thing where you’ll be conservativekind of thing to discuss with your doctor... because ifyou ask the question and leave it at that like you don’tknow if they’re gonna call social services on me …Like,‘Well, these are normal feelings to have right now’ or…‘How do you feel about that right now because I have acar waiting outside to take your baby away’.”(Participant 12)Feeling uncomfortable to be seen vulnerableSome participants reported being uncomfortable to beseen vulnerable. They perceived revealing emotional prob-lems and asking for help as a sign of weakness. Somewomen explained that it was difficult for them to exposetheir emotions and become emotional. A 32-year-old par-ticipant in her second pregnancy described sharing mentalhealth concerns as “hard” because she did not want to re-veal and expose her emotions:Bayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 Page 6 of 11“It’s a personal feeling kind of thing and sometimesit’s hard to share because you don’t like feeling thatway or you don’t like feeling you know extra weepyand everything. You don’t like exposing youremotions to people right?” (Participant 12)Perception about prenatal care providers’ roleSome participants perceived maternity care providers asresponsible for monitoring only the physical well-beingof the mother and the baby. These women consideredemotions personal matters and reported that they wouldnot communicate their personal problems. An immi-grant multiparous woman indicated that she would feelcomfortable discussing any physical concerns with hermaternity care provider but that she would communi-cate mental health concerns only with trusted familymembers. She commented:“If I talk … it would be in a professional way, medicalthings like that. But personal things, I don’t think so. Idon’t think so. It’s much better to talk to a person youcan trust, loved ones probably.” (Participant 2)Structural barriersStructural barriers included the lack of continuity ofcare, depersonalized care, lack of feedback, and unfamiliaritywith/uncertainty about the availability of support.Lack of continuity of careSeveral pregnant women reported that seeing one pro-vider at each prenatal care visit would make them feelmore comfortable sharing emotional concerns. Accord-ing to participants, the lack of care continuity hinderedtheir building a rapport with the provider to communi-cate sensitive issues. A 22-year-old expectant singlemother commented:“If I had the same … [provider] that came in to everysingle time might inspire me to talk about it [emotionalconcerns].” (Participant 11)Trust and sincerity were emerged as important consid-erations when sharing emotional concerns. In responseto the question regarding which qualities would encour-age the respondent to share mental health concerns, amultiparous woman stated: “somebody… I can trust...that understands your situation”. A nulliparous womancommented: “just sincerity.”Depersonalized careSome participants, particularly first-time mothers, re-ported experiencing an unwelcoming environment. Thislack of individual-centered care and medicalized prenatalcare discouraged communication around mental healthconcerns. Feeling like “just another number” was an ex-pression used by a 29-year-old first-time mother with ahistory of depression. She commented:“Its their job and they know their job well. Its just thatin your first appointment if they could make it a littlebit more personalized as opposed to you’re justanother number coming in… but like my initialappointment here and meeting with the nurse wasn’tlike ‘hey how are you, how are you doing?’ its just like‘I’m gonna ask you a whole bunch of questions andyou’re gonna tell me as fast as you can. Have you hadthis, this, this, this and that?’ and I’m just like ‘uh hi. Idon’t even know what you guys do here. This is myfirst pregnancy’. So it would have been a whole lotnicer to be like … ‘I understand that this is your firstpregnancy, have you ever had a history of this?’ andtrying to talk that into it instead of [snaps fingers 4times] and out. Goodbye. That would have beenbetter.” (Participant 3)Lack of feedbackSeveral participants who had previous experiences withscreening programs or mental health care services indi-cated that not receiving feedback discouraged them fromengaging or further sharing their mental health con-cerns. A multiparous woman with history of anxiety dis-orders stated:“Well, I think that I should talk to somebody but a lotof time you don’t get a lot of feedback back on it so Idon’t know if there’s any growth you actually couldsometimes get out of it. I would only learn to do stuffif you get feedback and I’m hoping that these peoplewho I’m hoping to see will give me feedback on it.Like here are some mechanisms for change or copingor something but a counsellor when you go and