Women’ Experiences of Seeking and Receiving Psychological and Psychosocial

Interventions for Postpartum Depression: A Systematic Review and Thematic Synthesis of

the Qualitative Literature

Précis

Women with postpartum depression find seeking professional psychosocial support difficult

but ultimately beneficial. Collaborative, integrated and compassionate healthcare is crucial

in improving healthcare for these women.

ABSTRACT

Introduction: Postpartum depression (PPD) is a serious maternal and infant health concern.

The importance of offering effective and acceptable treatments is well recognised,

particularly given the numerous barriers women face in accessing interventions for PPD. The

aim of this systematic review was to synthesise qualitative research exploring women’

experiences of professional psychological and psychosocial support for PPD.

Method: A systematic review of the literature was conducted in April 2017 April 2017 by

searching five electronic databases (CINAHL, MEDLINE, PubMed, Ovid and Web of Science).

Qualitative research studies published in English which explored women’ experiences of

professional psychosocial support for PPD were included, whereas studies exploring

women’s experiences of anti-depressant medication only were excluded. Seventeen papers

met inclusion criteria and were appraised for methodological quality. Data were synthesised

using the interpretive thematic synthesis method.

Results: An overarching theme of ‘the process of help-seeking’ was identified which

encompassed three themes: ‘barriers to seeking and accepting support’, ‘valued aspects of

support’ and ‘outcomes’. Women found the process of seeking help difficult, with several

barriers preventing them from both seeking and accepting professional support. Despite

this, women described the support received as beneficial and particularly valued the

therapeutic relationship. Women reported a) feeling more positive and confident after

receiving a psychological and/or psychosocial intervention and b) experiencing better

relationships with their infant and other family members.

Discussion: Although seeking and accepting professional support for PPD was a difficult

process, women highly valued mental health care support and perceived it as beneficial.

Clinical services should aim to address the barriers women face in accessing mental health

care and empower women to feel in control throughout the process, offering interventions

appropriate to each woman’s personal circumstance. Discharge experiences were an

important factor in maintaining the gains made following an intervention.

Keywords: metasynthesis, postnatal depression, perinatal mental health, women’s health.

Quick Points

Postpartum depression, a serious mental health concern, can have adverse consequences for mothers and their children.

Providing acceptable services to mothers with postpartum depression is essential and must address the barriers to accessing services that are experienced by these women.

Women valued support which promoted continuity of care, patient choice and provided the experience of a strong therapeutic relationship. Information related to parenting was also valued.

Increasing knowledge of, and challenging perceptions about, postpartum depression within health professions as well as in women is key to facilitating better access to services.

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INTRODUCTION

Postpartum depression (PPD), a serious maternal health concern, is defined as the presence

of subsyndromal or major depression in the first year after the birth of a child1. It affects

around 15%-20% of women2,3 and is associated with numerous adverse outcomes for both

the mother and the infant. As well as the short-term consequences for the mother’s quality

of life, PPD is also a risk factor for future mental health difficulties4. Additionally, PPD may

have a detrimental impact on maternal caretaking and parenting behaviour1: there is a large

body of research documenting the impact of PPD on the cognitive and emotional

development of the infant6. Several qualitative studies have explored the experiences of

women with perinatal depression and distress, and these have been synthesised into

systematic reviews6-8. Despite some variation in the results, these reviews reported themes

common to women across studies, such as unmet expectations of motherhood, shame, guilt

and extreme vulnerability. Many studies also reported the experience of stigma in relation

to the experience of PPD; not only the stigma associated with mental health problems but

also the connotation of PPD implying a failure as a mother9,10. Similar findings have been

reported when synthesising research with women with severe mental illness: being a

mother was an important aspect of women’s experiences of mental ill health11.

In the United Kingdom (UK), current recommendations for the treatment of PPD3

prioritise psychological therapy, such as cognitive behaviour therapy or interpersonal

therapy, with anti-depressant medication as a second-line treatment option. Similarly,

Australian guidelines12 recommend psychological therapy and anti-depressant medication in

the context of collaborative decision making with the service user. While there are no

specific clinical guidelines for PPD in the United States (US)13, universal depression screening

for new mothers is recommended by the US Preventive Services Task Force (USPSTF)14 and

psychological therapy and pharmacotherapy are typically the primary treatments offered in

outpatient settings13.

Although medication has been found to be effective for PPD in many cases,

adherence is generally poor in this population15. Furthermore, a Cochrane review16

concluded that psychosocial and psychological interventions were effective in reducing

depressive symptoms at least in the short term. Although these interventions are perceived

as acceptable to women17, women with PPD still face considerable barriers to attending and

engaging in such interventions. Barriers may include travelling and childcare practicalities,

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feelings of shame and concerns about being judged as a mother and children being

removed2,9,18,19.

The experiences of women who engage in therapy for PPD have been explored in

several qualitative studies. However, there have been few attempts to synthesise these

data. Additionally, the key mechanisms of change within psychological therapies for PPD are

not well established1. Understanding the help-seeking process and motivation to engage

may be important in designing interventions which facilitate help-seeking10.

