Authors: Dana Katz Krepak, Avital Bilitzky Kopit, Aya Biderman, Ilan Yehoshua, Limor Adler
Categories: Research, Postpartum depression, Qualitative study, Primary care, Early diagnosis, Treatment
Source: BMC Primary Care
Authors: Dana Katz Krepak, Avital Bilitzky Kopit, Aya Biderman, Ilan Yehoshua, Limor Adler
Postpartum depression has a significant impact on the lives of the mother, her family, and the newborn. Yet, there is a significant delay in the diagnosis and treatment. Although many primary-care physicians believe it is their role to identify and treat postpartum depression, many of them do not perform screening modalities, and do not initiate treatment. The aim of this research is to shed light on the experiences of the mothers and to describe the process of diagnosis and treatment from their perspective.
In this qualitative study, we conducted in-depth interviews with Israeli women experiencing postpartum depression in the past 3 years. We utilized thematic analysis model to identify themes related to the diagnosis and treatment of postpartum depression. Each researcher independently read the interviews and identified relevant ideas and quotes. Ideas were coded, and then grouped into central themes and sub-themes.
Nine women aged 29 to 45 participated in the study. We identified four main themes. The first was barriers in diagnosing postpartum depression. The women mentioned that physicians do not inquire about their mental state, lack of availability and coordination, women’s shame and judgmental attitude by the medical stuff. The second theme relates to the unique elements in postpartum depression including triggers, violence towards the baby, suicidal thoughts and difficulty in mother-baby bonding. The third theme was facilitators and barriers in the treatment. Women highlighted the importance of the family physician, other healthcare professionals, resources outside the healthcare-system, and fear to receive medications. The fourth theme pertains to women’s recommendations for improving the situation, such as getting support from other women, forming a specialized inpatient unit, administering the screening at a later period and discussion about depression before childbirth.
In this study, women highlighted the difficulties they faced in receiving treatment for postpartum depression within the framework of primary-care. In addition, we emphasized unique aspects that require specific attention from the medical-team. Training healthcare providers to properly address postpartum depression is of significant importance. It is essential to increase the awareness among physicians so that they can correctly diagnose and offer treatment when needed.
The online version contains supplementary material available at 10.1186/s12875-025-03004-8.
Postpartum depression (PPD) affects 12–15% of women after childbirth [1]. The prevalence in Israel is estimated around 5–20%, depending on ethnic background [2, 3]. According to the DSM-5, PPD is characterized as major depression that initiates either during pregnancy or within four weeks of delivery [4]. In several studies and according to WHO definitions, PPD can be diagnosed up to 12 months after childbirth [5, 6].
PPD negatively impacts women’s quality of life and the ability to care for and establish a proper connection with the infant. It is linked to the emotional, cognitive, and behavioral development of the child [7]. PPD poses a risk for maternal mortality [8] and health related issues in children [9, 10].
Despite its high prevalence, there is often a delay in diagnosis and treatment of PPD. The US Preventive Services Task Force (USPSTF) recommends screening for depression among pregnant and postpartum women [11]. Evidence suggests that screening for PPD can reduce depressive symptoms in women with depression and decrease the prevalence of depression in the population, especially when combined with treatment [12].
Treatment guidelines for PPD involve a combination of psychotherapy and antidepressant medications [5]. Yet, many women do not receive treatment for various reasons, including a lack of trust in the mental health system, fear and stigma associated with taking medications, guilt, and concerns about the effects of medications on breastfeeding [13, 14]. Some women also describe concealing their feelings to family physicians due to emotional barriers and their belief that only pharmacological treatment will be offered. Physicians, on the other hand, characterize the current health system as hindering early detection of PPD [15].
The healthcare system in Israel operates as a public health system funded through taxes and government allocation. It is managed by four health maintenance organizations (HMOs). During pregnancy, women are cared for by a family physician, gynecologist, and a pregnancy support nurse. After childbirth, women attend regular visits at “mother and child clinics” and receive pediatrician check-ups, postpartum gynecological examinations, and family physician consultations according to their preferences. Screening for PPD is recommended at two-time during pregnancy from the 26th week and 4–9 weeks after delivery. The recommended screening tool is the Edinburgh Postnatal Depression Scale (EPDS) questionnaire, which is translated into Hebrew, Russian, and Arabic. If a woman scores 10 or above on the EPDS, nurses are advised to assess her daily functioning and provide supportive counseling, with follow-up and reassessment weekly. In acute situations, nurses should refer the women to a mental health professional.
