Predictors of postpartum depression service use: A theory-informed, integrative systematic review

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Contents lists available at ScienceDirect

Women and Birth journal homepage: www.elsevier.com/locate/wombi

Predictors of postpartum depression service use: A theory-informed, integrative systematic review Rena Bina The Louis and Gabi Weisfeld School of Social Work, Bar Ilan University, 5290002 Ramat Gan, Israel

A R T I C L E I N F O

A B S T R A C T

Article history: Received 11 November 2018 Received in revised form 15 January 2019 Accepted 16 January 2019 Available online xxx

Problem: Postpartum depression affects many women globally, yet rates of treatment use are low. A comprehensive view of factors associated with treatment use, from women’s and providers’ perspectives, based on a theoretical model is lacking. Background: Several studies examined various factors associated with postpartum depression service use; however, each study focused on a small number of factors. Aim: This study describes a systematic literature review based on the Behavioral Model of Health Service Use. The purpose of this article is to review and synthesize the available literature regarding factors associated with women’s mental health service use for postpartum depression from women’s and healthcare providers’ perspectives, and provide a comprehensive integrative view of the subject. Methods: Three electronic databases were searched, and 35 studies published up to 2018 in English language journals met inclusion criteria for review. Factors associated with postpartum depression service use were classified according to the Behavioral Model of Health Service Use’s constructs. Findings: Service use for postpartum depression is a function of a woman’s predisposition to use mental health services; individual, familial, and communal factors which enable or pose barriers to use of mental health services; and the woman’s perceived or evaluated need for treatment. In addition, societal determinants impact the woman’s decision to seek help directly or through impacting the health and mental health care service system’s resources and organization. Conclusion: This review illustrates key factors for researchers and practitioners to consider when treating postpartum women and developing interventions to enhance postpartum depression treatment use. © 2019 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd.). All rights reserved.

Keywords: Postpartum depression Service use Barriers Facilitators Literature review

Statement of significance

Problem Treatment rates for postpartum depression are low, and a comprehensive view of factors associated with mental health service use, based on a theoretical model is lacking. What is already known Several studies examined factors associated with mental health service use for postpartum depression, each focusing on a limited aspect of the subject, whether intra-personal, interpersonal, communal or system-based.

E-mail address: [email protected] (R. Bina).

What this paper adds This review synthesizes the literature regarding factors associated with postpartum depression, from women’s and providers’ perspectives, based on the Behavioral Model of Health Service Use, and provides a multifaceted comprehensive view of the subject.

1. Introduction Postpartum depression (PPD), a depressive episode with a postpartum onset, affects between 13–19% of women worldwide1 and has negative consequences on the woman herself and on her entire family.2 Despite various treatment modalities which have proven successful3 many women do not seek help for their PPD.4–6 Moreover, screening programs for PPD have been implemented around the world in order to assist in identifying women with PPD

https://doi.org/10.1016/j.wombi.2019.01.006 1871-5192/ © 2019 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd.) on behalf of Australian College of Midwives.

Please cite this article in press as: R. Bina, Predictors of postpartum depression service use: A theory-informed, integrative systematic review, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.01.006

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Fig. 1. The Behavioral Model of Health Service (Anderson& Newman,1973 in the context of postpertam depression.

symptoms, however, also among those who are diagnosed and referred for help, many do not follow up with recommendations.7,8 Due to the adverse effects of PPD and low treatment use, it is important to identify factors that may serve as barriers or facilitators to mental health service use for PPD. The question of why many women with PPD do not seek mental health treatment has been the focus of several studies over the past years and various factors were found to be associated with seeking such help [e.g., Refs. 9,10]. Nonetheless, an overall integrative picture, focusing on individual, societal and system-based factors, while combining women’s and healthcare providers’ perspectives, and guided by a theoretical model, is lacking. A full understanding of the various factors which may be associated with seeking mental health treatment for PPD is important in order to develop programs tailored to women’s needs which reduce societal and system-related barriers, ultimately assisting in raising the number of women who receive needed help. The Behavioral Model of Health Service Use (BMHSU 11 ;) offers a comprehensive multifaceted explanation of service use and allows to examine how multiple intrapersonal, interpersonal, societal, and system-based factors influence women’s service use for PPD. Hence, it was chosen to guide the review of the literature. 1.1. The behavioral model of health service use The BMHSU proposes that a number of factors contribute to a person’s use of health services when faced with an illness, such as PPD. As depicted in Fig. 1, these factors include individual determinants, societal determinants and healthcare1 system determinants. The individual determinant include the person’s predisposition to use services, factors that hinder or enable one’s service use, and one’s need for care. Additionally, societal determinants impact the individual determinants directly and through the healthcare system. As a result, the person decides whether or not to use services.11,12 The purpose of this article is to review and synthesize the available literature regarding factors associated with women’s mental health service use for PPD from women’s and healthcare providers’ perspectives, and provide a comprehensive integrative view of the subject, based on the BMHSU. Findings of this review

