Barriers to addressing perinatal mental health issues in midwifery settings

Background: poor perinatal mental health is linked to various adverse pregnancy and child outcomes. Despite having a holistic philosophy of care, similar to other maternity care settings, perinatal mental health issues often remain under-diagnosed and untreated in midwifery settings. Aim: to determine midwives' perceived barriers to the screening, referral, and management of perinatal mental health issues. Design: integrative review. Methods: the following databases were searched: MEDLINE, CINAHL, EMBASE, and PsycINFO. We included qualitative, quantitative, and mixed methods studies published in a peer-reviewed journal in English. Two reviewers independently extracted data and subsequently integrated the extracted data into a single data matrix. The data matrix was compared iteratively across primary data sources to identify themes and sub-themes. The identified barriers to screening, management and referrals were subsequently categorized into provider-level and system-level barriers. The relevance and methodological quality of the included studies were evaluated using appropriate checklists. Findings: three hundreds and fifty six articles were retrieved. Twenty studies met the inclusion criteria and were included. Insufficient/lack of training, lack of clarity regarding the scope of practice and time constraints were common provider level barriers across various stages of addressing mental health issues from identification to management. The system-level barriers were more complex and diverse and included unclear pathways and unlinked services, lack of local guidelines or policies, continuity of care, structured office procedures, clinical support and supervision and accessible educational resources, scarcity of available referral resources, complex bureaucratic processes and challenges related to expansion of the scope of practice. Conclusions and implications for practice: training, expansion of the scope of practice and collaborative care are central for successful screening, management and appropriate and timely referrals of perinatal mental health issues. An integrative model of care may address fragmentation in perinatal mental health services and enable a holistic midwifery care.