Several Israeli studies have addressed the challenges surrounding PPD diagnosis and treatment. Glasser et al. surveyed primary care physicians and found that while nearly all recognized the importance of identifying PPD, few were confident initiating treatment, with most preferring to refer patients to other professionals [16]. Simhi et al. examined treatment preferences among 1,000 Israeli mothers and found that those with PPD symptoms preferred psychotherapy and community-based care over pharmacological or digital interventions. The preferred professionals were psychologists, alternative therapists and family physicians, underscoring a gap between women’s preferences and available services [17]. Bina et al. studied help-seeking behavior among Orthodox Jewish women and reported that only 24% of those diagnosed with PPD sought professional help often due to cultural stigma and lack of trust in mental health services [18]. Additionally, a focus group study among Indigenous Bedouin women revealed various barriers to treatment of PPD including stigma, lack of culturally appropriate services, and structural inequalities in healthcare access [19]. These findings demonstrate that despite national screening initiatives, substantial cultural, systemic, and individual barriers persist, limiting women’s access to timely and appropriate PPD care.
The aim of this study was to explore women’s perceptions and experiences regarding the diagnosis and treatment of postpartum depression (PPD) within the primary care setting. This research seeks to illuminate factors that support or hinder diagnosing and treating PPD in order to improve the knowledge and training of physicians and nurses in primary care. Understanding the difficulties, concerns, and expectations of women suffering from PPD will enable primary care teams to provide more comprehensive and individually tailored treatments to these women.
We chose the qualitative approach to understand women’s perceptions and thoughts. We performed in-depth interviews with women who experienced PPD during the last 3 years and were affiliated with Maccabi Healthcare Services (MHS), the second-largest HMO in Israel. MHS provides coverage for approximately 2.8 million individuals in Israel, more than a quarter of the entire population of Israel. The 3 years’ timeframe was chosen to balance recall accuracy with ensuring enough recovery time for reflection. The research was approved by the Helsinki Committee of MHS (0061-20-MHS). All participants signed an informed consent form before the interviews. The interviews were conducted with a semi-structured interview guide (supplementary material). The average interview duration was 60 min, conducted in Hebrew via Zoom (a video conferencing platform). All the interviews took place during 2021. The sample size was reached when saturation of themes was achieved. The interviews were recorded and transcribed. Subsequently, all researchers analyzed the transcripts, identifying key themes related to the diagnosis and treatment of PPD. When content related to violence or danger arose during the interview, the woman was directed to receive appropriate treatment by the relevant authority. Additionally, based on the needs identified during the interviews, the interviewer provided assistance and made recommendations for further treatment.
We chose to conduct individual in-depth interview in order to create a safe, private environment in which participants could freely share sensitive and personal experiences. PPD is often associated with stigma, feelings of shame, and emotional vulnerability; thus, one-on-one interviews were most appropriate for encouraging open and honest communication. Moreover, in-depth interviews enabled the interviewer to adapt questions in real-time based on participants’ responses.
The Inclusion criteria for the study women above the age of 18 who suffered from PPD in the last 3 years and had recovered, capable of giving consent for this research, and Hebrew-speaking. Exclusion criteria included women experiencing PPD symptoms during the interviews and women suffering from severe depression or other psychiatric disorders not stabilized during the interviews.
Recruitment of participants was done through social networks. The principal investigator posted an invitation message in several Facebook groups focused on maternal health and parenting in Israel. Women who were interested in participating responded privately via direct message to the principal investigator. Each respondent then received a follow-up phone call during which the principal investigator assessed their eligibility. During the preliminary phone call with each potential participant, the investigator inquired whether the woman had received a formal diagnosis of PPD. This diagnosis was confirmed either through a physician’s clinical assessment based on DSM-5 criteria or through the mother and child clinics system following a positive result on the Edinburgh Postnatal Depression Scale (EPDS). Only women with a formal diagnosis, as defined by these criteria, were included in the study. Women experiencing PPD or other significant mental health symptoms at the time of screening were excluded from the study. This process ensured appropriate and ethical recruitment. Demographic information was also collected for each participant, including age, birth number, place of residence, and education level.