A recent meta-synthesis highlighted the experience of mental health care for a range

of antenatal and postpartum mental health difficulties for women in the UK20. Megnin-

Viggars et al20 reported that women experienced several unmet needs; for example, for

information and for collaborative, integrated care. Consistent with the literature, women

identified stigma as an issue, with fears about children being removed, but women also

noted that healthcare professionals focused on the needs of the infant rather than on those

of the mother. However, there are no syntheses of studies exploring the experiences of

women seeking help specifically for PPD, and it is unclear whether there are experiences

which may be specific to depression because Megnin-Viggars et al’s meta-synthesis20 was an

amalgamation of all mental health difficulties which also focused on the experiences of

women in the UK only, despite PPD being a universal problem with similar experiences

reported across different countries21. Consequently, the aims of this systematic review were

to a) synthesise qualitative data on the experiences of mental health care for PPD across

different countries and b) explore whether there would be themes common to women

more universally. The research questions this systematic review aimed to answer were as

follows: 1. What did women perceive to be important in their experiences of psychological

and psychosocial interventions for PPD? 2. What was difficult about accessing this therapy?

3. What did women find useful or beneficial when accessing this therapy?

METHODS

The following databases were searched: CINAHL, MEDLINE, PubMed, Web of Science and

Ovid (which included PsychInfo, PsychArticles, Maternity and Infant Care, Embase and

Health and Psychosocial Instruments) to ascertain English language studies which used

qualitative methods to investigate women’s experiences and perceptions of professional

mental health support for PPD. The search, including all years to ensure maximum retrieval

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of published studies, was conducted on 8 April 2017. Search terms were created using the

SPIDER tool22. However, the last component (‘research type’) was not used in order to

conduct a broad search and avoid missing papers which did not explicitly specify the

research type, including papers which reported a qualitative adjunct to an efficacy trial.

After this stage, Google Scholar was used to search for any additional articles not found in

the above databases, and the reference lists of eligible papers were searched by hand.

[Insert Table 1 about here]

Studies using qualitative methodology (including mixed methods studies) were

included if they focused on mothers of any parity who had experienced PPD and their

experiences and views about seeking and receiving professional healthcare-based

psychosocial support for their mood difficulties. Only peer reviewed journal articles

published in English were included. Studies which explored the experiences of women who

had not had an infant (including pregnant women) and who did not have PPD were

excluded, as were studies which focused on the experience of antidepressant medication or

non-professional healthcare support (e.g., community groups). The review focussed on

postpartum women only to explore the unique experiences and the impact of having an

infant on accessing therapy.

The search process, illustrated in Figure 1, yielded a total of 8,592 initial articles.

PRISMA guidelines23 were followed. Inclusion and exclusion criteria were applied and a final

number of 17 texts were selected for the meta-synthesis.

[Insert Figure 1 about here]

The quality of the studies included in the metasynthesis was critically appraised

using a checklist24 which contained 12 criteria spanning eight stages of research, from scope

and purpose to relevance and transferability of findings. Although the amount of detail

provided within each criterion was considered a strength of the checklist, it also meant that

studies often met some of the conditions, but not others, within a single criterion.

Consequently, it was decided to include a score of 0.5 in addition to the usual 0 or 1

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awarded. For the purposes of this review, categories were developed to describe the overall

quality of each study. A rating of category ‘A’ was given to studies which scored between 9

and 12 out of a maximum score of 12, category ‘B’ given to studies scoring between 6 and

8.5, and category ‘C’ to those which scored below 6. The purpose of appraising the quality

of the studies was not to exclude low quality studies but to provide a context in which to

consider the results of the analysis.

The interpretive thematic synthesis method outlined by Thomas and Harden25 was

used to develop an understanding and interpretation of the themes across the studies. This

type of meta-synthesis aims to integrate the concepts and narratives from multiple

qualitative studies26. This analysis took place over three stages: line-by-line coding of the

results within the studies, developing ‘descriptive’ themes and developing a higher level of

‘analytical’ themes25. The codes derived from the text were grouped together into similar

areas to form descriptive themes, and in this way the descriptive themes remained close to

the data. Analytical themes were developed by using the descriptive themes to answer the

research questions of the review, and in doing so generate new conceptual links and

explanations25. Themes were derived inductively from identifying similarities and patterns

within the data in the results section of each paper, including quotes and authors’

interpretations. The themes from those papers were considered and compared against the

themes developed in the current analysis. During the analysis process, the findings were

discussed to ensure agreement with the themes generated. The final analysis consisted of

themes and subthemes within these, representing the analytical themes, which will be

presented below.

RESULTS

Characteristics of the Included Studies

The 17 studies represented the views of 585 women from the UK, Canada, Japan, and

Australia27-43 (see Table 2). Two studies specifically investigated the experiences of Black

Caribbean women living in the UK30,31, and one study focused on South Asian British

women35. The socio-economic status of the participants varied greatly both between and

within studies. Participants’ age range was not reported in every study, with some providing

only mean ages, but it ranged from 18 to 45 years. Most studies used purposive sampling

and recruited from health services, such as primary care or mental health services.

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However, one study31 also recruited from community groups and local churches. The

average sample size of the studies was 37, ranging from 7 to 111.

