"Magic happens when women come together": An exploration of perinatal mental health and the role of social relationships in supporting mothers

Perinatal mental health difficulties are considered a key global health concern and if undetected and untreated, can negatively affect maternal wellbeing and infant development. This thesis explores women’s experiences of perinatal mental health difficulties and what supports them in this period, both in the UK and in a range of Low- and Middle-Income Countries, along with accounts from clinicians working in perinatal services. Part one is a systematic review and meta-synthesis of qualitative studies which explore women’s experiences of perinatal psychological distress in Low- and Middle-Income Countries. A systematic search found 20 studies, the findings from which were synthesized using thematic analysis. The review discusses salient themes and how learning from these may be used to inform services providing support for women experiencing perinatal psychological distress both in Low- and Middle-Income Countries and potentially in other socio-cultural settings. Part two is a qualitative study seeking to understand mothers’ experiences of accessing, and clinicians’ experiences of providing, perinatal mental health services in the UK. Thirteen mothers and the same number of clinicians were interviewed about their experiences. The interview transcripts were analysed using thematic analysis. Themes relating to barriers and facilitators to mothers’ disclosing their mental health difficulties and concerns relating to the parent-infant relationship were derived, with a thread of the importance of social support and relationships being key. The findings support existing literature on mothers’ experiences of perinatal services as they highlight the social nature of the perinatal period, the role of relationships across system levels and the importance of compassionate, non-judgmental support in order to facilitate access to services. The findings have implications for service planning and delivery. 4 Part three is a critical appraisal of the research process, examining the researcher’s perspective through personal reflexivity and the impact of this on the research. Contextual factors of power and privilege, along with the context of the COVID-19 pandemic on the present thesis are discussed

Factors that influenced utilization of antenatal and immunization services in two local government areas in The Gambia during COVID-19: An interview-based qualitative study.

INTRODUCTION: Evidence is being consolidated that shows that the utilization of antenatal and immunization services has declined in low-income countries (LICs) during the COVID-19 pandemic. Very little is known about the effects of the pandemic on antenatal and immunization service utilization in The Gambia. We set out to explore the COVID-19-related factors affecting the utilization of antenatal and immunization services in two Local Government Areas (LGAs) in The Gambia. METHODS: A qualitative methodology was used to explore patients' and providers' experiences of antenatal and immunization services during the pandemic in two LGAs in The Gambia. Thirty-one study participants were recruited from four health facilities, applying a theory-driven sampling framework, including health workers as well as female patients. Qualitative evidence was collected through theory-driven semi-structured interviews, and was recorded, translated into English, transcribed, and analysed thematically, applying a social-ecological framework. RESULTS: In our interviews, we identified themes at five different levels: individual, interpersonal, community, institutional and policy factors. Individual factors revolved around patients' fear of being infected in the facilities, and of being quarantined, and their anxiety about passing on infections to family members. Interpersonal factors involved the reluctance of partners and family members, as well as perceived negligence and disrespect by health workers. Community factors included misinformation within the community and mistrust of vaccines. Institutional factors included the shortage of health workers, closures of health facilities, and the lack of personal protective equipment (PPEs) and essential medicines. Finally, policy factors revolved around the consequences of COVID-19 prevention measures, particularly the shortage of transport options and mandatory wearing of face masks. CONCLUSIONS: Our findings suggest that patients' fears of contagion, perceptions of poor treatment in the health system, and a general anxiety around the imposing of prevention measures, undermined the uptake of services. In future emergencies, the government in The Gambia, and governments in other LICs, will need to consider the unintended consequences of epidemic control measures on the uptake of antenatal and immunization services

Social determinants of mental health of pregnant women in Nepal: a sequential exploratory mixed methods research study