After completing the interviews, a professional transcriber transcribed each interview. DK, ABK, LA, and AB read the transcribed interviews. At least two researchers read each interview. The analysis followed the six-step thematic analysis model proposed by Kiger and Varpio [20]. In the first step, each researcher read the transcriptions to gain an understanding of the data. In the second step, each researcher independently identified ideas within the interviews and created codes reflecting concepts related to the diagnosis and treatment of PPD. The codes created by each researcher were consolidated into a shared Excel file, which included the codes along with corresponding quotes relevant to each code. Next, the codes were combined to create 17 sub-themes, which were then grouped into four main themes. In the subsequent collaborative discussion, each theme was thoroughly reviewed, and names were assigned to them. The final step involved writing the manuscript, including the translation of the selected quotes from Hebrew to English. Quotes were translated from Hebrew to English by AB. The translations were then reviewed and refined by a professional translator. This two-step process was undertaken to preserve the original intent, tone, and contextual meaning of participants’ narratives.
To ensure the validity and reliability of our findings, we adopted several strategies based on established qualitative research standards. Investigator triangulation was implemented, with at least two researchers independently analyzing each transcript and contributing to the coding framework. An audit trail was maintained, documenting coding decisions, theme development, and selected participant quotes in a shared file accessible to the entire research team. Regular team discussions allowed for reflection and consensus building. Prolonged engagement with the data and peer debriefing further enhanced the credibility and dependability of the analysis. These combined measures supported the overall trustworthiness of the study.
Nine women participated in the study and underwent in-depth interviews. Table 1 presents the study participants’ demographic characteristics. The average age was 35.8 years (range 29 to 45 years). All women in the study were secular Jewish. Most of the women reside in the central region of Israel. The majority of the interviewees experienced PPD after the birth of their first child (6 out of 9). Most of the women were educated, with 7 out of 9 having a university education.
Table 1Study participantsEducation levelResidenceBirth numberAge (years)PatientHigh schoolNorth Israel1381High schoolSouth Israel4452UniversityCentral Israel3373UniversityCentral Israel1314UniversityCentral Israel1395UniversityCentral Israel1336UniversitySouth Israel1377UniversityCentral Israel1298UniversityCentral Israel3339
In our study, we identified four main barriers in diagnosing postpartum depression, unique elements in postpartum depression, facilitators and barriers in the treatment of postpartum depression, and women’s recommendations for improving the diagnosis and treatment of postpartum depression. Every theme comprises four to five subthemes. (Table 2).
We present the four main themes, the subthemes, and some examples of the women’s citations from the interviews.
Table 2Challenges in diagnosing and treating postpartum depression in the primary care settingMAIN THEMESUBTHEMESBarriers in diagnosing postpartum depressionThe physician does not inquire about the woman’s mental stateLack of availability and coordination in the system for treating a woman experiencing postpartum depressionWomen’s shame as a barrier to diagnosisJudgmental attitudes by the medical staffUnique elements in postpartum depressionThe triggers for the onset of postpartum depression from the woman’s perspectiveViolence towards the babySuicide and suicidal thoughtsDifficulty in forming mother-baby bondingFacilitators and barriers in the treatment of postpartum depressionThe importance of the family physician in the therapeutic processThe importance of the healthcare system (the organization) in the treatment processResources and support factors outside the healthcare systemWomen’s fear to receive medications due to concerns regarding the babyWomen’s fear to receive medications due to concerns regarding themselvesWomen’s recommendations for improving the diagnosis and treatment of postpartum depressionGetting support from women who have experienced postpartum depressionThe need for a specialized inpatient unit for women with postpartum depressionAdministering the Edinburgh Postnatal Depression Scale (EPDS) at a later period after childbirth and not only immediately after deliveryDiscussion about postpartum depression during the pregnancy period
In relation to this theme, we recognized four the physician does not inquire about the woman’s mental state, lack of availability and coordination in the system for treating a woman experiencing postpartum depression, women’s shame as a barrier to diagnosis, judgmental attitudes by the medical staff.
Many women reported that physicians (family physicians, gynecologists, and pediatricians) did not inquire about their mental well-being, specifically regarding PPD.
‘I attended follow-up appointments, both at mother and child clinics and with the pediatrician. They didn’t ask me anything about myself; they didn’t inquire, and we only discussed the child. I also didn’t volunteer any information.’ (id #4).
