Acceptability of identification and management of perinatal anxiety: a qualitative interview study with postnatal women

3.2.1. Availability and accessibility of maternity care and mental health service support

This theme reflects affective attitudes to both the perinatal mental health pathway and the maternity care women received because this care had the potential to positively or negatively impact anxiety. Feelings were positive about services that were perceived as providing women with appropriate ease of access, even if that service was not eventually needed:

I had all the (psychiatric support) numbers I needed, I knew what I needed to do […] Knowing that the help is there if I need it. That was helpful. I needed to know that I can get that if I need to. (E04232).

Services that provided care tailored to individuals’ needs were also considered favorably. This included maternity care. For example, after previous pregnancy loss, there was potential to reduce anxiety through additional scans:

Because of the early bleeding I had an extra three scans I think, or four maybe. […] That definitely helped. The weeks following the scans I was definitely in a better mood and wasn’t as stressed. (S01022).

However, if maternity care was perceived as poor or lacking, anxiety could increase:

I lost some blood, but because of when it happened, because of Covid, it was really difficult to get a scan and it just really scared me. I think I was completely sure I was having another miscarriage. From that point until about 13 or 14 weeks in the pregnancy I just felt really, really anxious. (E01009).

Women also felt that their anxiety could worsen if told that a service would be provided but it was not, for example providing a telephone number but not answering the phone:

When you are that anxious, you want that touch point on speed dial, almost, that professional where you can go, oh is this normal? Is this okay? Am I okay? […] but then when she (midwife) did not reply it was worse. […] You’d try and call the service, and then they would not pick up…that would actually add to the anxiety, rather than alleviate it. (E01081).

3.2.2. Healthcare professionals’ responses to women’s anxiety

The way in which HCPs responded to women who disclosed their anxiety impacted women’s feelings about care received. For example, implying that anxiety may be damaging to the baby could unintentionally add further anxiety:

I had to then talk to a consultant or a doctor, on the phone. And it was just one thing they said to me, and I’m sure they did not mean it like they said it, but it was almost, they said because I’m in such a high state of anxiety, that I could be hurting the baby. That really, really upset me […] it just made it (anxiety) a hundred times worse. (E05033).

Similarly, telling women that they should enjoy their pregnancy was unhelpful:

He (CBT therapist) kept saying, … how we needed to be enjoying this time as a couple because it was never, ever going to be the same again as soon as the baby was born […] I was just like, this is making me feel worse, more anxious that I’m not making the best of the time now. (E12127).

Acknowledgement of anxiety and calm words of reassurance were helpful and made women feel positive about the care they were receiving, whether a health visitor who was a ‘motherly figure’ affirming that ‘everything [I] was doing was okay’ (E01077) or a psychiatric nurse providing more intensive support:

She (psychiatric nurse) used to come and see me every week. She made me feel normal, she made it sound like, “It’s no big deal, everything’s fine, this is a normal way for you to feel, given what you have been through.” And just a bit of sympathy and empathy about what had happened before. (E05002).

3.2.3. Health service characteristics

Women were concerned about the structure of health services, for instance there was a sense of t concern and anxiety about lack of continuity of midwife because this involved repeating their story multiple times to different people that they had no relationship with:

From 24 weeks on, every single appointment I said, this is the first time I’m meeting you (midwife), this makes me feel really anxious, it makes me feel upset. (E01035).

Conversely, when women experienced continuity it provided safety and comfort which facilitated honest conversations about mental health:

It wasn’t a tick-list, where they go, how is your mood? It was more, she (midwife) was sitting in front of me, and she looked at me and she went, are you okay? Because she’d seen me at all those previous appointments, she knew that there was a change in the way I was […] I’m glad that it was always her. (E04352).

There was also an awareness that perinatal mental healthcare would end at a specified timepoint in some services, which caused worry about options for future support or the possibility of having to cope alone:

I feel like there is a degree of anxiety at the moment, as soon as the baby turns one, then I do not have the Perinatal Service anymore. So, I then feel like I’m alone with it all again. (E12127).

3.3.1. Continuity of carer

Women were dismayed by having to tell their story or circumstances to multiple HCPs. Sometimes this effort dissuaded women from engaging with services at all:

I just feel like again I’m going to see four or five different people that all do not know me. I’ll have to re-explain the same stuff, over and over again. I’m never going to get anywhere, so I might as well just keep trying to deal with it myself. (E04098).

Ongoing care from the same HCP encouraged engagement and disclosure of feelings:

I had the same midwife every time…so she got to know me, and I had that kind of comfortable relationship with her where I felt like I could say, “Oh, actually, I’ve been a bit anxious this week,” or, she was able to pick up on things, that someone who had not seen me before might not have. (E12113).