Women during pregnancy are at risk of developing poor mental health, and it is one of the major concerns in low- and middle-income countries, including Nepal. This PhD study employed a sequential exploratory mixed methods approach to understand social determinants of the mental health of pregnant women by exploring their lived experiences within the socioeconomic and cultural context of Nepal, availability and accessibility of health services and social support, and how these aspects impact their mental health. Data collection included in-depth interviews with eight key informants and twenty pregnant women, followed by a survey with one hundred and twenty-eight pregnant women. The study used purposive sampling to recruit pregnant women through a district hospital in an Eastern region of Nepal, and key informants were recruited based on their experiences. Thematic analysis was used for qualitative data, and descriptive and inferential statistics were applied to analyse quantitative data. The theoretical underpinnings of the study were based on ecological theory and intersectionality. Qualitative findings highlighted the importance of social support for pregnant women’s mental health and reported a lack of structured social support during pregnancy, and this was prominent for those women from poorer socioeconomic backgrounds. Participants also raised concerns about the availability and accessibility of maternal health services that did not meet their mental health needs, mainly due to limited care provision, overcrowded hospitals, and shortages of skilled health professionals. The lived experiences of Nepalese pregnant women highlighted how they saw themselves within the sociocultural and economic context of Nepal and its impact on their mental health. In particular, the analysis highlighted how sociocultural factors intersect with individual and economic circumstances to present compounded risks of poor mental health for many pregnant women. The quantitative findings suggested that there was an association between poor mental health and experience of unsuccessful pregnancy, receiving social support other than husband during pregnancy, and early age of pregnancy. The study findings suggested that a better and more in-depth understanding of various social determinants of mental health are important prerequisites in meeting the mental health needs of women during pregnancy and to design appropriately tailored maternal health services

The accessibility and acceptability of a brief “IPT-informed” intervention for pregnant first-time mothers in the context of the COVID-19 pandemic

Introduction: This thesis project trialled a brief “IPT-informed” intervention with pregnant first-time mothers during the COVID-19 pandemic. Aims: The aims of the brief “IPT-informed” intervention were to 1) educate participants as to the symptoms of ‘baby blues’ and PND 2) provide participants with a brief overview of IPT as an intervention and the theoretical concepts underpinning it 3) help participants map out their social network through using the ‘interpersonal inventory’ 4) assist participants in anticipating the transitions to motherhood. The research questions were 1) Is this brief group intervention accessible and acceptable for expectant and new mothers? 2) Does this brief group intervention have any adverse effects for expectant and new mothers? 3) Could this trial provide evidence for a larger ‘preventative’ trial in the future? Method: The design of the study was a mixed-methods, uncontrolled, longitudinal feasibility study. Twelve first-time mothers who were 6+ months pregnant took part in a brief “IPT-informed” group intervention prior to birth. All twelve mothers also took part in an individual follow-up session and brief semi-structured interview around two to three months after birth. Participants completed the EPDS and MSPSS at the time of the group (T1) and at follow-up (T2). The groups and individual follow-ups were recorded and transcribed. Comparison of means and individual levels of change were used to analyse the quantitative data, alongside ‘process evaluation’ data (Moore et al., 2014). Thematic analysis was used to analyse the qualitative data. Results: Overall, a comparison of means found that the EPDS scores remained relatively stable from group (M= 6.83, SD= 3.35) to individual follow-up (M= 6.91, SD= 3.91). Similarly, scores on the MSPSS remained relatively stable from group (M= 6.18, SD= .63) to follow-up (M= 6.17, SD= .58). Individual levels of change were also explored. A ‘process evaluation’ was completed which included sample, reach, drop-out rates, and implementation/ fidelity of the intervention. Four higher-order themes and several sub-themes were identified in the qualitative analysis; 1) “This is about you, you are important” 2) “Leaving one kind of life and starting another one” 3) A search for connection, 4) Changes to interpersonal relationships. Discussion/ conclusion: This study is unable to conclude whether the brief “IPT-informed” intervention is accessible and acceptable to women in the perinatal period. Whilst mothers who took part reportedly benefitted from and enjoyed the intervention, the study identified several limitations and refinements that are required for future studies to address to adequately assess the accessibility and acceptability of the brief “IPT-informed” intervention for perinatal women. Generally, the intervention does not seem to have any adverse effects for expectant and new mothers. However, individual levels of change did show a slight deterioration for four mothers on their EPDS scores from T1 to T2. Due to the design of the study, it is difficult to deduce whether this was due to the intervention and whether the intervention prevented more significant deterioration amongst participants. Evidence from this study highlights that a further pilot/feasibility study is required addressing some of the refinements and limitations noted in the results and discussion, prior to a larger scale RCT examining efficacy of the intervention on the prevention on PND