‘When I meet with physicians, they don’t ask; they say that’s what mother and child clinics are for. Women physicians don’t check on that (on PPD), and at mother and child clinics, they give you a questionnaire, and you can mark everything as “fine”. There was no discussion about how I was feeling.’ (id #7).
The majority of women expressed frustration with the lack of availability of appointments for mental health treatment, including psychiatrists or psychologists, leading to delays in receiving diagnosis and treatment.
' I thought that the gynecologist would be more sympathetic, but he only referred me…Everything during the pregnancy revolved around the issues with my baby. Until the police were involved, no one knew that my condition was problematic. I talked to the family physician, and she gave me a referral, but I didn’t do anything about it because there are no available appointments with a psychiatrist’ (id #7).
‘After giving birth, I contacted the nurse with whom I had filled out the pregnancy questionnaire and told her I was depressed. She referred me to a gynecologist. I also told the gynecologist that I was depressed, and she told me that with the right treatment, it would pass. That was the end of it. She didn’t follow up. I kept searching for help all the time’ (id#1).
A number of women referred to shame as one of the major factors that delayed diagnosis. These women mentioned feeling shame both in front of their physician and their community.
‘It’s also a problem,* in my opinion*,* because we feel ashamed of our depression. Ironically*,* on Facebook*,* I dare to speak up and be open. But if I were going to a physician*,* I wouldn’t tell him because there are things I’d find easier to share if I were asked’ (id#6).*
‘I care a lot about what people will say. I returned to work when my son was 3 months old because I couldn’t handle him alone at home. I constantly thought about what people at work would say,* what they would say about me. I said that I wasn’t ready for treatment*,* not even in an outpatient hospitalization. And then*,* I just refused everything’ (id#3).*
Two women reported during the interviews that they experienced a judgmental attitude and a lack of empathy from the healthcare providers.
‘I went to someone (psychiatrist),* and it was a horrible experience. I felt that she was judging me… I left her crying; she judged me and criticized me. She asked me why I don’t sleep when he (the baby) sleeps. I said I clean the house*,* and she said*,* ‘You never relax and take a break?’ I felt extreme lack of empathy from her’. (id#8).*
Regarding this theme we identified four the triggers for the onset of postpartum depression from the woman’s perspective, violence towards the baby, suicide and suicidal thoughts, difficulty in mother-baby bonding.
Women raised issues in interviews that distinguish PPD from other types of depression. The triggers for PPD are different compared to depression at other stages in life. Additionally, concerns arise about the mother’s ability to care for and attend to the baby, as well as violence towards the infant. These elements highlight unique aspects that medical teams need to recognize and be aware of.
Two women described traumatic childbirth experiences and obstetric violence as triggers for PPD. Another two women outlined difficulties in breastfeeding as a significant trigger for the onset of depression.
‘Apparently,* the umbilical cord was wrapped around his neck (the baby)… The nurse*,* who had been nice all along*,* jumped onto the bed*,* held down my legs*,* opened a vein despite my request not to*,* and forcefully stripped me. From here on*,* it was a real trauma. They simply took me to the operating room. All I remember from this birth is being forcibly laid on the bed*,* looking up at the fluorescents*,* and hearing the sounds of the metal bed… Inside the operating room*,* I experienced violence. (id#3)*
‘We spent 6 weeks in the neonatal intensive care unit (NICU)…An endless battle with my desire to breastfeed,* it was crucial for me. My breast milk was the only thing I could provide her. I hardly slept. There*,* something inside me began to crack. Anxiety started. And then*,* when we were discharged from the NICU*,* I experienced a real breakdown’ (id#9)*.
‘Everything began with a traumatic birth,* as I almost died during labor. I spent 6 days in the delivery room*,* where they didn’t allow me to eat. For 6 days*,* I went without food. Eventually*,* they decided to perform a cesarean section. From there*,* it deteriorated because I lost a lot of blood. It further declined as I developed bacterial infection in my abdomen. So*,* I was hospitalized in an isolated department a month after giving birth. I didn’t see my child for a whole month. From there*,* it started to deteriorate. I developed a very severe depression‘(id#6).*
One woman shared a very difficult story of violence towards the baby during the period of depression. In this case the social worker, the welfare services and even the police were involved.
‘All the outbursts were around the baby’s sleep,* and at a certain stage*,* I would lose control. I would throw her on the bed*,* hit her*,* and close her in the room. The difficulty persisted for years*,* and I had outbursts’ (id#5)*.