All the studies captured depressed women’ beliefs and views about receiving

professional mental health care for PPD. Three studies30,31,34 were included which focused on

women who had had contact with primary care or perinatal mental health services, but not

received a specific intervention. These studies explored potential preferences when

receiving support as opposed to their views about interventions already received. The

remaining 14 studies explored women’ experiences of receiving professional mental health

interventions for PPD. Specific interventions varied and included mental health nursing,

clinical psychology input, local authority outreach, listening visits (delivered by a health

visitor), a parent-baby day care unit and psychotherapy. One study explored the experience

of group therapy35. One study included counselling and support groups along with General

Practitioner (GP) and maternal health nurse support33. Seven studies28,22,35,32,41-43 conducted a

qualitative investigation as part of a larger trial assessing the efficacy of that particular

intervention.

Quality of Studies

Thirteen of the studies included in this metasynthesis were rated as category ‘A’, and three

were rated as category ‘B’4,13,14. One study35 was rated as category ‘C’ with a score of 5 out of

12. This study was retained but its potential limitations have to be considered in the

analysis. Only two of the 17 studies29,37 made reference to reflexivity within the research

process, which was a quality appraisal criterion and therefore considered a general

weakness of the studies on the whole. A table containing scores for each study against the

checklist can be requested from the authors.

[Insert Table 2 about here]

Themes

Four themes were developed during the synthesis, reflecting different aspects of the

women’ experiences of seeking and receiving professional mental health support for PPD:

‘the process of help-seeking’ ‘barriers to seeking and accepting support’, ‘valued aspects of

support’ and ’outcomes’. The help-seeking process included subthemes of the early stages

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of help seeking and the discharge process, and was thought to overarch the remaining three

themes. The theme ‘barriers to seeking and accepting support’ included subthemes of views

and expectations of healthcare, views of the medical model, views about the self and

knowledge of PPD. The theme ‘valued aspects of support’ included subthemes of the

relationship with the health professional, therapeutic elements, information and ideal

support wishes. The themes and their relation to one another are depicted in Figure 2.

[Insert Figure 2 about here]

Theme 1: The Process of Help-Seeking

Subtheme 1.1: The Early Stages of Seeking Help

This subtheme related to the process of seeking professional help for PPD, a process

described as complex and multi-layered. Women appeared to have different forms of

informal support, which they called upon before seeking support from their health

professional. This included social support from friends and family or using the Internet30,31.

This approach indicated a hierarchy because less formal support was initially preferred. In

any case, women commonly reported that recognising that ‘something was wrong’ was a

vital first step in the help seeking process, even when they were not necessarily recognising

that they were experiencing PPD40,41. The sense that something was ‘not quite right’ was

often shared by family members and spouses, and it was they who instigated the help

seeking process36.

“Yeah, well, every time I have a bad day like yesterday, my husband will say you need to call [women’s health clinic], you need to call, you know.” (Sword et al., 200841 p1167)

As seeking help from healthcare professionals might have been the last resort after

first being supported by family and friends, some women did not seek professional help

until they reached ‘crisis point’36,38.

It was noted in several studies that the extent to which women had control over

their referral to services was an important aspect of their experience. Women who felt as

though decisions were made by health professionals rather than themselves experienced

greater discomfort than women who had voluntarily sought a referral36,37,43. Women

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reported they felt they had even less control in situations where there were concerns about

risk to themselves or the infant37.

“Researcher: How was that for you –to decide it is time to take medication?

Mother: It wasn’t an option.

Researcher: Were you told that?

Mother: No, I wasn’t told, but [community mental health nurse] said, ‘I think it is going to be

in the best interests that you do’.” (McCarthy & McMahon, 200836 p10)

Subtheme 1.2: The Discharge Process

Ending therapy or contact with professionals was a difficult process; for women in four

studies32,35,37,43, it brought up further feelings of distress and anxiety. This was particularly

the case when women felt as though they had little control over the decision to end

therapy, or felt as though they had not resolved their difficulties during this time which was

perceived to have a detrimental impact on the benefits of the therapy overall43.

“Just me thinking about it [ending the visits] now makes me feel quite panicky... What would

have been the point of ripping off the plaster and starting to abrade the wound only to just

then say, oh well” (Turner et al., 201043 p237)

Theme 2: Barriers to Seeking and Accepting Support

Subtheme 2.1: Views and Expectations of Healthcare

Many women across the studies had reservations about, and had therefore delayed, seeking

help from their GPs, health visitors or other health professionals, due to negative

perceptions of these services or expectations that they would not be helpful. For some

women, this reluctance was shaped by expectations of how they would be treated based on

their experiences in previous healthcare interactions, even in different services. One woman

in Edge’s study31 explained how her experiences during childbirth had meant that she no

longer trusted services to provide compassionate care. Some women referred to

disconnection from health services created by a sense of social hierarchy and

powerlessness29.

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Many women also reported that they would not be taken seriously when discussing

their PPD with professionals33,34,40,41. Having symptoms dismissed or attributed to factors

other than PPD by healthcare professionals was commonly cited by women when discussing

reservations about accessing help: women resorted to “remaining silent” (p50)27 if they felt

dismissed and unable to share their experiences or they perceived that their difficulties

would only be taken seriously at the point where there were concerns about risk of harm to

themselves or the infant29.