sitwith them, they really just don’t. They really just listenand don’t give anything back so it’s hard because youcome away with feeling bad about yourself and nomechanisms of change so...” (Participant 14)A nulliparous women with history of panic disorderscommented:“Well they’re not really like ... they’re more um it’sjust quick in “how are you doing?” and stuff like that“I’m ok” and yeah. It’s not really beneficial, it’s justmore to make sure that my head’s in the right place Iguess.” (Participant 9)A need to review screening results and receive feed-back or have a follow up appointment after an initialscreening also emerged. A participant who had realizedBayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 Page 7 of 11she was suffering from anxiety after completing ascreening form described that not receiving feedbackafter screening made her feel lost in the system:“I think I was expressive of what I was going throughand emotionally distressed and a nurse probablyshould have picked up on it. I remember there was aquestionnaire that I filled out and I think it wouldhave shown that I had post-partum anxiety… and itnever was reviewed so uh I guess it was my chancethen to ask for help. I guess I was just waiting forsomebody to ask you know, ‘how are you feeling aboutthis? Or would you like support in this area?’…I waswaiting for it to be uncovered but no one uncoveredit…. It’s really up to women to take up their ownhealthcare into their hands and seek the help theyneed because nobody’s really looking after you, I find.”(Participant 7)Unfamiliarity with/uncertainty about the availability ofsupportNot knowing what support would be available if a diag-nosis were ascertained also hindered the disclosure. Apregnant mother who was struggling with uncertaintyabout the normality of her feelings noted that if she real-ized her thoughts were not normal, she would need “im-mediate support.” She commented:“... if it’s not normal there has to be immediatesupport rather than “gee I’ll go and sleep on this andoh, my gosh I’m not... I’m not a normal person”.There has to be support... like from what I’ve heardthis is not a normal feeling so right now we need youto…” (Participant 12)Women’s and their partners’ unfamiliarity with avail-able resources and how to receive support for mentalhealth problems also emerged. A 38-year-old multipar-ous woman who was not aware that she was strugglingwith anxiety in her previous pregnancy stated that al-though her partner and friends were aware of her strug-gles, they did not know how they could identify withand support her:“I think I saw a lot of friends recognize that I wasstruggling but didn’t quite know what to do. I know itwas difficult for my husband to see me go through itand he didn’t know quite what to do. So in thatinstance I wish I would have gotten more support.”(Participant 7)DiscussionThe method of administering screening tools is a com-ponent of acceptability for perinatal mental healthscreening [19]. Acceptability refers to the willingness tocomplete or administer an instrument or conduct a pro-cedure. There is no uniform psychometrically tested toolto measure acceptability [19]. The research on the ac-ceptability of perinatal mental health screening hasmainly focused on examining specific types of screeningtools. With few exceptions, evidence on the impact ofscreening settings (e.g., home, clinic) on women’s com-fort [33, 34] or the method of screening is scarce [21,35]. In Drake et al., postpartum women described onlinescreening as an unintimidating and easy approach toscreen for depression that can help in overcoming thechallenges of fear and stigma. In our study, while somewomen favored an online approach as a venue to sustainpersonal space, others brought up concerns regardingthe safety of online screening, time constraints, and alack of human interaction. Kingston et al. reportedpaper-based screening as the most comfortable andtelephone-based screening as the least comfortable ap-proaches for women [21]. In our study, some partici-pants who preferred “paper-based” screening explainedthat they did not want to become emotional in the pres-ence of others. Two women explained that this methodwould give them some time to think and provide “thebest answer.” One of these women was suffering fromintrusive thoughts of harming her toddler and did notreport a previous mental health problem. In our study,women with known mental health issues who had previ-ously interacted with mental health specialists preferredan interactive and in-person screening approach in orderto receive feedback. These findings may suggest thatwomen with undiagnosed mental health conditions maychoose a less interactive approach and be reluctant todisclose their struggles. Several sources of uncertaintyregarding the normality of symptoms, potential conse-quences of disclosure, and availability of immediate sup-port contributed to the concealment of mental healthproblems among our participants. Chew-Graham et al.