‘From the clinic,* they called the police. This was because I confided that I wanted to harm the baby. The investigator told me there were allegations of child abuse‘(id#5)*.
Few women described an extremely difficult situation involving suicidal thoughts and even concrete plans for self-harm.
‘In the first few months after giving birth,* I thought it was just baby blues*,* but my mood swings and internal anger escalated. The inability to sleep*,* the scent*,* and the sounds from the operating room had a profound impact on me. I felt lost. I truly believed that it was better for my children without me…I wanted to do it with the car*,* to crash into a wall’ (id#3).*
‘I was very lonely,* and I wanted to die. There was a voice in my head saying that everyone would be better off without me. I couldn’t cope with it anymore’ (id#7).*
A number of women shared in interviews about the hard feeling of guilt due to the inability to connect with the baby and experience love towards them. The women described feeling detached from the baby for many months.
‘Part of the feeling was that I couldn’t love my daughter. I don’t want to hurt her,* but I don’t love her. I think I only fell in love with her in the last few months’ (id#7).*
‘I didn’t take care of the baby. In the hospital,* I didn’t breastfeed*,* but I pumped*,* did what needed to be done like a robot*,* pumping*,* pumping*,* pumping. I tried to make sure she was okay*,* but I didn’t feel anything. Like everyone talk about*,* a bonding’ (id#1).*
For this theme we identified five the importance of the family physician in the therapeutic process, the importance of the healthcare system (the organization) in the treatment process, resources and support factors outside the healthcare system, women’s fear to receive medications due to concerns regarding the baby, women’s fear to receive medications due to concerns regarding themselves.
During the interviews, women mentioned several factors that assisted them in the treatment process, such as family physicians, nurses at mother and child clinics, and mothers’ support groups. On the other hand, they also shared obstacles to receiving treatment, such as negative attitudes from healthcare providers and a fear that treatment might harm them or their babies.
Women described the significance of a family physician as a supportive and caring figure who assisted in the healing process, and the importance of the connection between the treating psychiatrist and the family physician. Women who did not receive assistance from a family physician and only received a referral to a psychiatrist expressed significant frustration.
‘One of the things that helped me is that my family physician is a community-oriented physician. I had her phone number; I could call her for help. She had the option to adjust my medication until I met with the psychiatrist. She also spoke with her (with the psychiatrist). It was somewhat helpful. I only became ill during pregnancy,* and suddenly the connection with my family physician became one where she genuinely cares for me and treats me. She helped me.’ (id#7)*.
‘The family physician came to our home because I couldn’t even walk for five minutes… He really supported me,* called to check on me*,* told me whether to increase or decrease my medication. He really helped me*,* and he was available’. (id#4)*
‘She (the family physician) said she wants an opinion from a psychiatrist to change the treatment. She left me alone,* and I cried all day. The family physician just didn’t see me*,* couldn’t understand my distress’ (id#9)*.
Women described the importance of coordination between the different healthcare providers, including the connection between the nurses at mother and child clinics, family physicians, and the psychiatric system. On the other hand, women also described that the frequent change of medical staff, affected the ability to receive continuous effective treatment.
‘And then in the mother and child clinic,* there were those whom I called my angels. It was a situation where my entire family was helpless. There were threats to take the child*,* and Child Protective Services got involved… Then I went to the clinic*,* and there was a wonderful family physician who knew the story. The nurses who took care of my baby… were very involved. They entered the room; it was an unforgettable day because they saved my life. I had already planned to jump off the mall bridge. Every day was filled with suicidal thoughts*,* and on that day*,* I had already decided to do it. The nurses there decided to take me to psychiatric hospital… They took me in their private car. We arrived there’ (id#1)*.
‘In every visit (in the mother and child clinic) there’s a different nurse taking care,* it’s very focused on the baby*,* and it doesn’t really feel like a place to receive advice on other topics. It doesn’t feel like a place with intimacy or something that encourages me to speak… There are plenty of people there*,* you with the baby*,* he’s crying or nursing*,* you’re busy with his care*,* there’s no opportunity to sit and talk’ (id#8).*
Many women highlighted the importance of support they received from factors outside the healthcare system, such as psychologists, welfare services, mothers’ groups, and community members in their place of residence.
‘She [the psychologist] saw how I appeared and recognized that it was depression. She asked for my husband’s and family’s phone numbers. She became my guardian angel. She called my husband and my sister and explained to them. I would go to her,* even if I had anxieties*,* I would write to her*,* and she would respond and help me’ (id#2)*.