“I kept going to this doctor and he used to give me a pep talk and send me home [...]

those years were horrible because virtually he said to me ... that I would just have to put up

and shut up!” (Holopainen, 200133 p5)

“There’s just nothing that’s done to help you with the emotional side of becoming a

mum and childbirth. One maternal nurse just told me to suck it up. Babies scream. That was

helpful!” (Bilszta et al., 201027 p50)

Additionally, many women were unclear about the role of health visitors and

expressed a belief that their main remit related to the health of the child rather than the

mother; consequently, they did not feel that they should discuss their own mental

health31,38,40. Some women were worried that the role of the health visitor was to ‘check up’

on the infant’s wellbeing, to the extent that they could make decisions about removing a

child29,33 .

“I thought that the care would be more round care, as opposed to just being about

my baby’s weight, which is basically all it’s ever been about.” (Cooke et al., 201229 p10)

“I thought it was just snooping... That's what I thought health visiting was. It's trying

to see if you're doing anything wrong with your children for social services. I didn't realise

that it's not about that, it's about keeping families together, not tearing them apart.” (Slade

et al., 201040 p444)

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Another common perception of services was that they were under-resourced:

women expected them to be unable to meet their needs, discouraging them from

approaching health professionals for help. Healthcare in general was viewed as fragmented,

particularly between antenatal and postpartum services, and continuity appeared to be an

important factor in allowing women to feel comfortable in sharing their experiences34,38,39.

Similarly, in two studies27,33 women explained that they were not aware of what help was

available or how these services could meet their needs.

“I think it was just that they were really busy and just didn't really have enough time

for everybody with their kids.” (Shakespeare et al., 200739 p11)

Many women also expressed an aversion to the medical model and the idea that

PPD was ‘an illness’31,39,41. For example, women in one study29 favoured psychosocial

explanations for their emotional difficulties. Relatedly, a common theme was the reluctance

to take antidepressant medication: Women in one study27 expressed shame at not being

able to cope on their own and stigmatised for taking medication. Some women believed

that this was likely to make them worse, while others were concerned about the side

effects. Still others disagreed with neurochemical explanations for PPD or believed that that

medication was reserved for ‘serious’ mental health difficulties. In contrast, some women in

one study33 reported that taking medication helped them to cope by increasing their sense

of control, especially whilst waiting for further support.

“I approve of psychiatry, I approve of psychology, but I don't want to be a person who needs

chemical adjustment.” (Shakespeare et al., 200739 p9)

Subtheme 2.2: Views about the Self with PPD

A major barrier to seeking and receiving help for PPD was the view that the women held

about themselves as women and how depression related to this. Many women across the

studies27,30,34,36 referred to the stigma attached to experiencing PPD and appeared to have

internalised this stigma, expressing shame and embarrassment.

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“I think there's a stigma as well… About failure and not being able to cope. The whole word

'depression'... It's got such negative connotations. So perhaps that actually keeps us from

actually going to ask for help.” (Edge & MacKian, 201030 p19)

One of the main implications of experiencing PPD for the women was an inference that

they were not able to cope. Women viewed themselves as a ‘failure’ and ‘weak’ if they

experienced PPD27,39,40. The reluctance to present this image to others was a major barrier to

sharing their difficulties with professionals.

“I thought I could cope on my own, I didn’t want to admit that I, I like to think I'm a strong

person, I like to think I can cope and I didn't want to admit that I wasn't coping I don't think.”

(Shakespeare et al., 200739 p8).

Views about PPD and coping also appeared closely linked to ideas about

motherhood. Women referred to idealised comparisons of ‘perfect mothers’, not wanting

to be seen as different to mothers who could cope29. Many women expressed the belief that

experiencing PPD meant that they were a ‘bad mother’ and were unable to look after their

child34,39,40: the label of ‘bad mother’ was perceived to be worse than the label of

“depressed” (p4827). Many women worried that this was the conclusion health professionals

would reach if they knew they were depressed, and one consequence of this was that their

children would be removed from them34,40.

“I even went in at 3 months and I talked to a health nurse, and I just lied through my

teeth because I thought, what are they going to do if they find out I can't be a good mom?”

(Letourneau et al., 200734 p445)

Subtheme 2.3: Knowledge about PPD

One other barrier to accessing professional support was the lack of knowledge women had

about PPD. This impacted on their ability to recognise the symptoms and act accordingly36,41.

As noted in Theme 1, recognising the symptoms of depression was an important first step in

the process to seeking help, which took longer when women lacked knowledge about PPD.

Furthermore, when relatives and spouses had limited knowledge about PPD affected how

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women framed their experiences41. Women’s own views of PPD also posed a barrier to

accessing professional support. For example, some women believed that PPD was

untreatable, in particular if the social circumstances around them did not change30,43.

Conversely, some women believed that the symptoms would resolve on their own, without

any need for intervention41.

“[Depression] it was just a shock to me. I mean I didn't notice I had it. I was just crying. I

thought I had the baby blues, that's all.” (Sword et al., 200841 p1165)

Theme 3: Valued Aspects of Support

Subtheme 3.1: Relationship with the Health Professional

A prominent theme in many of the 17 papers, regardless of the type of intervention or

support offered, was the pivotal role of the relationship with the provider of that support in

determining how the experience was perceived. The providers were health visitors, mental

health nurses and therapists. Many studies described this relationship as crucial, and some

women alluded to a good relationship equalling a good experience, and a bad relationship

equalling a bad experience38,39.