(2009) found that women described making a consciousdecision about whether to disclose their feelings to theirhealth care providers [36]. Williams et al. (2016) also re-ported that while many women would share their emo-tional issues with their care providers, some would not[20]. Kingston et al. (2015) found that 21 % of womenindicated that they could be only somewhat or not at allhonest during screening mainly due to fear that theirprovider would view them as bad mothers [22]. Womenin our study reported that a trust relationship and anunderstanding attitude of the care provider would en-courage them to share their concerns. For some women,continuity of care was important in building the trust re-lationship. A nonjudgmental attitude of the care pro-vider was reported to help women disclose theiremotional problems [20].Bayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 Page 8 of 11Uncertainty about potential implications after sharingtheir thoughts or feelings regarding poor mental healthwas identified as an important barrier for disclosure byparticipants. A recent study, similar to ours, found thatmost participants were unsure about the kind of helpthat was available and some reported this as a reason forwithholding their true feelings [20]. Unclear pathwaysand protocols may also impact health care providers’ at-titudes towards mental health screening [36]. Chew-Graham et al. (2009), in a qualitative study, found thatmaternity care providers used strategies to hinder dis-closure and were reluctant to make a diagnosis of post-natal depression, due to the lack of referral services forfurther assessment and treatment [36].Some participants in our study stated that they wouldbe more comfortable to share mental health issues withfamily members and significant others. This is consistentwith previous quantitative research [37], particularlyamong those in minority groups [38]. In a qualitativestudy, pregnant women reported that during their pre-natal care visits, they expected the assessment of thephysical progress of pregnancy and the development oftheir baby but not their emotional health. This lack ofclarity about the role of prenatal care providers madesome women feel as if they were “being watched” andfeel uncomfortable [39].In our study, women who initially communicated theirmental health concerns voiced a continuous need to re-ceive feedback throughout the process. According towomen, receiving feedback was a vital component notonly for communicating but also for sustaining their en-gagement throughout the follow-up process. A lack offeedback was discouraging for our participants as it wasviewed as not offering any mechanism for addressingmental health problems.Mental health literacy is defined as knowledge aboutmental health symptoms, risk factors, causes, and treat-ments [32]. Some participants reported that they did notcommunicate their emotional challenges because theywere not able to understand their feelings. Severalwomen in our study also reported that they were notable to differentiate normal and non-normal symptomsdespite doubting their mental well-being. Thus, theytried to understand these feelings on their own or hopedthat the symptoms would be relieved by taking it “day-by-day”. The findings also highlighted the educationalaspect of screening that helped one of the participantsrealize she was struggling with anxiety. In a recent study,Fonseca (2015) found that the most frequently identifiedbarriers to women’s seeking professional help were re-lated to the level of mental health literacy, followed bypractical and structural barriers, such as time and costconstraints, and attitudinal barriers, such as shame andstigma. They reported that over half of the women whoscreened positive for depression during the perinatal periodwere unable to recognize the presence of an emotional orpsychological problem [14]. Raising the level of public men-tal health literacy can contribute to early recognition andappropriate intervention-seeking behaviors [32].Due to the paucity of qualitative evidence on themethods of perinatal mental health screening, one of thestrengths of this study is its exploratory nature, whichenabled us to understand the underlying reasons forscreening preferences. Another strength of the study wasconducting two interviews during pregnancy. However,our study has several limitations that require consider-ation when interpreting and applying the findings. Thisis a small study in an urban geographical area. Thus, thefindings might not be applicable for all settings. The ma-jority of participants in our study were educated, Cauca-sian, and partnered, and some were