Antenatal depression in Sri Lanka: a qualitative study of public health midwives’ views and practices

Background Almost all pregnant people in Sri Lanka receive antenatal care by public health midwives. While there is strong infrastructure in Sri Lanka for postpartum mental health care, the current practices within antenatal mental health care have not been externally evaluated. The purpose of this study is to investigate the current clinical guidelines and experiences of how public health midwives diagnose and treat antenatal depression. Methods We conducted in-depth interviews with 12 public health midwives from four antenatal clinics in the Bope Poddala division in Galle, Sri Lanka and reviewed and extracted information on antenatal depression from clinical guidelines. Data was collected in Sinhala and translated into English. We used applied thematic analysis and worked closely with our local team to ensure data trustworthiness. Results Midwives (n = 12) reported varying degrees of knowledge on antenatal depression and did not have standardized diagnosis patterns. However, they were very consistent in their clinical practices, following guidelines for referral and follow-up of case management, building strong rapport. In their practice, midwives continue to face challenges of lack of human resources and high stigma around mental illness. They suggested that that care could be improved with use of a standardized diagnostic tool, and easier access to specialist care. We found the clinical guideline on the diagnosis and treatment of antenatal depression is lacking key details on symptoms for appropriate diagnosis, but it clearly guides on how to navigate treatment. Conclusions Public health midwives are following the clinical guideline to refer pregnant women who need intervention for antenatal depression and follow-up for case management. However, there is a need for more specific and context-relevant guidelines, especially for diagnosis of antenatal depression. Formative research is needed to explore intervention strategies to improve antenatal depression management in Sri Lanka.publishedVersio

Eliminating HIV transmission through breast milk from women taking antiretroviral drugs

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Exploring modifiable risk factors for premature birth in the context of COVID-19 mitigation measures: A discussion paper

© 2020 Elsevier Ltd. All rights reserved. This manuscript is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Licence http://creativecommons.org/licenses/by-nc-nd/4.0/.During the COVID-19 pandemic, parents with sick or premature babies have faced challenges following admission to a neonatal unit due to the imposed lock-down restrictions on social contact, hospital visitation and the wearing of personal protective equipment. The negative short-term impact on neonatal care in relation to the prevention of close proximity, contact and bonding between parents and babies is potentially significant. However, an interesting finding has been reported of a reduction in premature birth admissions to the neonatal intensive care unit during the pandemic, raising important questions. Why was this? Was it related to the effect of the modifiable risk-factors for premature birth? This discussion paper focuses on an exploration of these factors in the light of the potential impact of COVID-19 restrictions on neonatal care. After contextualising both the effect of premature birth and the pandemic on neonatal and parental short-term outcomes, the discussion turns to the modifiable risk-factors for premature birth and makes recommendations relevant to the education, advice and care given to expectant mothers.Peer reviewe

Exploring ethnic minority women’s experiences of maternity care during the SARS-CoV-2 pandemic::a qualitative study

OBJECTIVE: To explore the experiences of pregnancy, childbirth, antenatal and postnatal care in women belonging to ethnic minorities and to identify any specific challenges that these women faced during the SARS-CoV-2 pandemic. DESIGN: This was a qualitative study using semistructured interviews of pregnant women or those who were 6 weeks postnatal from Black, Asian and minority ethnic backgrounds. The study included 16 women in a predominantly urban Scottish health board area. RESULTS: The finding are presented in four themes: ‘communication’, ‘interactions with healthcare professionals’, ‘racism’ and ‘the pandemic effect’. Each theme had relevant subthemes. ‘Communication’ encompassed respect, accent bias, language barrier and cultural dissonance; ‘interactions with healthcare professionals’: continuity of care, empathy, informed decision making and dissonance with other healthcare systems; ‘racism’ was deemed to be institutional, interpersonal or internalised; and ‘the pandemic effect’ consisted of isolation, psychological impact and barriers to access of care. CONCLUSIONS: This study provides insight into the specific challenges faced by ethnic minority women in pregnancy, which intersect with the unique problems posed by the ongoing SARS-CoV-2 pandemic to potentially widen existing ethnic disparities in maternal outcomes and experiences of maternity care