1 The BMHSU originally referred to healthcare issues and therefore to the healthcare system, however as this review focuses on a mental health issue, the mental healthcare system will be referred to as well.

elucidate key factors for researchers and practitioners to consider when developing programs to promote mental health use for PPD. 2. Methods A systematic literature review was conducted to identify factors associated with mental health service use for PPD. Three electronic databases were searched in order to find studies that met inclusion criteria, PubMed, APA Psychnet and Social Work Abstract. The databases were searched by the author and a research assistant independently with a combination of the following search terms: “postpartum depression”, “postnatal depression”, “postpartum distress”, “seeking help”, “utilization”, “use”, “barriers” and “treatment”. All databases were searched through October 19, 2018. Included studies were published up to 2018 (including). 2.1. Selection criteria Studies were included in the review if their focus of analysis was on factors associated with service use for PPD among women aged 18 and above. Studies were also included if they focused on the broader term “postpartum distress”, which includes other emotional distresses (such as anxiety) in addition to depression. Studies were excluded if they were not primary sources, and if they focused on prenatal or perinatal depression, as seeking help experiences of pregnant women may differ from those of postpartum women.13 However, if a study focused on the perinatal period and performed a separate data analysis for factors associated with PPD it was included in the review with reference only to findings from the postpartum period. Studies were excluded also if they described reasons for not seeking help but did not analyze them in a qualitative or quantitative way. Finally, only studies published in English were included in this review. 2.1.1. Selection of studies Electronic database searches retrieved a total of 1065 articles. After duplicates were removed and each article had its title reviewed, 106 articles (representing 98 studies) were identified as potentially relevant. All abstracts of these potentially relevant articles were reviewed in relation to the inclusion and exclusion criteria. Unless the abstract clearly described an exclusion criterion, the full article (64 articles) was examined to determine whether it met the inclusion and exclusion criteria. Following the full-text review, 35 articles (representing 35 exclusive studies) met the eligibility criteria and were included in this review. The search

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as psychiatrists, psychologists, social workers and general practitioners. 3.2. Societal determinants The BMHSU suggests that societal determinants impact a person’s use of services. These determinants include political, physical and economic mechanisms of the external environment,12 as well as societal norms which refer to methods where social systems encourage or guarantee normal compliance by their members.11 3.2.1. Physical, political, and economic factors These factors were found to be dominant barriers to PPD help seeking in studies on immigrant and refugee women in the U.S. and Canada. Researchers found that unsettled immigration and economic status, social isolation, limited English proficiency,6,14 limited access to information about one’s rights, and fear of losing their infant and being deported14 were barriers to seeking services for PPD among these women. In addition, lack of culturally appropriate care was a barrier to seeking help for PPD among Vietnamese American women.15

Fig. 2. Review process of article for inclusion in systematic review(PRISMA flowchart).

was carried out by the author and a research assistant, each independently compiling a list of articles to be considered for inclusion in the review. Discrepancies between the two lists were discussed between the author and research assistant until a consensus was reached about each study. Information about excluded studies is available by request. See Fig. 2 for review process of studies for inclusion in this systematic review, according to PRISMA guidelines. All content of articles included in the review were analyzed with regard to inclusion criteria, i.e., factors associated with service use for PPD. Then, all factors found were grouped into “themes”, i.e., the components of the BMHSU. 3. Results As can be seen from Table 1, which depicts characteristics of the included studies, nearly half of the studies (n = 16) were carried out in the U.S, the rest were carried out in Australia (n = 5), U.K (n = 4), Canada (n = 4) or other countries (n = 6). Half of the studies used a qualitative study design (n = 17), most of which used in-depth interviews (n = 12). The other half (n = 17) used quantitative study designs, with most using surveys (n = 12). Most of the studies (n = 30) focused on women’s points of view regarding personal, community and system-related barriers, while the rest (n = 5) described service provider’s perceived barriers to detecting women’s PPD. 3.1. Integrative review of the PPD service use literature in light of the BMHSU services use According to the BMHSU the term “service use” refers to use of services provided by various healthcare providers (such as physicians and hospitals).11 In the case of PPD, and based on review of the literature, “service use” refers to turning to a professional caregiver for mental health treatment. Such treatment could include psychotherapy, psychopharmacology or any professional intervention that addresses reducing women’s depression, and could be given by various types of professional caregivers, such