“It would be much nicer to have the health visitor if it's somebody that you actually get on

with. I mean that's the big 'if' isnt it, you don't normally have the choice, sort of, finding

somebody that you click with.” (Shakespeare et al., 200841 p10)

One aspect of the relationship which was particularly valued was the sense of feeling

cared for by their health professional. Phrases used to describe this included ‘all for me’, ‘it

wasn’t just a job’, ‘my time’ and ‘my special time’37,43. Many studies referred to strong bonds

having developed between the woman and health professional, and a perception of an

equal relationship without hierarchy29. While believing the health visitor’s role prioritised

the child was a barrier to accessing support, feeling as though they were the focus of the

professional’s support was valued by many of the women. Women spoke of feeling as

though the health professional was ‘genuinely interested’ in them28,31,36,39-43. Participants in

one study27 described this experience as “mothering the mother” (p50).

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“The opportunity to develop a trusting relationship with [the nurse] who I could ask any

questions without feeling inadequate, fearful or guilty in the comfort of my own home [was

useful].” (Rossiter et al., 201238 p7)

Another valued aspect of the relationship was the continuity of having the same

health professional involved over the course of the intervention38 which engendered a

sense of containment, comfort and trust. Women felt enabled to be more open, which

made the support feel more useful27,32,39-42. Additionally, there appeared to be a sense of

security from knowing that someone familiar would be in contact40.

“So she was like supportive and kept in contact quite a lot, ringing me to see I was ok and if I

needed to talk, she was there sort of thing.” (Slade et al., 201040 p444)

Subtheme 3.2: Therapeutic Elements

Across the studies, a commonly cited element of the support that was valued was the non-

judgemental approach taken by the health professional32,35,38-43. The ability to share

experiences or thoughts without fear of judgment enabled the women to gain more from

the intervention. Given the concerns women had about how PPD might be viewed, this

seemed particularly important43.

Relatedly, the opportunity to talk and have someone ‘really listen’ was considered to

be therapeutic, giving the women the opportunity to ‘offload’ and ‘get things off [my]

chest’28,34,35,37,43. When the women felt listened to, they also felt validated. This process in

itself appeared to be useful, but also helped women to ‘order their thoughts’ and gain a

different perspective42. Another factor which facilitated this ability to be open about

thoughts was the confidential nature of the support and its ‘separateness’ to other aspects

of the women’ life, including their General Practitioner (GP)32,35,38,39.

“Seeing a [Community Psychiatric Nurse] has been very useful to be able to talk to

someone outside the family is very important. I would recommend it.” (Boath et al., 200428

p7)

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The opportunity to reflect on and normalise experiences was considered beneficial,

particularly if this was perceived as a joint, collaborative process of ”wondering together”38.

When women received a model-specific therapeutic intervention, the specific techniques

related to this were perceived as useful, such as cognitive behaviour therapy (CBT)40. For

some women32, therapy included reflecting on and ‘re-examining’ difficult birth experiences.

“These questions have to come from somewhere and they come from experience so it

helps you understanding that you’re not abnormal. Like it’s all normal what you’re going

through.” (Fenwick et al., 201332 p221)

Finally, another commonly valued aspect of support was receiving information or

psycho-education from the health professional. While the women found it helpful to learn

about mental health and PPD29,32,37, they particularly valued the inclusion of information

about parenting32,34,38. Specifically, women valued receiving feedback on their parenting,

particularly given their worries about being a ‘bad mother’. Support was viewed positively if

the professional was viewed as knowledgeable32,34,37. Women also valued the opportunity to

develop skills in problem solving and the opportunity to practise these collaboratively. One

study reported that the women had learned a ‘psychological language’36, and many studies

referred to an improvement in the understanding and perception of PPD.

“Your suggestions gave me many ideas about how to cope with stress.” (Tamaki, 200842 p4)

“It was nice to have someone tell me I was doing OK when I was suffering a bad dose of

mother guilt.” (Rossiter et al., 201238 p8)

Subtheme 3.3: Ideal Support Wishes

As well as discussing what had been found to be helpful within the support that they had

received, women also shared their views on what an ideal professional psychosocial

intervention would look like. This was particularly the case in studies in which participants

had not received a specific intervention, but were supported within primary care31,34. In

general, views on the ideal support matched women’s actual experiences of an intervention.

Support adapted to the mothers’ individual needs, including their particular cultural

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background, was viewed as ideal30. The key factor in this appeared to be the professional’s

ability to understand the mother’s point of view. Similarly, women also referred to the

benefit of accessing support from peers, or from women who had previously recovered

from PPD. Some women33,34,39 believed that this should extend to health professionals

themselves having experienced PPD.

“Another woman that had been through it; that's kind of the support that I was

looking for.” (Letourneau et al, 200734 p445)

Support based within the community was viewed as ideal, especially when it

addressed their practical needs. For example, concerns about arranging childcare could be

alleviated by having visits at home43. In general, women described holistic, ‘round’ care as

ideal29. Women also valued the idea of health professionals recognising their distress early

on in the PPD experience so they could “see it coming and take control”27.