3.3.2. Treatment access and engagement

If women were told to self-refer to or call a service themselves, the experience could be inconvenient because it was hard to find time whilst caring for a new baby, potentially other children, and being sleep-deprived. Self-referral could be difficult because of not knowing what to say or how to navigate entry into a service, or considered to be pointless because the long waiting list could mean that a pregnant woman’s baby would be born before she could access therapy:

They say that they have a mental health support team they could have referred me but the wait was about six months. Given that I started talking with the midwife at three months, in the pregnancy, it (referral) was entirely irrelevant. (E01009).

If services could offer some flexibility in offering online or in-person appointments, or within the times that they could visit women at home, this reduced the burden of engagement:

She’d (HCP) always made it around the time that I wanted, and that was really good. […] I think she did set days, but yeah, the times were quite flexible. (E05033).

3.4.1. Focus of postnatal services on baby not mother

Women felt that postnatal care/service focused only on the baby and did not account for their own needs. For some women, support that incorporated their baby worked well but for others individual care was needed:

…There wasn’t any service where I as a person could be dealt with. It felt like the only options were related to your kid, and you have to go to a Children’s Centre and sit on a carpet with your kid, and they’d talk to you about that. (E01025).

3.4.2. Concerns minimized or not respected

Women valued being treated with respect as an individual who should be listened to. When women were asked questions about their wellbeing or mental health, they wanted this to be done with meaning, not simply as a requirement:

Anything I said additionally around like how I felt, it wasn’t that it was ignored, but it was, I mean every midwife appointment I had they asked the question, like how do you feel, but it was more the let us tick that box on the form and make sure I’ve asked that question. (E06064).

3.4.3. Acknowledgement of preferences

Women wanted their own values and beliefs to be acknowledged by HCPs. Decisions about parenting and medication for example were sometimes not respected such as a GP telling a mother to let her baby cry when she did not want to and was very distressed by this, and a psychiatrist who did not acknowledge a woman’s wishes not to be treated with medication immediately:

I used to dread going (to the psychiatrist), I used to feel like I wasn’t listened to. She was always pushing medication, which I repeatedly said that at first I wanted to try without. (E02002).

Women valued scenarios in which they felt listened to, and this encouraged them to engage with services and attend appointments:

I was offered a referral to the perinatal mental health team, I kind of voiced that I wasn’t sure, wasn’t really that confident with being put on medication. I was assured that’s not the only thing that they would be able to support us with. So, they seemed to understand. (S01024).

3.5.1. Information about services

Most women recognized that they would benefit from some level of support, but they were unable to specify what that help could be. It was therefore important for HCPs to clearly articulate the pathway that women would access.

Participants also expressed some confusion around specific services that were available to them as well as the estimated waiting time for help and support. For example, women did not know whether they would be referred to specialist perinatal metal health or generic Talking Therapy services (psychological treatments that involve discussing mental health concerns with a trained therapist including cognitive behavioral therapy and counseling). This was particularly confusing for women whose first language was not English:

The information she (midwife) gave me was not, was insufficient. I’m not sure whether it’s useful for me or not. […] They just provide me the numbers, and saying that you should seek help if you think you need it. But I’m not sure … they would just say it’s a psychiatric service, but I’m not sure what is going to happen. […] we are new to the country. I had no idea what I … and under what circumstances I should seek GP’s help, I do not know. Honestly, I do not know, I do not even know now. (E01042).

In order to make an informed decision when seeking help, women required clarity on waiting times and availability of different types of support. When HCPs took time to explain a pathway, the impact of understanding the process was reassuring:

We spoke about things like medication and talking therapy and what support they can offer and how long they’ll be there and how they can support me after baby arrives and all this kind of stuff and just talked about the whole journey so that I sort of knew what to expect, that was wonderful. (S01024).

3.5.2. Understanding interventions

Once enrolled in treatment, women did not necessarily need to understand what the treatment was to engage in it successfully:

I’m not sure, really, what things come under CBT because it was all integrated in our sessions, it wasn’t like, “Today, we are going to do CBT.” She’d come round and we’d talk. (E05002).

Understanding that they would be given time, would not be judged, would be listened to and could talk openly and honestly to someone who understood what they were experiencing were important to women:

I could say things to her that might sound completely ridiculous to someone else but I knew she would take me seriously about it as well and understand how I was feeling. (E10090).

3.6.1. Repercussions/reputational damage

In addition to feeling judged by HCPs and by family or friends, women also feared not being able to return to their career or experiencing reputational damage should they disclose how they were feeling to HCPs:

I do not feel able, I did not feel able to reach out to the GP and say that I feared I had postnatal depression, because I then would not be able to go back into my job, potentially. (E04332).