3.2.2. Societal norms Societal norms also seem to impact mental health service use in the postpartum period. These norms emphasize the positive side of the postpartum period, expecting women to be happy and capable of coping on their own16 and to be “strong women”.6,17 These norms may place a societal stigma on women with PPD and may reduce their motivation to seek needed help.17 3.3. The health and mental health care system 3.3.1. Resources and structure According to the BMHSU,11 the health care system, specifically its structure and resources, influences a person’s decision to use services. Specifically, the less wait time and travel time, and the more equipment and personnel in a specific area, the more likely a person will be to access treatment. Structural barriers, including lack of transportation,6,14 long waiting time,17,18 long distance to care,4 and difficulty finding the appropriate provider within a reasonable time frame19 have been found to serve as women’s barriers to service use for PPD. 3.3.2. Healthcare providers Some studies examined structural barriers to PPD service use from healthcare providers’ (such as gynecologists, pharmacists, health visitors physicians and nurses) perspectives. These studies found that limited time available for PPD screening and consultation,20,21 no clear organizational guidelines for detecting PPD16,22 and low reimbursement for consultations 21 served as barriers to service provision for PPD. Also, limited mental health resources and services,18,21 overburdened agency staff,18 and healthcare environment not equipped or designed to offer mental health support17,20,22 served as barriers to PPD service provision. Other studies examined the difficulty of health care providers to detect PPD, which posed a barrier for women’s service use. Health care providers, such as obstetrician-gynecologists who routinely examine women at their six-week postpartum visit or health visitors, child health nurses and physicians who meet postpartum women with their babies at health check visits, come in contact, quite frequently, with women in their postpartum period. However, many times these providers do not detect women’s PPD.16,21,23–25 Reasons for this difficulty to detect PPD may be due to limited knowledge and experience regarding PPD,20,22 limited training for

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Table 1 Characteristics of articles included in the review. Authors

Country

Sample size Participants’ characteristics

How was PPD/ postpartum distress assessed?

Aim of study2

Azale et al.4

Ethiopia

N = 385

PHQ-9 ≧ 5

To examine factors associated with seeking Quantitative (home mental health care interviews)

Author5

Israel

N = 88

EPDS ≧ 9

To examine factors associated with seeking Quantitative mental health treatment (telephone interview survey)

Callister et al.6

USA

N = 20

PDSS-Spanish version > 60

To describe problems with finding and accessing treatment for PPD

Qualitative (indepth interviews)

EPDS ≧ 10 BDI-II ≧ 16

To examine mental health treatment rates at 3 and 4 months postpartum for women who screened positive for PPD symptoms

Quantitative (telephone or mail screening and survey)

Self-identified postpartum mood disorder (PPMD)

To explore enablers and barriers for women Qualitative (into seeking help for a PPMD depth interviews)

EPDS ≧ 18

To describe views of women with high levels of PPD symptoms regarding acceptance of postpartum care for their depression by health visitors To describe how immigrant and refugee women with PPD seek help and access health care, and what external factors might contribute to the health care practices of these women. To explore factors that influence a decision to seek mental health Services for PPD

Women 1–12 months postpartum with PPD symptoms; door-to-door recruitment Women 2 months postpartum with PPD symptoms; recruited from a hospital maternity department after giving birth. Hispanic immigrant women 6– 12 months postpartum with PPD symptoms; recruited from a community health center Women who were identified with PPD symptoms at 2 to 4 weeks postpartum and/or at 2, 3, and 4 months postpartum and were encouraged to seek treatment; recruited in hospital after giving birth Women 0–24 months postpartum with previous or current postpartum mood disorders; recruited from well-baby clinics Women 6 months postpartum with PPD, registered with a GP practice participating in the PoNDER trial

USA AndrewsHorowitz & Cousins7

N = 122

Foulkes et al.9

Canada

N = 10

Slade et al.10

UK

N = 39

O’Mahony et al.14

Canada

N = 30

Immigrant and refugee women with PPD

Ta Park et al.15

USA

N = 15

EPDS ≧ 10 Vietnamese women up to 1 year postpartum; recruited via flyers in grocery stores, community centers, and obstetrician and pediatrician waiting rooms, as well as referrals from community partners and word of mouth Health visitors in Primary Care Trusts N/A