recruited from amental health clinic; these characteristics may also limitthe transferability of the findings. To enable clinicians todetermine the applicability of the findings to their popu-lations, we provided details of participants’ characteris-tics in two tables and throughout the paper.ConclusionsWhile the benefits of screening for perinatal mentalhealth outweigh the harms [15], several considerationsneed to be taken into account for successful screeningprograms. In the present study, women with knownmental health issues preferred an in-person approachwhile women without a known mental health historywho struggled with emotional problems were inclinedtowards less interactive approaches and reported a reluc-tance to share their concerns. This is an important find-ing, as these women are the central target of screeningprograms but might be missing in the current screeningsystem. Clarity around the outcomes of communicatingmental health concerns and the availability of immediatesupport were perceived by the women as essential forsharing mental health concerns. The overlaps betweensome themes identified for the reasons behind a pre-ferred screening approach and barriers reported bywomen to communicate mental health concerns suggestthat having options may help women overcome some ofthe current disclosure barriers and enable them to en-gage in the process. For example, a lack of trust and notknowing the provider was perceived as a barrier bywomen. On the other hand, women described that anin-person interactive screening approach would givethem an opportunity to know their provider better andmake them more inclined to share their concerns. Theseresults may have implications in settings where the con-tinuity of care is not feasible. Based on these findings,the disclosure of mental health struggles requires theavailability of multiple screening approaches to addressBayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 Page 9 of 11the needs of all women, continuity of care to establishtrust, clarity around the outcomes of communicatingmental health concerns, availability of immediate sup-port and a system of care with clear pathways to helpwomen move from providing “the best answer” to pro-viding an authentic answer. A culture of maternity carein which asking for help to clarify or understand emo-tional concerns is perceived safe by women should bepromoted to reduce fear of being judged or social inter-ventions. Furthermore, increasing public knowledgeabout symptoms of perinatal mental health problemsand what is considered “normal” can encourage help-seeking behaviors.AcknowledgementsDr. Bayrampour was supported by the Alberta Innovates - Health Solutionspostgraduate fellowship during this study.FundingThis study was supported by a research allowance from Faculty of Medicine,University of Calgary.Availability of data and materialsCoding scheme is available from the corresponding author on reasonablerequest.Authors’ contributionsHB and ST conceptualized and designed the study. HB and CS conductedinterviews. HB, DM, KB analyzed the data. HB ST DM KB CS and KGcontributed to development of the manuscript. All authors read andapproved the final manuscript.Ethics approval and consent to participateThe study was approved by the University of Calgary’s Conjoint Health ResearchEthics Board (E-24854) on October 1st 2012 and participants signed writteninformed consent form.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.Author details1Department of Family Practice, Midwifery Program, University of BritishColumbia, 3rd Floor David Strangway Building, 320–5950 UniversityBoulevard, Vancouver, BC V6T 1Z3, Canada. 2Alberta Health Services andAssociate Professor in Faculty of Nursing and Department of CommunityHealth Sciences Cumming School of Medicine, University of Calgary, CalgaryT2W 3N2, Canada. 3Professor in Faculty of Nursing, University of Calgary,Calgary T2N 1N4, Canada. 4Department of Community Health Sciences,Cumming School of Medicine, University of Calgary, Calgary T2N 1N4,Canada. 5Midwifery Program, Department of Family Practice, Faculty ofMedicine, University Boulevard, Vancouver, BC V6T 1Z3, Canada. 6AlbertaInnovates Health Solutions Health Scholar and Professor in Department ofPediatrics and Community Health Sciences, University of Calgary, Calgary T3B6A8, Canada.Received: 13 March 2017 Accepted: 15 September 2017References1. 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Digging over that old ground: anAustralian perspective of women's experience of psychosocial assessmentand depression screening in pregnancy and following birth. BMC WomensHealth. 2013;13:18.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Bayrampour et al. BMC Pregnancy and Childbirth  (2017) 17:339 Page 11 of 11


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