Regarding the question "In your clinical practice do you asks women about..." (possible answers: never = 0, only to women at risk = 1, to all women = 2 "), a number of key issues were not asked to women, for example more than 50% of all professionals did not ask about “past trauma, grief or loss experiences”, “experience of mood disorders”, “experience of intimate partner violence”, “usual mental health coping strategies”, “suicidal thoughts or behaviors” (Supplementary materials Table S7).

Besides we calculated two current practice indexes, each adding the items of the following questions: (1) "In your clinical practice, do you..." and  (2) "In your clinical practice do you asks women about...", respectively. Then, comparing their median values among the healthcare professional groups we observed significant differences (Figure 2A and Figure 2B). In particular, a Kruskal-Wallis H test showed that there was a significant difference in current clinical practices made (question 1) between the healthcare professionals, χ2(2) = 10.858, p = 0.004, with a mean rank current practices score of 23.17 for nurses, 20.04 for gynecologists and 35.80 for midwives. Post hoc tests using Bonferroni correction revealed that midwives had higher current practices score than nurses (p = 0.032) and gynecologists (p = 0.009) (Figure 2A). We observed significant differences also in the current practice to ask women about … (question 2) between the healthcare professionals, χ2(2) = 6.296, p = 0.043, with a mean rank current practices score of 25.92 for nurses, 20.25 for gynecologists and 33.41 for midwives. Post hoc tests using Bonferroni correction revealed that midwives had significant higher current practices score than gynecologists (p = 0.042) (Figure 2B).

Figure 2: Healthcare professionals’ current practices indexes, by occupation (nurses, gynecologists, midwives).

3.3 Perinatal mental health services and barriers

Overall, the availability of services, policies and education in relation to perinatal mental health was reported to be low by the healthcare professionals. Only 13.0% reported to have a designated place in women’s medical records to document a mental health plan of care for women and 18.5% reported the presence of in-service education in the field of mental health (Supplementary materials Table S8).

Healthcare professionals were also asked to rate a series of topics that could be considered as barriers to quality perinatal mental health care. The barriers rated most were “organizational” issues such as “heavy workload” (35.2%), “time allocated too short” (35.2%), “not seeing regularly to build relationship” (33.3%), “perinatal mental health services not available” (33.3%), “lacks knowledge of how to access mental health services” (31.5%). Among “individual/sociocultural” barriers the “lack of knowledge on perinatal mental health and women from different culture” had the highest score (37.0%) followed by the “lack of knowledge on perinatal mental health” (31.5%), (Supplementary materials Table S9).

A Kruskal-Wallis H test showed that there was a statistically significant difference in perceived organizational/structural barriers score between the healthcare professionals, χ²(2) = 5.964, p = 0.05, with a mean rank organizational/structural barriers score of 34.33 for nurses, 27.11 for gynecologists and 22.16 for midwives. Post hoc tests using Bonferroni correction revealed that nurses perceived higher organizational/structural barriers than midwives (p = 0.048) (Figure 3A). Conversely, we did not observe difference in perceived individual/sociocultural barriers score between the healthcare professionals, χ²(2) = 0.688, p = 0.709, with a mean rank individual/sociocultural barriers score of 25.58 for nurses, 30.21 for gynecologists and 27.34 for midwives (Figure 3B).

Figure 3: Organizational/structural (A) and Individual/Sociocultural (B) barriers to discussing mental health with women, by occupation (nurses, gynecologists, midwives).

3.4. Women’s perception of PMDs issues management compared to healthcare professional answers.

Women, unlike healthcare professionals, reported that most health professionals did not include mental health as a dimension of the assessment, especially as regards perinatal mental health (Tables 5).

*Chi-square test

Table 5: During your interview, do healthcare professionals:

From the comparison between the women’s answers, about what healthcare professionals ask to them during the interview, and the healthcare professionals’ ones differences emerged regarding every issues (Table 6).

*Obsessive-compulsive disorder.

Table 6: During your interview, do healthcare professionals ask you about:

Women rated healthcare professionals’ skill in asking them about a number of issues giving a very poor mean score (less than 1.5) in asking women about alcohol and substance use, mood, anxiety, eating behaviors, psychosis, suicidal thoughts, intimate partner violence and sexual abuse/ sexual violence (Supplementary materials Table S10). Conversely, they rated professionals as having better skills in providing support to women who are concerned regarding the safety of the child (3.55±1.39), and their owns safety (2.81±1.45). However, healthcare professionals’ skill in providing support to partner/family in relation to their mental health was not rated as high (1.93±1.45) (Supplementary materials Table S11).

4. Discussion

This is the first Italian survey on the perinatal mental health management both from HPs' and women’s who gave birth perspective. The main findings of our survey lay in lacks both in knowledge, skills and current practices of some perinatal mental health issues (suicide, ask/discuss about mental health, screening tools), in the low case-load of women with PMDs in the last six months reported by HPs, as well as in the discrepancies between the reported opinions of women compared to HPs ones.

The HPs, without differences among the categories, perceived their knowledge and skills on perinatal suicide little close to average. These results need to be improved because perinatal depression and anxiety represent a major risk factor for suicide, but despite growing attention to this field very little is known about suicide, that is considered one of the leading causes of maternal death [7, 4]. Moreover, in our survey 53.8% of HPs reported never asking women if they have any suicidal thoughts or behavior. In many societies suicide is an extremely controversial topic and this is particularly true in perinatal period that it is supposed to be one of the most joyful times in a woman’s life [8, 19, 20]. Our results could reflect this situation but detection of suicidal ideation among pregnant women should be a priority. Few studies have investigated knowledge, skills and current practices of midwives and nurses in perinatal mental health management and as far as we are aware, no data about gynecologists are available [15, 21-23]. In particular, these studies show that midwife reported lower scores than ours in self-rated knowledge and skills about PMDs, especially compared to their knowledge in other professional tasks, even if they have more awareness of depression and anxiety [15, 22, 23]. These differences could be attributed to the non-homogeneity of the studies, as well as to the different training / education of the recruited health professionals.