Theme 4: Outcomes

Almost all studies specifically referred to the support being perceived as beneficial or a

positive experience on the whole, with some women describing it as a ‘lifeline’ and the

sessions being ‘key to [their] recovery’43. There was a reduction in distress and anxiety for

many women, and an increase in coping28,32,35. Women also reported that their confidence in

parenting had increased; this appeared linked to the information or feedback they received

in this respect during their intervention39,42. Another outcome was that many women

reported that they had experienced an improvement in their relationships both with their

infant and significant others39. Women felt that this had been achieved through either

improving their communication skills or learning to set more realistic expectations40.

“It's the classes and the therapist. My life segments are still there but I have changed my

thought process. I have a coping strategy for my problems.” (Masood et al., 201535 p5)

DISCUSSION

This systematic literature review aimed to synthesise qualitative data on the experience of

women accessing and receiving professional mental health care support for PPD. Overall,

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the stories told by participants suggested that initiating the process of seeking and accepting

help for PPD was difficult and impeded by many barriers. These barriers included views and

expectations of healthcare, knowledge and views about PPD, and views of the self with PPD.

However, once received, professional psychosocial support was valued and perceived as

instrumental to change. The value of such support appeared to hinge on several factors, the

most prominent of which was the relationship developed with the health professional.

Other factors included having the opportunity have their experiences validated in a

confidential, non-judgemental environment, which facilitated the development of coping

strategies, as well as learning more about PPD and gaining feedback on parenting.

Outcomes salient to women were the improvements in confidence as a parent, increases in

coping and improvements in their relationships, including with their infant. Many women

described the ending of support or the discharge process as a difficult time and one which

had the potential to diminish the improvements seen during the intervention.

The themes developed within the current synthesis were consistent across studies

from different countries, suggesting some universality to the experiences of women seeking

and receiving professional psychosocial and psychological support for PPD, although it is

acknowledged that only a small number of countries were included. The themes relating to

barriers to accessing treatment were consistent with previous literature around PPD9,20, and

highlight the significance of perceptions of, and stigma towards, PPD. The emergence of

stigma as a key theme also reflects the findings of syntheses of the experience of women

with PPD6,7 and other mental health problems during motherhood11,8. More widely, parallels

may be drawn with the literature regarding the experience of stigma relating to mental

health difficulties in the general population and its deleterious effect on accessing care45.

There were other commonalities with mental health literature; for example, poor

recognition of depression has previously been identified as a barrier to help seeking46.

Furthermore, the importance of the relationship with the health professional described by

women across the current review resonates with the well established notion in mental

health literature that the therapeutic relationship is a key factor in the outcome of a

psychological intervention47. The qualitative nature of the current metasynthesis allows

insight into the elements which women believe facilitated this relationship. For example,

women valued continuity of the health professional involved and the health professional’s

skills in building a strong rapport, which made them feel ‘cared for’. These factors have been

17

recognised as important in the experience of psychological therapy in other qualitative

studies48. Specifically in PPD, feeling cared for during therapy may be particularly important

because women may perceive that their needs have been overlooked in relation to their

infants’ needs49. Additionally, women with PPD are likely to report experiences of isolation7

and low levels of social support50.

The themes developed in the current synthesis both corroborate and supplement

findings from a metasynthesis of mental health care for women with a range of mental

health problems20: there were similarities in the reported importance of shame and stigma,

integrated and collaborative care and the therapeutic relationship. The current

metasynthesis added to these findings by analysing a further 12 studies, providing further

insight into the experiences of women accessing services specifically for PPD. For example,

the current metasynthesis highlighted the perceived implication that to experience PPD was

to be a ‘bad mother’, and that this was a key barrier to accessing services. As this was not a

salient feature of Megnin-Viggars et al’s metasynthesis20, it is possible that this is an

experience particularly relevant for PPD in comparison with other postpartum mental health

difficulties. Indeed, key aspects of depression include negative beliefs about the self and the

belief that PPD as a sign of failure as a mother has been highlighted already6,7. Additionally,

the current review had a greater focus on intervention outcomes: women reported feeling

less depressed, more confident and experiencing improvements in their relationships with

significant others.

Clinical and Research Implications

The current findings have important clinical implications at both an organisational and policy

level. The importance of health services facilitating continuity and integration in women’

care is highlighted and reflects previous recommendations20. Where possible, continuity of

care across the antenatal and postpartum period would improve experiences for women

and facilitate open communication. Decisions about care, including discharge, should be

collaborative, with adequate follow-up provided. Health plans as described by the US

National Institute of Health Care Management (NIHCM)14 may be an approach which

promotes continuity of care and appropriate referrals for women with PPD. The current

findings also echo the call by Dolman et al11 for appropriate training for health professionals

present in the perinatal and postpartum phase to increase knowledge and understanding of

18

PPD. The US-based Support and Training to Enhance Primary Care for Postpartum

Depression (STEP-PPD)13 may be a useful program to provide training and resources to

primary care providers on best practices in the management of PPD. However, training for

health professionals should also focus on increasing compassionate care and promoting

skills which facilitate engagement and the therapeutic relationship, given the importance of

these elements for women. For example, skills in active listening, validation and empathy

should be promoted in training and supervision. In addition, service provision should include

a greater amount of psycho-education for expectant and new women on PPD in order to

facilitate recognition and challenge harmful beliefs that encourage shame and stigma and

pose a barrier to service use, for example, about being a ‘bad parent’6. Women across the

studies in the current review reported that having their experiences normalised was

beneficial; this suggests that health professionals providing data on the prevalence of PPD

and its symptoms may allow women to feel more able to share their distress. The

recommendation by the USPSTF to universally screen new mothers for depression13 may

also encourage women to share their distress at an earlier stage.