‘The welfare services organized people to come and sit with me. Then,* from my community*,* someone saw that I was in a difficult situation…. She suggested that I come sleep at her place at night*,* and she would take care of my baby. In the morning*,* she would bring me home*,* and no one would know. And that’s how it was. God sent me angels’ (id#2)*.
‘The nurse told me that a support group for mothers had opened,* led by someone with training*,* and that I should join…I will always thank her for that. I went to the group meetings*,* and it really helped me to see other mothers*,* to get out of the house’ (id#8).*
Several women describe refusing pharmacological treatment during pregnancy due to fear that it might cause harm to the fetus, especially after reading the leaflets of the medications. After childbirth, women express concerns regarding taking antidepressants during breastfeeding.
‘She (the psychologist) explained to me about the pills,* that it would help me*,* but also mentioned that it might harm the fetus. So*,* even at the peak of my depression*,* I refused to take them to avoid harming the fetus’ (id#2).*
‘She (the psychiatrist) prescribed me pills,* and I insisted that it would be okay with breastfeeding. Even though she suggested medication that is safe to take during breastfeeding*,* something within me wasn’t ready for it in that situation’ (id#8).*
Many women reported concerns about the side effects of medications and also expressed apprehension about the stigma associated with mental illness once they start treatment.
‘I was afraid of the stigma associated with the (psychiatric) pills,* and it was very difficult for me to accept it. I didn’t even go to buy the pills. I didn’t have enough trust in the psychiatrist*,* and I didn’t have enough knowledge from her. I didn’t understand at all what she was suggesting to me and what the impact would be on me. I also didn’t know how to ask then; only in retrospect do I know that it was something she should have told me’. (id#8)*
We identified four subthemes regarding this getting support from women who have experienced postpartum depression, the need for a specialized inpatient unit for women with postpartum depression, administering the Edinburgh Postnatal Depression Scale (EPDS) at a later period after childbirth and not only immediately after delivery, discussion about postpartum depression during the pregnancy period.
Many women have talked about the importance that women who have experienced PPD would support each other. Women have shared stories about support groups for women, women’s organizations, and also support through Facebook. Some women described that when they helped other women, they also greatly benefited from it.
‘When I started the drug therapy,* I joined Facebook groups. Over time*,* when I saw various posts*,* especially authentic ones about specific struggles*,* I would immediately reach out privately. I try to share my experiences*,* letting them know they are not alone. I don’t believe that the system can truly offer support. In the high-tech world*,* they call it a ‘buddy’, someone who accompanies you*,* even to the dining room*,* introduces you to other people*,* and explains what’s going on. I want someone like that’. (id#3)*
‘I was very,* very involved. On Facebook*,* I was in plenty of groups*,* wrote to many women*,* and it really*,* really helped me to be there for other women.’ (id#9).*
In one of the interviews, there was a suggestion to open a dedicated inpatient units for women with PPD. Other women mentioned that they did not want to be hospitalized in regular psychiatric wards.
‘I think there should be a department (for women with PPD); women would go there. If I had known that there was such a department,* maybe I would have gone’ (id#2).*
Despite the screening conducted in Israel, many women report delays in the diagnosis of PPD due to the absence of questionnaire administration or administering the questionnaires at an inappropriate time.
‘They (nurses) only gave it (the EPDS questionnaire) to me during pregnancy; my nurse during pregnancy handed it to me. But everything was fine because I wasn’t depressed before giving birth. They didn’t give me one (questionnaire) after giving birth. Even if they had asked me when I returned home,* I would have said everything was fine. It all started afterward’. (Id#6).*
Some of the women mentioned that a discussion during pregnancy about PPD could have helped them to cope later on with the feelings of depression, leading to earlier diagnosis. These women expressed a desire to receive early explanations during pregnancy about the symptoms of depression, similar to the explanations they received about breastfeeding and the delivery process.
