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