While valued aspects across different therapies were identified, the metasynthesis

was not able to explore in depth any specific techniques of a particular approach, due to the

heterogeneity of interventions included. For example, participants who had received CBT

described the benefit of specific psychological techniques, such as thought challenging.

Further research is required to explore the aspects of CBT and other specific therapeutic

modalities that are salient to women with PPD. Furthermore, women in the reviewed 17

studies commonly described outcomes involving the infant, such as increased confidence in

parenting and improved mother-infant relationships, despite the fact that these may not

have been explicitly focused on within the intervention. A new body of research has recently

begun to explore the effects of offering parenting interventions for PPD51 and there is

emerging evidence to suggest that mother-infant-interventions are clinically and cost

effective for both mother and infant52. The results of the current metasynthesis add to the

view that parenting-related outcomes are important for women with PPD11. Therefore,

research should continue to examine the impact of specifically addressing parenting within

an intervention for PPD.

Strengths and Limitations

19

A strength of the current review was that studies from different countries and cultures were

included. Thus, consistencies were identified in themes across the 17 studies, suggesting a

potential universality to the experiences of seeking and receiving support for PPD. However,

it is recognised that the countries included were small in number and similar in terms of

cultural and societal structure, including the provision of health services (e.g., the UK,

Australia and Canada).

Although the goal of qualitative research is not to produce generalisable results25,

the experience of mental health care in other countries has not been reflected in the

current review. In particular, the views of women in developing countries or those with

different health care systems have not been represented. Hence, future research should

include studies published in a variety of languages. Due to the constraints of the project, the

search was limited to studies written in English.

Additionally, the current review synthesised the experiences of different types of

therapy, which may not capture intrinsic experiences unique to the specific type of therapy.

Therefore, conclusions cannot be drawn about one particular type of therapy. Furthermore,

there was variability of services within which these therapies were offered, and so service-

specific conclusions may not be drawn. Despite this, this review provides a detailed picture

of the therapeutic elements common across the different types of psychological

interventions.

Based on the criteria set by Walsh and Downe24, the majority of studies included in

the current review were of very good methodological quality. Most studies had a clear

rationale and replicable design, used an appropriate analytical method, and had

interpretations grounded in the data. However, one study42 met only five of the 12 criteria.

As this study focused primarily on a quantitative investigation of the reported intervention,

less detail was provided regarding qualitative methodology which meant that many criteria

were not met. Furthermore, only two29,37 of the 17 included studies made reference to

reflexivity, which can be described as a key component of quality control in qualitative

research53.

CONCLUSION

PPD is a significant mental health problem with detrimental consequences for both mother

and infant. Despite barriers in accessing them, professional psychosocial interventions were

20

found to be beneficial and acceptable to women. The therapeutic relationship appeared to

be a key factor in the experience of receiving an intervention. Women highlighted changes

to parent-related outcomes, despite these rarely being explicitly focused on in the

interventions used. Several recommendations have been made in both a clinical and

research context to improve the care provided to this group of women.

21

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Table 1. Search terms used in systematic literature search

Domain Search Terms

S Sample New mother* OR maternal OR postpartum OR postpartum OR newborn AND depress* OR low mood

PI Phenomenon of Interest Psycholog* intervention OR therap* OR Psycholog* intervention OR therap* OR cognitive behavio* therap* OR cognitive therap* OR counselling OR psychodynamic OR interpersonal OR psychoanaly* OR cognitive analytic therap*

D Design Interview OR survey OR focus group OR questionnaire

E Evaluation View OR experienc* OR attitude OR belie* OR perce* OR feel OR know OR understand

R Research Type Qualitative research

27

Table 2. Characteristics and quality appraisal rating for each study included in the metasynthesis

Study no.

Author(s) YearCountry

Participant characteristics and sampling methods

Research aims Intervention received

Data collection

Method of analysis

Quality ratingcategory

1 Bilszta, Ericksen, Buist & Milgrom27

2010Australia

40 womenPurposive sampling

Explore how women’s experiences of PPD influence their beliefs, attitudes and choice to seek help. Also explore ways family, friends and health professionals can facilitate help seeking behaviour.

Hospital based outpatient PPD treatment or community based support groups

Semi-structured focus groupsMaximum of 90 minutes

Interpretive phenomenological analysis

11/12Category A

2 Boath, Bradley & Anthony28

2004UK

60 women: 30 who accessed Parent and Baby Unit and 30 who accessed routine primary carePurposive sampling

Elicit service user views to understand the role of specialist and routine care in PPD treatment and pinpoint which aspects of specialist care are important to women.