‘…In the hospital,* there are plenty of brochures about breastfeeding*,* but not about postpartum depression. During the childbirth preparation course*,* the instructor briefly mentioned it*,* but the feeling is that it won’t happen. If it does*,* I’ll turn to someone*,* but in reality*,* it’s not possible. It is very frightening’ (id#4).*
‘I think that if someone had talked to me about it (PPD),* my experience would have been much less about guilt and shame. I wouldn’t have felt such a bad mom. I took a childbirth preparation course*,* and no one prepared me for this scenario. They only prepared me for childbirth. No one prepared me that I would feel awful. In the future*,* I’ll know that I’m sick*,* that I need a lot of help’ (id#4).*
‘I believe that every gynecologist should thoroughly explain about the emotional aspect,* about postpartum depression. Not just explain about tests for the fetus. I would like physicians to also focus on that’ (id#1).*
In this qualitative study, we examined the challenges in early diagnosis and treatment of PPD within the primary care setting. Based on the ideas generated through discussions with the women, several themes emerged, including barriers in diagnosing PPD, unique aspects of PPD, facilitators and barriers in the treatment of PPD and women’s recommendations for improving the diagnosis and treatment of PPD.
Women expressed frustration that medical attention during pregnancy and after childbirth revolves around the child, often overlooking the mental well-being of the mother. They describe that pediatricians, gynecologists, and family physicians seldom inquire about their emotional state, leading many women not to disclose their feelings. This is in line with a study conducted in the United Kingdom by Carolyn Chew-Graham et al., in which family physicians were interviewed. Family physicians reported that they do not perform formal screenings or actively seek signs of PPD but rely on intuition, hoping that if there are signs of depression, they will notice them [21]. Many studies have shown consensus among PCPs that it is their role to diagnose PPD[16, 21, 22], yet there is a significant gap between this data and the fact that most physicians do not actually diagnose PPD. Our research, alongside previous studies, emphasizes the importance of PCPs directly asking women about their mental state during pregnancy and after childbirth beyond the EPDS surveys.
Our interviews reveal that meeting with the nurses in the ‘mother and child’ clinics plays a critical role in interacting with mothers after childbirth. In these encounters, nurses have the ability, on one hand, to “rescue” the mothers by offering quick diagnosis and assistance, and on the other hand, they can miss the diagnosis if they do not allocate time for assessing the woman’s mental health. Many women describe feeling that ‘mother and child’ clinics primarily focus on the baby’s care and not on the mother. This issue is supported by additional studies indicating factors that can assist in the early diagnosis of PPD by community nurses [23, 24]. Among these factors are home visits, explicitly stating that the purpose of the visit is to treat both the mother and the baby, longer meetings without time constraints, and continuity of care. Women mentioned in interviews that one of the difficulties was encountering a different nurse each time, which made them hesitant to open up and share their feelings. Consistency in care, with the same nurse treating the woman and the baby over time, can help in diagnosing and treating PPD [25].
Diagnosing PPD based solely on a one-time questionnaire administered after childbirth might miss many cases. Rose Coates et al. reported that many women feel the questionnaire is insufficient and sometimes not conducted at the appropriate time [26]. Establishing a personal connection with the medical staff who administers the questionnaire is crucial to identifying depression.
Several women have raised the issue of traumatic childbirth and obstetric violence as triggers for PPD. Similar to our study, in a qualitative study conducted by Julián Rodríguez-Almagro et al., maternal narratives emerge concerning negative childbirth experiences and their impact on the postpartum period and PPD [27]. Additional studies support the link between traumatic childbirth and a higher risk of developing PPD[23, 28, 29]. It is important to raise awareness of this issue among medical staff. It may be advisable to conduct PPD screenings multiple times for such women and to inquire about their mental state during each clinic visit.
Women describe the negative impact of PPD on bonding with their baby. This notion is supported by numerous studies emphasizing the importance of early diagnosis and treatment of PPD [30, 31]. A mother’s depression deeply affects her ability to care for and nurture her baby. During the interviews, one mother even described her violence towards her infant. This data is in line with the 87% of pediatricians who agreed that assessing the woman’s mental state is crucial to evaluating child care [32].
A significant factor contributing to the delay in diagnosing PPD is that many women refrain from sharing their feelings with their PCPs. During the interviews, women raised concerns about stigma, embarrassment, and fear of medications, among the factors that prevented them from speaking up. Other studies have echoed similar responses among women, including difficulty admitting to challenges, feelings of failure, fear of being judged as bad mothers, concerns about having their children taken away by social services, and fear of judgmental attitudes from the medical staff [15, 23]. Patients also note the difficulty of disclosing their feelings to the physician and the perception of the physician as someone who is unwilling to listen and lacks time for it. Semra Pinar et al. mention two factors that could help women disclose their feelings to their family a non-judgmental approach and the perception that the family physician has knowledge about the symptoms, treatment and referral options, and the ability to clearly explain them to the woman [23].