No information

Brown & UK Bacigalupo16

N=6

Edge & MacKian17

UK

N = 12

EPDS ≧ 11 Black Caribbean women 6 months postpartum; recruited from community clinics and a large hospital

Boyd et al.18

USA

N = 16

Guy et al.19

USA

N = 25

Elkhodr et al.20

Australia

N = 20

N/A Community health workers working within a community nonprofit agency serving low-income postpartum women CES-D ≧ 16 Low income women 12–24 months postpartum (15 of them had depressive symptoms) Community pharmacists N/A

Pawils et al.21 Germany N = 1034

Gynecologists

N/A

Santos Junior Brazil et al.22

N = 17

physicians and nurses in primary healthcare settings

N/A

Abrams et al.23

N = 14 women; N = 11 community key informants; N = 12 service providers

Low-income ethnic minority women Self-report of PPD who experienced PPD symptoms in the symptoms past year; recruited from Women, Infant, and Children (WIC) federal nutrition program clinics

2

USA

Study design

Qualitative (indepth interviews)

Qualitative (indepth critical ethnographic interviews) Qualitative (semistructured interviews)

To determine how health visitors identify PPD and the implications this has for practice To explore Black Caribbean women’s approaches to help-seeking for their depression and their experiences of receiving help from professional helpgivers To examine providers practices, barriers, and facilitators in mental health referrals for women with PPD

Qualitative (semistructured interviews) Qualitative (indepth interviews)

To share knowledge and beliefs about seeking help for PPD symptoms

Qualitative (focus group)

To explore community pharmacists’ perspectives on their potential roles in perinatal mental health promotion and factors affecting these roles To assess barriers for diagnostics and management of PPD To describe primary healthcare physicians’ and nurses’ knowledge and experience in screening and treating women with PPD factors preventing adequate care of PPD, To investigate perceived barriers to mental health service use for PPD among lowincome ethnic minority mothers, from individual, community, and providers’ perspectives

Qualitative (semistructured interviews)

Qualitative (focus groups)

Quantitative (survey) Qualitative (openended interviews, observations, and field diary records) Qualitative (focus groups and in-depth individual interviews)

If the study had a number of aims, listed here are only the aims related to seeking help for PPD.

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Table 1 (Continued) Authors

Country

Sample size Participants’ characteristics

How was PPD/ postpartum distress assessed?

Bilszta et al.24

Australia

N = 40

Mean EPDS = 13.9 (SD = 6.9)

