Semi-structured interviews had been performed with 37 healthcare employees who offered care to pregnant ladies or managed workers offering the care (Desk 1). Nearly all of the healthcare employees had been feminine (91.9%), older than 35 years (75.7%), employed by an NPO (56.8%) and labored at an MOU (67.5%).
Desk 1 Demographic traits of healthcare employees (n = 37). Full measurement desk
100 and fifty-six pregnant ladies had been screened for signs of CMDs and experiences of home violence. Thirty-eight ladies (24%) screened optimistic and had been invited to take part in a semi-structured interview (Desk 2). Nearly all of ladies interviewed had been 26 years or older (55.2%) and had been unemployed (44.7%). Virtually all the ladies interviewed scored ≥ 2 on the psychological misery questionnaire (94.7%), whereas 29% (n = 11) scored ≥ 2 on the home violence questionnaire.
Desk 2 Demographic and medical traits of pregnant ladies (n = 38). Full measurement desk
The facilitators and limitations recognized by healthcare employees and pregnant ladies have been organised into three classes: system-level, provider-level and patient-level (Desk 3). The facilitators and limitations will likely be introduced underneath two most important headings consultant of the phases alongside the care pathway: (1) detection, and (2) referral and remedy.
Desk 3 System-, provider- and patient-level facilitators and limitations to detection, referral and remedy for frequent psychological issues (CMDs) and experiences of home violence. Full measurement desk
Detection
Instruments for detection
Various charges of antenatal psychological well being and home violence screening had been reported throughout the 4 services. The Perinatal Psychological Well being Undertaking (PMHP)41 supported one of many services by offering an on-site screening and counselling service to all pregnant ladies attending the MOU for his or her first antenatal go to. As a part of the service, a well being promotion officer screened all pregnant ladies at their first antenatal go to for signs of CMDs and the dangers thereof. Girls who screened optimistic had been referred to the on-site counsellor. The PMHP reported detecting many ladies with signs of melancholy and anxiousness—“I suppose six out of ten” (Well being Promotion Officer), whereas the opposite services detected fewer ladies—“I see two or three on a weekly foundation” (Well being Promotion Officer), and “It’s very uncommon…” (ANC Nurse). Throughout information assortment, an up to date model of the Maternity Case Document (MCR)42—the nationwide stationery used to report all features of the being pregnant—was launched. The up to date MCR contained a psychological well being screening tool29 (the identical questionnaire used on this examine to detect psychological misery), to be administered by ANC nurses on the sufferers’ first clinic go to.
Detecting ladies with experiences of home violence was much less frequent in all services. Healthcare employees reported that they didn’t particularly enquire about home violence and solely detected it when a bodily examination revealed indicators of bodily abuse, or when the lady voluntarily disclosed the data. One ANC nurse reported detecting ladies who had been abused “twice or thrice a month”, whereas an MOU supervisor reported that detecting ladies who had been abused was “not typically, however we do”. A well being promotion officer admitted that if she particularly enquired about home violence, she would detect many ladies as “home violence is so excessive right here on this space”.
Perceived significance of detection
All aside from one of many facility-based healthcare employees interviewed felt that it was necessary to display screen pregnant ladies for psychological misery and experiences of home violence. One psychological well being nurse made the hyperlink between psychological misery that was left untreated and the results to the mom and youngster by saying: “I feel it is essential that these items must be picked up as a result of it may solely worsen when the infant is born”. Many healthcare employees felt that screening ought to happen in any respect clinic visits. One ANC nurse talked about that CMDs might happen at any level through the perinatal interval, not simply when ladies attended the MOU for the primary time as psychological misery “can begin any time throughout being pregnant”.
Perceived lack of confidentiality
Whereas nearly all of pregnant ladies reported that they might be completely happy to reveal their emotions and experiences of home violence, a number of ladies expressed their considerations concerning confidentiality. One pregnant lady was particularly involved about whether or not such delicate info would stay confidential by saying: “… particularly in a neighborhood the place everybody is aware of everybody, I don’t belief them [nurses]”. Equally, some healthcare employees expressed doubts about whether or not the pregnant ladies would disclose their emotions by saying: “… bear in mind folks put up a pleasant face hey, they don’t need folks to understand how they feeling” (Breastfeeding Counsellor).
Within the context of the 4 services, many ladies had been financially depending on their companions, and had been involved about disclosing their experiences of home violence. A breastfeeding counsellor defined why ladies who had been abused not often spoke about their experiences by saying: “A few of them are ashamed that they are truly having to inform you this”, whereas a pregnant lady referred to the potential penalties of revealing her abuse by saying “… so we’ve to suppose twice earlier than you do one thing that you will remorse”.