3.6.2. Choices taken away/expectations not fulfilled

Further costs related to the available treatments being limited in scope and not being able to access the type of treatment that women felt was required. One woman who reached out for support felt that the offer of CBT was not appropriate for her, but nothing else was available:

The IAPT Team and the triage and everything, just decided that it was CBT that I was having and I kind of felt at the time, that I was hoping that I would get more of a counselling- based service, but yes, I did not get a choice, they just said that’s what I was having… I do not really feel like that helped me…I was kind of, felt like I was a bit stuck with what I got. (E12127).

3.7.1. Referral process and signposting

As women often did not know what services or support may be available, they relied on HCPs to help them navigate this. This did not have to be clinicians but could also be ancillary staff:

She (GP receptionist) just literally asked me, what’s the call about? I explained what I wanted to talk about. She was lovely, she was really professional, she was like, “Actually, I think there’s a service that you would be better suited to,” explained what it was, and she was really nice and I was like, no, that does sound better…she was perfect. (E06108).

3.7.2. Timeliness of access

Expectations were of long waiting times to access care, which impacted women in different ways. Some turned to private healthcare options which were also perceived as providing choice and autonomy over the type of treatment preferred. Those with pre-existing symptoms of anxiety who were already accessing private mental health support continued through their pregnancy and benefited from the existing trusting relationship with a therapist. For those who did try to access NHS care, some women experienced a long wait, and others were surprised when they were able to see a specialist within several weeks:

I did a self-referral and then had a triage call, a week later. So, it was pretty quick this time and then I, I think I started therapy three weeks after that, four weeks after that. So, it was very efficient. I know if you are on the perinatal pathway, you are seen sooner, but I was surprised how soon I was seen. (E04277).

3.7.3. Effectiveness of care

When discussing how anxiety was managed, women cited the importance of emotional and practical support from their partners, family, friends and existing networks foremost. Existing networks also enabled attendance at appointments for further support. Attending groups and talking to peers was particularly useful for participants as it allowed them the opportunity to discuss anxieties and normalize their thoughts. In some cases, HCPs had facilitated support groups by signposting women to local groups, NCT courses and setting up WhatsApp groups. Women who felt that they needed something more than a support group sometimes found that being able to talk with a HCP frequently was effective:

I reached out to her (Health Visitor) and said, you know, “I keep having really bad thoughts.” And she was amazing, she was like, “I’ll do weekly calls with you, or I can come round to your house every week, and we can just talk about it.” She did offer to refer me for Talking Therapy but, actually, just having her there really helped. (E1077).

Those who utilized talking therapies discussed the benefits of engaging in therapy and understanding their own mental health. They also highlighted points for improvement which included the need for individual sessions rather than group, flexibility to participate remotely or face to face, and reducing the use of therapy ‘homework’ exercises. Participants expressed a preference for mental health support by professionals with expertise in perinatal issues rather than general mental health support as this was thought to be more beneficial. Some felt that the generic talking therapy they were offered was ineffective, with cited reasons being that it focused more on daily functioning, which was not the key problem, or because therapy was time-limited or its effects did not last:

I think a lot of the [CBT] stuff never had a long-lasting impact. […] and ultimately I think it’s about trying to deal with the root cause. (E01081).

3.7.4. Discharge from treatment

A further aspect of perceived ineffective treatment was being discharged from care too soon. Women feared being left to cope with problems alone, and questioned why services could not be flexible in providing less frequent appointments but over a longer period:

I’d got to a point where, because I was phoning her, I was on the phone to her weekly, a lot had not really changed in my life. So, I probably would have preferred her, rather than discharging me, turn it to more infrequent calls. So, you know, just popping in, “I’m just checking in, how are you doing?” (E07192).

3.8.1. Confidence in accessing services

If women overcame concerns about implications of engaging with services, a period followed of building up to making a telephone call or speaking with a HCP. This was facilitated by having an ongoing or trusting relationship with an HCP:

I think at that point I knew I could call up, I called up the talking therapies team and they signed me up to a new mothers and baby group which was really, really good. (E10090).

However, not all women were confident in speaking with services; for example, women whose first language was not English or who had recently come to the UK found navigating services difficult:

I did talk to the midwives, they offered me, like I say, if you want to you can do a clinical service, attend a psychiatric service. And, then they provide me the information, but it’s … But it seems like the information they give me is overwhelming. Well, like you have to apply (to) the clinical service yourself. … I mean the procedure is quite difficult for me so I do not want to do it. So it ended up I did not seek. (E01042).

3.8.2. Ability to engage with intervention

Once women had entered a service, confidence in engaging was high, although there were specific processes that were difficult such as completing CBT ‘homework’ due to lack of time or energy, and technological difficulties with online appointments:

It was very, “Oh, you need to do the homework and you need to do the work, otherwise it will not work,” and it was like, well, I’m really struggling… because I cannot even manage to get ready, get dressed some days. […] It was just making things worse really and I think it would have been better if he had approached it, as like, “What do you feel you could do, as the first step?” Then it might have just been something really tiny, that I felt like I could build it from there. (E12127).