Sword et al.25 Canada

N = 18

Holt et al.26

N = 469

Australia

New McCarthy & McMahon27 Zealand

N = 15

Martinez et al.28

Chile

N = 63

McGarry et al.29

USA

N = 337

Huang et al.30

USA

N = 1392

Kozhimannil et al.31

USA

N = 1850

ZittelPalamara et al.32

USA

N = 45

Byatt et al.33

USA

N = 27

Reilly et al.34

Australia

N = 380

Maloni et al.35

USA

N = 53 women

Women experiencing PPD and receiving treatment or attending support groups

Aim of study2

To gain insight into how women’s experience of PPD influences their beliefs and attitudes towards acknowledging their distress and seeking treatment To explore care seeking among women Women 8- weeks postpartum, 4 weeks EPDS ≧ 12 post positive PPD screening at a local And/or positive after public health nurse referral for public health unit’s Healthy Babies, answer on question probable PPD, including responses to being Healthy Children Program. 10 referred, specific factors that hindered or facilitated care seeking, experiences seeking care, and responses to interventions offered To examine whether a brief motivational EPDS ≧ 13 and/or Women 4 weeks- 12 months postpartum (148 of them experienced positive answer on interviewing intervention delivered by postpartum distress); recruited from question 10 Maternal and Child Health Nurses during Maternal and Child Health Clinics BDI ≧ 20 routine emotional health assessments DASS ≧ 10 improves help-seeking for distress following childbirth Clinical interview Women with PPD who had received To investigate the acceptance and treatment from a community mental experience of treatment for PPD health service and were discharged within the past 18 months To examine predictors of no access to Women 2–6 months postpartum with EPDS (authors did PPD who participated in monitoring of not indicate what treatment in women with PPD in public child health in primary care centers the cutoff score health centers was) and confirmation of diagnosis of Major depressive postpartum episode according to the structured psychiatric interview MINI Women 2–6 months postpartum who Positive answers to To investigate demographic differences reported having PPD on the Utah 2 questions between women who report PPD Pregnancy Risk Assessment Monitoring regarding mood symptoms and seek help versus those who System (PRAMS) do not seek help Women 6–12 months postpartum who Moderate to severe To examine help-seeking patterns by race/ had moderate to severe depression depressive ethnicity symptoms on the symptomatology; sampled via registered births from the National CES-D Center for Health Statistics vital statistics system To characterize racial-ethnic differences in Initiation of Medicaid recipient women 6 months postpartum who initiated postpartum antidepressant mental health care utilization associated treatment or mental health care with PPD outpatient mental health services To examine connection to desired Women experiencing PPD symptoms; Self-identified as recruited via newspaper having experienced treatment in women with PPD symptoms advertisements and referrals from local PPD OB/GYNs Women 3–36 months postpartum with Self-identified To explore factors that hinder and facilitate history of perinatal engaging women in treatment via pediatric a history of perinatal depression or emotional complications; recruited depression, anxiety setting for PPD from a community organization or other emotional providing education and advocacy for complications perinatal women. Women were asked To examine whether assessment of mental Women 1–2 years postpartum who participated in the Australian if they had been health, received with or without referral for Longitudinal Study on Women’s Health asked by their additional support, is associated with help(ALSWH) and experienced significant health practitioner/ seeking during the postpartum emotional distress during the s about their postpartum period current emotional health (e.g., given a questionnaire to complete) or mental health history EPDS ≧ 6 Women 2 weeks to 6 months To determine women’s barriers to postpartum with PPD symptoms who treatment for PPD had been hospitalized for pregnancy complications; internet recruitment.

Study design

Qualitative (focus groups)

Qualitative (indepth, semistructured telephone interviews)

Randomized controlled trial

Qualitative (individual interviews) Quantitative (structured telephone interview)

Quantitative (administrative data analysis) Quantitative (administrative data analysis)

Quantitative (administrative data analysis)

Quantitative (telephone interview survey) Qualitative (focus groups)

Quantitative (survey)

Quantitative (online survey)

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Table 1 (Continued) Sample size Participants’ characteristics

How was PPD/ postpartum distress assessed?

Aim of study2

Study design

Prevatt and USA Desmarais36

N = 211

Self-identification of postpartum mood disorder

To explore perceived barriers and facilitators to disclosure of postpartum mood disorder symptoms to healthcare professionals

Quantitative (online survey)

McIntosh37

Scotland

N = 38

To explore help seeking patterns and experiences

Qualitative (semistructured interviews)

Thomas et al.38

USA

N = 30

Woolhouse et al.40

Australia

N = 204

Dennis et al.41

Canada

N = 547

Authors

Country

Bauer et al.43 USA

N = 73

Yawn et al.44

N = 650

USA

Women within 3 years postpartum; recruited through OB-GYN and pediatrician offices, practice websites, and media advertisements (107 of them reported experiencing disrupted postpartum mood) Women 0–9 months postpartum with PPD symptoms; randomly selected from antenatal clinics

Self-report of depressed mood for at least 2 weeks after the first postpartum week Women’s stories posted on an online Self-identified as group “I had post-partum depression” having experienced PPD EPDS ≧ 10 and/or First time mothers 6-9 months postpartum who reported emotional positive answers to difficulties; recruited from women who questions asking booked to give birth at metropolitan whether women public hospitals had experienced depression lasting 2 weeks or longer and/or intense anxiety or panic attacks in the previous 3 months STAI > 40 Chinese immigrant women 4 weeks postpartum; recruited via public health home visitors, community-based health organizations, study flyers, and advertisements in Chinese newspapers Women 0–2 years postpartum whose EPDS (no cutoff children received medical care at a score indicated) pediatric clinics, screened positive for PPD symptoms and were recommended to seek additional help Women 5–12 weeks postpartum (399 EPDS, PHQ ≧ 10 in intervention group- PPD screening, And/or suicidal 255 in TAU group- no specific ideation screening; recruited from family medicine research network practices