We also found both an inadequate knowledge and use of mental health tools to screen for or assess PMDs. This result is in line with past research, which has recognized that HPs may not utilize screening tools because of time constraints, lack of training, and lack of knowledge of diagnostic criteria [24]. The lack of routine mental health screening is a main barrier to early identification of PMD’s 25, although universal screening of pregnant and postpartum women for depression is now recommended by numerous professional organizations [26-28] and many states legally mandate perinatal depression screening [28-30]. Reinforcing the findings from other studies, we also found that HPs reported they were not adequately prepared for the use of screening and diagnosis tools in their clinical practice and they rated their knowledge and skills in this field as very low. A number of mental health screening questionnaires have been created over the last two decades, most of them developed to detect depression, but PMDs include a wide range of disorders that need to be addressed [25]. While screening alone is not enough to improve perinatal outcomes [31], different studies reported that the majority of women identified screening as beneficial and reported that it made them feel that their provider cared [32-35].

Moreover, we found that midwives' current practice indexes (referring to the following questions: (1) "In your clinical practice, do you..." and (2) "In your clinical practice do you asks women about...") had higher scores than nurses and gynecologists. It could be due to a greater focus of obstetric training courses on issues related to perinatal mental health of women, as well as a more confidential relationship between midwife and woman than other health professionals, more often males, which allows them to discuss such complex and delicate topics.

The low caseload of women with PMDs in the last six months reported by HPs may be an underestimate of women experiencing PMDs considering that about one in five women will experience a perinatal mental health problem [14]. Likewise, all the women in our survey declaring they did not suffer from any mental disorders during pregnancy might be related to the stigma of being considered an incompetent mother, the shame for guilt for not feeling happy [36-39] and the pressure to be ‘good mothers’ [40]. A meta-synthesis highlighted that women may not understand the significance of their symptoms [40] and another recent study reported women not knowing what were ‘normal’ or ‘abnormal’ emotions in pregnancy and the postnatal period [41].

This survey also indicates the need to fill the widespread deficiencies reported by HPs regarding services, first of all to "designed place in women's medical records to document a mental health plan of care for women" and "in-service education on mental health issues". Such deficiencies, in fact, have been shown to impact the practices of HPs [42-44].

Previous studies identified barriers at four levels: individual (e.g, stigma, poor awareness), organizational (e.g. resource inadequacies, service fragmentation), sociocultural (e.g. language/cultural barriers) and structural (e.g. unclear policy) levels [39]. Consistent with previous findings [17] in our study the barriers rated with highest scores were organizational barriers such as lack of perinatal mental health services, absence of care pathways, heavy workload, lack of time, lack of privacy and not seeing women regularly enough to build a relationship.

Finally, our survey highlighted discrepancies between women’s and HPs’ opinions on “ask about mental health”, infact in contrast to the HPs the maiority of women’s reported that they were not asked. A national survey in UK showed that most women recalled being asked about their mental health in pregnancy (82 %) and in the postnatal period (90 %) [45].  Nagle et al. found that all women were asked about their mental health at least once in the most recent pregnancy, mainly by a midwife at the antenatal booking visit [41]. On the other hand, Redshaw et al. found that non-white women and those living in deprived areas are less likely to be asked about mental health [45]. Our results about discussing on psychopharmacology during pregnancy and/or breastfeeding and on past history/diagnosis conflict with previous study which reported that women who disclosed a history of mental health problems were asked about their mental health more frequently[41]. But sadly, our findings highlighted women's reluctance to disclose about their mental health. In addition, they declared to not suffer from any mental disorders during pregnancy and this raises further suspicion because health professionals’ answers did not confirm these statements. Differently with literature [46,47] our results showed that substance and alcohol use during pregnancy were addressed by healthcare professionals, although not all women confirm this. On the other hand, accordingly to literature [41], we found that the percentage of women who declared to have been interviewed on issues relating to more delicate items/less common disorders such as psychosis, eating disorders, personality disorders or Post Traumatic Stress Disorders and suicidal thoughts was lower than “alcohol and substance use”. Finally, one of the most neglected item was ”experience of intimate partner violence”, which is of concern as previous studies showed that intimate partner violence frequently escalates during pregnancy [31, 48].

5. Study limitation and strengths

This study had some limitations, which must be acknowledged. First, it was based on a survey design therefore respondents might not feel encouraged to provide accurate, honest answers. For example, there is no way of knowing if the self-reported practices by HPs actually reflected clinical practices and how much social desirability impacted the findings. However the inclusion of the women helps towards triangulation of data. Second, despite the high response rate of healthcare professionals, our sample size was small.  But nevertheless, we chose to conduct a single-center survey to study a homogeneous sample. Third, we lacked information about HPs’ type and duration of work experience in perinatal mental health settings. It was beyond the scope of this study to address these questions, but it may be a suggestion for future study.

6. Conclusions

Our findings may have important implications not only for the setting in which the survey took place. It was clear that good knowledge, skills and current clinical practices represent a key role in the prevention of PMDs. Based on these findings, the promotion of appropriate training and education on identifying and managing PMD’s, organizational support and investment into perinatal mental health services with clear protocols and standards of care are recommended. Also, it should be improve the knowledge on the adequate use of screening tool for PMDs, which will be helpful to identify women suffering from PMDs. Finally, it is appropriate to provide for a designed place in women’s medical records to document a mental health plan of care for women