Parent and Baby Day Unit

Questionnaire open ended questions(part of a trial)

Content analysis 10/12Category A

3 Cooke, Smith, Arnold & Turl29

2012UK

Seven womenPurposive sampling from local community clinics

Explore parent’s perceptions of accessing local services when experiencing psychological distress after having their baby

Clinical psychology, mental health crisis team, local authority outreach, primary care

Semi-structured interviewsLength not stated

Thematic analysis

10/12Category A

4 Edge & MacKian 30

2010UK

12 womenTheoretical sampling: drawn from a larger mixed-methods studyBlack Caribbean women

Explore Black Caribbean women’s approaches to help-seeking and their experiences of receiving help from professional ‘help-givers’.

Primary care In depth interviews using topic guide lasting between 45-120 mins

Constant comparison and goodness of fit

8/12Category B

5 Edge31

2011UK

42 womenPurposive sampling from the local communityBlack Caribbean women in the UK

Explore reasons for low engagement with services and diagnosis of PPD in Black Caribbean women

Primary care/perinatal mental health services

Focus groups Framework analysis

11/12Category A

6 Fenwick, Gamble, Creedy, Barclay, Buist & Ryding32

2013UK

33 women Convenience sampling: subgroup from a larger postpartum distress intervention study:16 from intervention, 12 from active control, 5 from matched control

Explore women’s perceptions about the components and outcomes of participating in a postpartum distress intervention and examine how women talked about the emotional support received.

PRIME intervention/ home visiting

Telephone interviews:Intervention and active control: 30-60 minsActive control: 15 mins.(part of a trial)

Thematic analysis/ constant comparison‘Editing analysis’ style

10.5/12Category A

7 Holopainen33 2001Australia

7 womenPurposive samplingAge range 24-43

Explore women’s experiences of support and treatment for PPD

Primary care and/or counselling/suppo

Interviews, around 90 mins

Hermeneutic phenomenology

10/12Category A

29

rt groups8 Letourneau

et al.34

2007Canada

52Convenience and purposive sampling. Mean age 31 years

Explore women’s views on support needs, support available and accessed, barriers to support, and preferred type of support intervention.

Prospective – not received intervention

Mix of individual semi-structured and group interviews

Inductive thematic analysis

10.5/12Category A

9 Masood et al.35

2015UK

17 womenConvenience sampling: subgroup from a larger randomised controlled trialSouth Asian women

Assess the acceptability and overall experience of the Positive Health Programme by British South Asian women

Group psychological intervention

In depth using a topic guide: around 45 mins.Interviews conducted in Urdu and translated to English(part of a trial)

Thematic analysis

11/12Category A

10 McCarthy & McMahon36

2008Australia

15 womenPurposive sampling from community mental health clinic

Identify factors that influence the decision to seek and accept treatment for PPD and describe women’s experiences of treatment in order to understand factors that influence ongoing engagement in

Mental health nursing home visits

Semi-structured interviews: 60-120 mins.

Modified analytic inductionHypotheses developed prior to analysis

9.5/12Category A

30

treatment11 Myors,

Schmied, Johnson & Cleary37

2014Australia

11 womenPurposive sampling from perinatal mental health setting

Explore how women interpret and experience specialist perinatal mental health services

Perinatal mental health service: mental health nursing

Semi-structured interviews: up to 40 mins.

Thematic analysis

11.5/12Category A

12 Rossiter. Fowler, McMahon & Kowalenka38

2012Australia

111 womenPurposive sampling from home visiting programme

Explore the responses of women who experienced distress and depression after childbirth and received a home visiting service

Intervention based on relationship between mother and infant

Open ended written survey questions(part of a trial)

Thematic content analysis

10/12Category A

13 Shakespeare, Blake & Garcia 39

2007UK

39 womenPurposive sampling: health visiting clinics.

Explore the experiences of women who have received listening visits for PPD

Health visitor-delivered listening visits

Interviews 21-80 minutes

Thematic analysis

8/12Category B

14 Slade, Morrell, Rigby, Ricci, Spittlehouse & Brugha40

2010UK

30 womenPurposive sampling from randomised controlled trialAge range 18-45

Explore post-natal women’s experiences of the identification and management of symptoms of depression and the offer and acceptance of postpartum care by health visitors

Psychological interventions delivered by health visitor either CBT or person-centred

Semi structured interviews around 60 mins(part of a trial)

Template approach

8.5/12Category B

15 Sword, Busser,

18 womenPurposive sampling

Explore women’s care-seeking experiences

Public health nurse-delivered

Semi structured

Content analysis 11/12Category A

31

Gannan, MacMillan & Swinton41

2008Canada

from child health unitMean age 29.4 yearsCanada

after referral for PPD home visits telephone interviews

16 Tamaki42

2008Japan

16 womenPurposive sampling from child health clinics, mean age 33Japan

Evaluate the effectiveness of home visits by mental health nurses for PPD

Mental health nursing model: active listening, support, psycho-education and problem solving

Open-ended written responses to survey questions

Content analysis 5/12Category C

17 Turner, Chew-Graham, Folkes & Sharp 43

2010UK

22 womenPurposive sampling from a larger RCTAge range 19-45

Explore women’s views and experience of receiving listening visits as a treatment for PPD

Health visitor-delivered listening visits

Semi structured interviews 40-120 mins(part of a trial)

Framework analysis

9.5/12Category A

32

Figure 1. Flow diagram depicting the systematic literature search process and results

Figure 2. Diagram depicting the themes and subthemes in the thematic synthesis

34