PPD detection,16 or difficulty in differentiating between a mother’s normal distress, as a result of her adjustment to her new role, and a psychiatric disorder.18,23 Physicians may also minimize a woman’s distress and normalize her symptoms as they want to be reassuring.24,25 Furthermore, perception that PPD is solely a domain of psychiatry 22 or poor communication between health care providers and mental health care providers 18,25 may pose further barriers to treating women with PPD. On the other hand, a good relationship between provider and women may facilitate PPD detection.16,20 Also health visitors reported that having a structured screening tool, such as the EPDS, facilitated their detection of PPD.16 Moreover, interventions carried out by healthcare providers to increase seeking help, namely motivational interviewing,26 have been found to increase seeking help rates among women with PPD. Also, if healthcare providers who detect women with PPD refer women to a mental health provider,27 arrange a first appointment with a mental health provider or accompany women to an initial appointment, women will be more likely to seek that help.18 3.4. Individual determinants: predisposing factors According to the BMHSU individuals have a predisposed tendency to use services. Predisposing factors include demographic and social structural characteristics as well as health beliefs. This

To explore facilitators and barriers to help seeking for PPD

Analysis of unsolicited, online stories To investigate what women say about Quantitative seeking help for emotional difficulties after (computer-assisted telephone childbirth interview)

To determine if healthcare utilization varies Quantitative (telephone by anxiety group membership (noninterviews) anxious, anxious-improving, consistently anxious) To describe the rate at which mothers sought treatment after a positive PPD screen & to explore factors that predict mothers’ help seeking behavior

Quantitative (telephone interview survey)

To determine the effect of a practice-based Intervention effectiveness study training program for screening, diagnosis and management of PPD

predisposed tendency may influence perceptions of need and preferences toward use of health services.11 3.4.1. Socio-demographic factors Findings from the literature are inconclusive as to whether socio-demographic factors influence postpartum women’s service use for depression. In a study among Israeli postpartum women, socio-demographic factors, namely age, number of children and level of income, were not significant predictors of service use for depression5 ; however in a study done in rural Africa, being multiparous was associated with seeking help for PPD4 and in a study done in Utah researchers found that being older was a significant predictor of seeking help for PPD. Furthermore, having a history of depression or anxiety and/or treatment for it was found to be associated with service use for PPD26,28,29; however, if this past experience was a negative one it served as a barrier to service use.17,19 Another study which looked at socio-demographic factors found that women living in a rural community were more likely to seek help for PPD compared to women who lived in an urban community.29 3.4.2. Social structural factors These factors refer to the status of a person in society as measured by characteristics such as education and ethnicity. Researchers which examined the association between ethnicity and seeking help for PPD found that Caucasian women were more

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likely to seek help than non-Caucasian women,29–31 and US-born mothers were more likely to seek help than foreign-born mothers.30 In addition, being more educated was also associated with service use for PPD,29 and lack of language skills due to being an immigrant ware found to be a barrier to service use.14 3.4.3. Health beliefs Health beliefs are attitudes, values, and knowledge that people have regarding health and health services which may influence their perception of need and use of services.11 3.4.3.1. Attitudes and values. Several researchers described women’s negative attitudes towards healthcare providers’ conducts as impeding their help seeking for PPD. Women with PPD often perceived their health care providers as offering nonquality services, as being non-responsive to their needs or as dismissing their feelings and claiming they don’t need help, causing them to not want to share their emotional feelings.17,23–25,32 Furthermore, not knowing healthcare providers well enough or perceiving them as difficult to relate to emotionally caused women to decline meetings with them.10 Also, many times women were concerned with the side effects and suitability of medication9,15,17,19,23–25,32 and therefore did not seek help for their PPD. Furthermore, when women experienced healthcare providers as lacking training33 or knowledge9 regarding PPD, as avoiding addressing PPD,34 or as possibly sharing their depressed state with members of the community19 they did not turn to them or to other providers for help. Along the same lines, women’s confidence in mental health professionals was found to be associated with increased mental health treatment use.5 Finally, recognizing that something is emotionally wrong may cause women to worry that if they admit this to their health care providers they will be labeled as mentally ill and unfit mothers6,9,15,17,35,36 and their baby may be taken away from them.19,33,37 Along the same lines, fear of being stigmatized by family and society was mentioned by women in a number of studies as a barrier to seeking help.17,23,25,27 In addition, feeling shameful and a failure as a mother and woman due to PPD may also prevent women from admitting their feelings and turning for help.7 3.4.3.2. Knowledge. Lack of knowledge regarding PPD, namely not knowing what PPD is and what treatments may be available, was found as an important predictor of women’s not seeking mental health services.6,23–25,32,38 In addition, not knowing where to get help from9,15,32,35 and when to turn for help6 prevented women from seeking help. 3.5. Individual determinants: enabling factors According to the BMHSU, in order to use services, a predisposition is not enough; some enabling factors must be available to people in order to encourage their use of services. These may include personal resources, such as insurance and income, and familial and community resources, such as social support, which could help facilitate or serve as barriers to use of services.39 3.5.1. Individual resources Cost of care and insurance coverage are often mentioned as barriers to PPD treatment. The fact that insurance coverage for mental health problems is often limited and that out-of-pocket costs must be paid may prevent women from using services for PPD.7 Indeed, lack of insurance and inability to pay for services due to financial constraints prevented women from seeking help in a number of studies.4,6,14,15,23,35,38 On the other hand, other studies