Women describe that if they had received preparation regarding PPD around childbirth, they might have sought help earlier. Similar to the guidance provided for breastfeeding, diapering, bathing, and routine infant care, mothers need to be taught how to take care of themselves. Mothers after childbirth need to recognize the symptoms of PPD and know when to seek advice and assistance[33, 34].
Many women feel that healthcare teams in primary care clinics lack knowledge about PPD. Studies conducted among medical teams indeed demonstrate the difficulty of healthcare teams in diagnosing and treating PPD [16, 35]. In a study conducted among pediatricians, the majority of physicians stated that they did not receive adequate training to diagnose maternal mental health conditions, and they also expressed a lack of knowledge about the resources available for treating PPD [32]. Physicians do not always know where to refer patients, and women feel they are bounced from one medical entity to another without receiving proper treatment.
PCPs often feel hesitant to initiate medication treatment for PPD and prefer referring women to psychiatrists for further assessment and care. However, the availability of appointments with psychiatrists is limited, leaving many women without treatment. This highlights the need for systematic training of PCPs in diagnosing and providing initial treatment for PPD. Jeannette Milgrom et al. demonstrated that training family physicians to treat PPD significantly improved symptoms [36]. Su-Chin Serene Olin et al. examined 18 programs for PPD treatment in primary care settings and found that diagnosis and treatment can be provided by nurses, family physicians, and pediatricians in primary care settings, underscoring the importance of training medical teams [37]. Furthermore, there is significant importance in collaboration among nurses, family physicians, and psychiatrists to provide adequate treatment for PPD [24].
The strength of qualitative research lies in obtaining information about the feelings and thoughts of participants through conducting in-depth interviews with each participant. In this study, thematic saturation was reached, supporting the adequacy of the sample size for qualitative analysis. While the small sample size is typical and appropriate for this methodology, a limitation of the study is the limited generalizability of the findings. All participants were Israeli, Jewish women aged 29 to 45 years, affiliated with a single healthcare organization in Israel. As such, the insights gathered may not fully represent the experiences of more diverse populations, including women of different ethnic, linguistic or cultural backgrounds. Furthermore, the study is prone to selection bias because the women who expressed a willingness to participate in the research are educated individuals connected to social networks through which they were exposed to the study. These women sometimes consume more medical services and are more critical of the services they receive. Additionally, it is possible that women who wanted to be interviewed were those experiencing more significant symptoms of depression and those who had more difficult experiences, making it important for them to share. Another limitation of the study is its exclusive focus on the perspectives of women who experienced PPD, without incorporating views from healthcare providers, policymakers, or family members. While we acknowledge that these additional perspectives could provide important context and enhance the broader understanding of postpartum mental health care, the goal of this study was to explore the lived experiences of affected women. We believe that this is a critical step toward informing more patient-centered healthcare practices. Future research may benefit from including multiple stakeholder perspectives to build a more comprehensive picture.
It is also important to consider the potential influence of the COVID-19 pandemic on the study context and participants’ responses. All interviews were conducted in 2021, during a time when Israel was still experiencing pandemic-related disruptions. Although participants were not experiencing active depressive symptoms at the time of the interviews, the broader atmosphere of uncertainty, social isolation, and changes in healthcare access may have shaped how participants interpreted and described their past experiences with PPD. Furthermore, the use of Zoom for conducting interviews—while essential for ensuring safety and accessibility—may have influenced the interview dynamic, particularly in terms of non-verbal communication and interpersonal connection typically afforded in face-to-face settings. These factors should be considered when interpreting the findings.
This study focused on the challenges of diagnosing and treating women with PPD in the primary care setting. PPD presents unique characteristics compared to depression at other stages of life, necessitating comprehensive attention from healthcare professionals, including nurses, family physicians, pediatricians, and gynecologists. The healthcare team should address issues such as postpartum trauma, mother-infant bonding, breastfeeding, domestic violence, and the risk of suicide. It is crucial to train medical teams to feel capable of diagnosing and treating PPD effectively. Improving physicians’ knowledge of PPD and raising awareness among the medical staff about the challenges faced by women suffering from PPD are fundamental steps toward enhancing diagnosis and treatment.
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