Perceptions of barriers to accessing perinatal mental health care in midwifery: A scoping review

BACKGROUND: Despite greater contact with the healthcare system during the perinatal period, detection and treatment of perinatal mental health conditions remain suboptimal. AIM: To explore midwives' and midwifery clients' perceptions of factors that impede access to perinatal mental health care in high resource settings. DESIGN: Scoping review. METHODS: Arksey and O'Malley's (2006) framework for scoping studies was employed. A systematic search of the literature was completed. Included publications must have (1) addressed barriers to obtaining perinatal mental health care; (2) been either peer-reviewed primary literature or grey literature; (3) if primary literature, the study explored the perceptions of midwives or those in midwifery care; and (4) if grey literature, the publication pertained directly to midwifery care. A study was excluded from the review if (1) it was published in a language other than English; (2) it was published prior to the year 2000; or (3) it took place in a country with a Maternal Mortality Ratio (MMR) above 14. Identified barriers were mapped onto Levesque et al.'s (2013) ten-dimension framework (five supply-side dimensions and five demand-side dimensions) on access to health care in order to determine which points along the chain to accessing perinatal mental health care were most adversely impacted. FINDINGS: The search yielded a total of 1051 records, and twenty-six were included in the review (qualitative, quantitative, mixed methods, grey literature). Supply-side barriers included midwives' lack of PMH training, knowledge, and confidence, both generally and cross-culturally; inconsistent screening practices; broken referral pathways; lack of specialized services; underlying stigma toward those with PMH concerns; inefficiently long wait lists for services; and midwives' perception that PMH is not within their scope of practice. Demand-side barriers included emotional isolation and loneliness; normalization of PMH concerns as symptoms of pregnancy; cultural norms surrounding motherhood and mental health; and symptoms of PMH concerns as inhibiting the ability to obtain help. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Twenty-one out of the twenty-six publications included in this review identified problems at the very beginning of the care-accessing process, suggesting that PMH care is often unapproachable, or that people are unable to perceive their need for care in the first place. Midwives can help ameliorate these initial barriers by engaging in additional perinatal mental health training in order to increase knowledge and confidence; being aware of community resources and referral pathways; and initiating discussion about perinatal mental health with all clients with the help of a validated screening tool.