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did not find a significant association between lack of insurance or level of income and under-use of services.5,29 Furthermore, lack of time6,35,36,40 and difficulty finding a caretaker for their baby6,17,35 were expressed by postpartum depressed women as barriers to seeking mental health services. Interestingly, in Abrams et al.’s23 study, child care was not expressed by women with PPD as a barrier to seeking help, but rather it was the service providers who conveyed that absence of child care was a barrier to seeking help. 3.5.2. Family and community resources The role of family and community as enabling factors in the seeking help process was examined in a number of studies in the PPD literature. Some studies found that encouragement by family and friends to turn for help, alongside expressions of concern and worry, served as an enabler for postpartum women to get help for their depression.10,25,38,36 Similarly, another study found that a relative’s referral to a mental health provider encouraged women to use that service.27 On the other hand, feeling that no one around ever experienced PPD and therefore could not help38 and feeling pressure from family and friends32 served as barriers to seeking help for PPD. Another community resource that women mentioned as an enabler for seeking help for PPD was having a comprehensive medical care system, offered at well-baby clinics, which met their own and their baby’s physical, psychological and emotional needs.9 3.6. Individual determinants: need The BMHSU proposes that predisposing and enabling factors are not enough to ensure service use, but rather individuals need to be aware of their condition, e.g. PPD, in order for use of services to take place. This need component is the most direct cause of health service use, and it may either be perceived by the individual or evaluated by the health care system.11 3.6.1. Perceived need The PPD service use literature emphasizes women’s attribution of their sad feelings to natural hormonal changes and their expectation that they will naturally disappear, therefore not feeling a need to get help.4,17,24,25,27 Some researchers pointed to women’s denial of their condition and of their need to seek help, minimizing the seriousness of their condition and not recognizing the importance of seeking help.7,15,23,40 Moreover, some women felt that they were able to deal with their difficulties on their own and therefore there was no need for them to seek help.4,40 Other women attributed their feelings to physical causes and therefore sought physical help and not mental health treatment.4 Yet others attributed their feelings to external pressures (such as stresses of motherhood), perceiving themselves as suffering from a normal reaction to abnormal stresses and not perceiving themselves as needing help.37 Perceived need as a seeking help enabler was illustrated in a number of studies, demonstrating that recognition and awareness of difficulties and symptoms were a trigger for seeking help for PPD.10,25 Other researchers found that women who turned to mental health services for their PPD did so because their normal functioning had significantly deteriorated and they wanted to relieve their symptoms.27,38 Interestingly, the association between severity of PPD and treatment use is unclear. Some researchers found that women who had high depressive symptomatology were more likely to receive psychotherapy than women with low symptomatology,5,7 while others found that severe symptoms made it difficult for women to seek help.15,32 Along the same lines, Dennis et al.41 found that a higher percentage of women with improving anxiety during the postpartum period saw a mental health professional compared to

Please cite this article in press as: R. Bina, Predictors of postpartum depression service use: A theory-informed, integrative systematic review, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.01.006

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women who remained anxious; however, these differences were not statistically significant. The findings of these studies render a more deep exploration of the connection between levels of postpartum distress and seeking treatment.

should be further investigated in order to more fully understand their complex impact on seeking help for PPD.