Heavy workload
All ANC nurses had been involved in regards to the period of time it took to evaluate sufferers’ psychological well being as their heavy workload and enormous affected person numbers allowed them restricted time with every affected person. One ANC nurse highlighted her heavy workload in relation to her position as a midwife by saying: “I am unable to [screen all patients] as a result of now it is gonna take me a very long time… you then fear, I have to see the subsequent affected person.…. so I will not be giving a lot time to her. I’ll solely simply be very…simply so, simply on the highest”. As well as, ANC nurses reported feeling involved that they might not have the ability to present a complete session if that they had the added duty of asking ladies about their psychological well being. One ANC nurse selected to attend for sufferers to say that they had been feeling distressed, as an alternative of administering the screening device to all sufferers—“if she’s not gonna ask you or inform you about her downside you then oversee that—you overlook that, as a result of she seems to be completely happy, she’s not wanting aggravating.” Most of the ANC nurses had been additionally involved in regards to the period of time it took to comprise a affected person who felt distressed on account of administering the screening device. One ANC nurse mirrored on her experiences by saying: “generally they are going to begin opening up after which it is an issue. You open a can of worms. Trigger these questions are thought-provoking.…in the event that they’re gonna begin crying…after which for me it sounds impolite to simply okay, I am gonna ship you to ….”
Discomfort with psychological well being points
Many ANC nurses felt uncomfortable discussing psychological well being points with sufferers. They considered themselves as clinicians who had been primarily accountable for the bodily well-being of the pregnant lady and her foetus, and that they weren’t educated to adequately handle psychological well being points. One ANC nurse described the discomfort she skilled when discussing points associated to psychological well being by saying: “I can speak and every little thing however there is a level the place proper, I am not educated for this … I do not need to soak up a lot as a result of it additionally takes a lot out from you”. Different healthcare employees had been involved that they weren’t educated to handle ladies who screened optimistic—“for those who probe and also you ask these three questions [the screening tool], what do you do if the reply is sure?” (ANC Nurse).
Referral and remedy
Lack of availability of referral pathways
Referral pathways diversified throughout the 4 services and trusted the difficulty requiring referral. Sufferers with melancholy or anxiousness had been referred to the psychological well being nurse, a social employee, a registered psychologist (if obtainable) or to the district hospital, whereas those that felt suicidal had been referred to the psychological well being nurse, a medical officer, the trauma unit or to a registered psychologist. Girls who reported experiencing home violence had been most frequently referred to the social employee, if one was obtainable. Nonetheless, specialists equivalent to social employees, psychological well being nurses and registered psychologists carried a heavy workload and will typically solely see ladies who had been referred a number of weeks later. Whereas some healthcare employees had been conscious of the referral pathway of their facility, many weren’t. One lay healthcare employee voiced her uncertainty by saying: “I don’t even generally know the place to refer the moms to” (HIV Counsellor). Nearly all of pregnant ladies had been additionally unaware of tips on how to entry psychological well being care, or whether or not it was obtainable on the healthcare services.
Perceived significance of counselling
Each healthcare employees and pregnant ladies thought that offering a counselling service was necessary. A healthcare employee expressed her ideas on the significance of counselling by saying: “… many ladies who’re untreated, or undiagnosed or not caught within the system do find yourself afterward in life right here at psychiatry and even with worse signs and now it isn’t solely affected themselves however now additionally the infant after its being born” (Psychological Well being Nurse). Equally, a pregnant lady agreed that counselling was necessary by saying: “I feel it could be good, sure, as a result of speaking about it makes you are feeling significantly better and for me speaking to a stranger is significantly better than speaking to those that is aware of you”.
Cultural beliefs and stigma
Whereas the significance of offering a counselling service was highlighted, healthcare employees additionally identified that many ladies who had been referred for psychological well being counselling, declined the supply. One ANC nurse defined that psychological well being points had been stigmatised in the neighborhood and that sufferers had been involved that they might be branded as “…mad for those who go for counselling”. A lay healthcare employee defined that the neighborhood was very small, and that sufferers had been involved that “… they [neighbours] have a look at others they usually level fingers” (CHW).
Healthcare employees blamed the normalisation of psychological and bodily abuse in the neighborhood for the poor uptake of referrals by ladies who had been abused, whereas pregnant ladies attributed their monetary dependence on their associate or husband. Healthcare employees thought that girls who had been abused believed that the abuse was “… how he’s displaying his love” (Breastfeeding Counsellor), or that he “didn’t imply to harm them” (ANC Nurse), or that the ladies “deserve it” (Breastfeeding Counsellor). A pregnant lady verified the normalisation of home violence in her neighborhood by saying: “… it [the abuse] shouldn’t be an enormous factor for them [family and friends], as a result of it occurs quite a bit”. Many pregnant ladies who had been abused felt {that a} referral for psychological well being counselling wouldn’t assist them as it could not have the ability to change their dependence on their abusive companions. One pregnant lady defined that she had accepted her abusive relationship by saying: “Everybody mos [anyway] has their very own issues …”, whereas one other pregnant lady defined that counselling couldn’t change her scenario as “I’m not working. He’s the breadwinner”.