3.6.2. Evaluated need Routine screening has been found to raise rates of PPD detection, as many women are not aware of the severity of their depression and therefore do not recognize their need for help.42 Overall, studies that examined the impact of screening for PPD on women’s seeking help found the screening to be useful, although treatment use rates remained quite low. These screening procedures took place in different settings around the world and most of them used the EPDS as a screening tool for PPD. Studies that checked the rate of women who screened positive for PPD symptoms and sought help found service use rates to range from 12% to 37%.5,7,43 Other studies compared women who were screened to those who were not screened for PPD and found that rates of seeking help were higher among those who were screened as compared to those who were not screened34,44 and among those who were screened and referred as compared to those who were screened and not referred.34 Furthermore, women who experienced a more shared decision-making style from those who screened them for PPD (i.e., providers explained the importance of seeking help and what treatment options were available and the benefits and disadvantages of each) and whose providers used the term “postpartum depression” to describe screening results were more likely to seek further treatment than those who experienced a less shared-decision-making style and who did not recall their providers mentioning the term “postpartum depression”.43

Reviewing a large body of literature requires attention to many details throughout the search, study selection and review process, and therefore it may be that some studies on factors associated with PPD service use were accidently excluded. Another limitation pertains to the fact that the BMHSU does not account for use of non-professional services. As a consequence, the literature review did not focus on factors associated with non-professional help for PPD, although many times women turn to these sources of help, such as to family, friends and pastors5 which seem reduce PPD symptomatology. However, this was beyond the scope of this review and further literature reviews could examine these types of help sources. Finally, the populations and settings of the various studies included in this literature review were diverse, and the fact that each study focused on only a number of factors and that there were contrasting findings could be accounted for by this diversity. It is therefore recommended to further investigate the multifaceted factors associated with PPD service use among various populations.

4. Discussion Results showed that a significant number of studies examined factors associated with service use for PPD. The purpose of this literature review was to systematically analyze this body of research based on an integrative over-arching model of health service use and to provide a comprehensive overview of the subject, and the BMHSU seems to fit in with the postpartum mental health use literature. Findings show that mental health service use for PPD is influenced by a woman’s predisposition to use mental health services, including socio-demographic factors, attitudes and values towards providers and towards using mental health services, and knowledge regarding PPD and available treatments; individual, familial, and communal elements which facilitate or impede use of mental health services; and the woman’s perceived or evaluated need for treatment. In addition, societal factors, such as issues related to immigration and societal norms, seem to impact the woman’s decision to use services directly or through the health and mental health care service system. There may also be factors within the health care system which may hinder the detection of PPD and women’s referral to treatment. In analyzing the literature, there seem to be some discrepancies among findings that should be further investigated. The impact of socio-demographic factors on service use for PPD is not always clear, especially with regard to age and number of children.4,5 Also the relationship between individual enabling factors, i.e., level of income, insurance status and child care availability, and PPD service use is not clear as contrasting results were found [e.g., Refs. 6,23,29]. Severity of symptoms is yet another factor to be further investigated as it is not clear whether it promotes service use [e.g., Ref. 7] or hinders it [e.g., Ref. 15]. Finally, studies on the impact of screening procedures on PPD service use are beginning to build up, yet only three studies examined the impact of PPD screening on mental health service use and rates of seeking help following screening procedures remain quite low [e.g., Ref. 43]. These factors

4.1. Limitations

4.2. Implications Reviewing the literature regarding factors associated with seeking help for PPD will hopefully promote awareness of health and mental health providers to the fact that many women do not seek help and are not treated for PPD, and that this is due to various factors. There is a need to get more women into treatment, and discovering important facilitators to seeking such help should be a priority. Taking into account all components of the BMHSU can assist researchers and clinicians in understanding the complex nature of seeking help for PPD and in developing interventions and treatment engagement procedures which address personal, social, provider and healthcare-system barriers, ultimately enhancing mental health service use among women with PPD. Of important note is the screening procedure for PPD, which is a simple selfreport method, used by health and mental health providers to promote women’s awareness to their PPD and encourage mental health services use. In accordance with the review, more research is needed in order to determine the impact of such screening procedures on mental health service use. 5. Conclusion PPD is a common disorder with serious personal and familial consequences. Appropriate and timely treatment is crucial in order to help women cope with their situation and reduce the devastating consequences. The small numbers of women who utilize treatment for PPD is of concern, and the issue should be further examined with an understanding that a complexity of intrapersonal, interpersonal, communal and societal factors impact the seeking help process. The Behavioral model of Health Service Use seems to fit in with the postpartum help seeking literature, and provides a comprehensive multifaceted overview of factors associated with seeking help for PPD, illustrating key factors for researchers and practitioners to consider when treating postpartum women and developing interventions to enhance postpartum treatment use. Ethical statement This study did not involve human subjects. It solely included review of published literature.

Please cite this article in press as: R. Bina, Predictors of postpartum depression service use: A theory-informed, integrative systematic review, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.01.006

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Please cite this article in press as: R. Bina, Predictors of postpartum depression service use: A theory-informed, integrative systematic review, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.01.006