Unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety during the COVID-19 pandemic.

OBJECTIVE/BACKGROUND: Unmet needs in perinatal mental healthcare are an important public health issue particularly in the context of a stressful life event such as the COVID-19 pandemic but data on the extent of this problem are needed. AIM: The aim of this study is to determine the (1) proportion of women with clinically significant symptoms of perinatal depression, anxiety or comorbid symptoms of depression and anxiety, receiving mental healthcare overall and by country and (2) factors associated with receiving mental healthcare. METHOD: Women in the perinatal period (pregnancy or up to 6 months postpartum) participating in the Riseup-PPD-COVID-19 cross-sectional study, reported on sociodemographic, social support health-related factors, and COVID-19 related factors, and on symptoms of depression (Edinburgh Postnatal Depression Scale [EPDS]) and anxiety (Generalised Anxiety Disorder [GAD-7]) using self-report questionnaires. Clinically significant symptoms were defined as EPDS ≥ 13 for depression and GAD-7 ≥ 10 for anxiety. Mental healthcare was defined as self-reported current mental health treatment. RESULTS: Of the 11 809 participants from 12 countries included in the analysis, 4 379 (37.1%) reported clinically significant symptoms of depression (n = 1 228; 10.4%; EPDS ≥ 13 and GAD-7 ⟨ 10), anxiety (n = 848; 7.2%; GAD-7 ≥ 10 and EPDS ⟨ 13) or comorbid symptoms of depression and anxiety (n = 2 303; 19.5%; EPDS ≥ 13 and GAD-7 ≥ 10). Most women with clinically significant symptoms of depression, anxiety, or comorbid symptoms of depression and anxiety were not receiving mental healthcare (89.0%). Variation in the proportion of women with clinically significant symptoms of depression and/or anxiety reporting mental healthcare was high (4.7% in Turkey to 21.6% in Brazil). Women in the postpartum (vs. pregnancy) were less likely (OR 0.72; 95% CI 0.59-0.88), whereas women with previous mental health problems (vs. no previous mental health problems) (OR 5.56; 95% CI 4.41-7.01), were more likely to receive mental healthcare. CONCLUSION: There are high unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety across countries during the COVID-19 pandemic. Studies beyond the COVID-19 pandemic and covering the whole range of mental health problems in the perinatal period are warranted to understand the gaps in perinatal mental healthcare.

Paternal peripartum depression: emerging issues and questions on prevention, diagnosis and treatment. A consensus report from the cost action Riseup-PPD.

INTRODUCTION: Paternal peripartum depression (P-PPD) is a serious and understudied public health problem associated with impaired family functioning and child development. The lack of recognition of P-PPD may result in limited access to both information and professional help. OBJECTIVE: The aim of the study was to review studies on paternal peripartum depression and to identify issues and questions where future research and theory formation are needed. METHODS: A literature search for systematic reviews, meta-analyses and primary studies was conducted using PubMed, Web of Science, Embase, Scopus, Medline, PsychInfo and Informit databases. Key results within the retrieved articles were summarised and integrated to address the review objectives. RESULTS: Based on the literature, the knowledge related to prevalence, screening, risk factorsunique to fathers, management strategies and outcomes of P-PPD is lacking. Currently, there is no consensual understanding of the definition of P-PPD and recommendations for dealing with P-PPD. Limited data were available regarding the barriers preventing fathers from accessing support systems. CONCLUSION: Emerging issues that need to be addressed in future research include: P-PPD definition and pathogenetic pathways; prevention strategies and assessment tools; self-help seeking and engagement with interventions; the cost-effectiveness of P-PPD management; needs of health professionals; effect on child development, and public awareness. Future studies and clinical practice should account the complexities that may arise from the father's perceptions of health care services. Results from this review highlights the critical issues on how to plan, provide and resource health services, to meet the health needs of fathers.

A cross-country study on the impact of governmental responses to the COVID-19 pandemic on perinatal mental health.

This study aimed to analyse the role of governmental responses to the coronavirus disease 2019 (COVID-19) outbreak, measured by the Containment and Health Index (CHI), on symptoms of anxiety and depression during pregnancy and postpartum, while considering the countries' Inequality-adjusted Human Development Index (IHDI) and individual factors such as age, gravidity, and exposure to COVID-19. A cross-sectional study using baseline data from the Riseup-PPD-COVID-19 observational prospective international study (ClinicalTrials.gov: NCT04595123) was carried out between June and October 2020 in 12 countries (Albania, Brazil, Bulgaria, Chile, Cyprus, Greece, Israel, Malta, Portugal, Spain, Turkey, and the United Kingdom). Participants were 7645 pregnant women or mothers in the postpartum period-with an infant aged up to 6 months-who completed the Edinburgh Postnatal Depression Scale (EPDS) or the Generalised Anxiety Disorder Assessment (GAD-7) during pregnancy or the postpartum period. The overall prevalence of clinically significant depression symptoms (EPDS ≥ 13) was 30%, ranging from 20,5% in Cyprus to 44,3% in Brazil. The prevalence of clinically significant anxiety symptoms (GAD-7 ≥ 10) was 23,6% (ranging from 14,2% in Israel and Turkey to 39,5% in Brazil). Higher symptoms of anxiety or depression were observed in multigravida exposed to COVID-19 or living in countries with a higher number of deaths due to COVID-19. Furthermore, multigravida from countries with lower IHDI or CHI had higher symptoms of anxiety and depression. Perinatal mental health is context-dependent, with women from more disadvantaged countries at higher risk for poor mental health. Implementing more restrictive measures seems to be a protective factor for mental health, at least in the initial phase of the COVID-19.

Validation of the generalized anxiety disorder screener (GAD-7) in Cypriot pregnant and postpartum women.

BACKGROUND: Anxiety is increasingly acknowledged as a common mental health issue during the perinatal period. Its prevalence as well as the associated adverse effects constitute screening imperative. This study evaluates the psychometric properties and underlying factor structures of a Greek version of GAD-7 among pregnant and postpartum women (up to 6 months) in Cyprus. METHODS: This study was conducted from June to December 2020. A total of 457 Cypriot women in the perinatal period (222 pregnant and 235 postpartum) were surveyed. The assessment included anxiety (GAD-7) and depression (EPDS), and psychosocial factors related with anxiety. The internal consistency and factor structure of GAD-7 were evaluated using reliability coefficients, Cronbach's Alpha and McDonald's Omega, and factor analysis, both Exploratory as well as Confirmatory. RESULTS: GAD-7 demonstrated good internal consistency (α = 0.907; Ω = 0.909). Horn's parallel analysis indicated a single factor as the most appropriate. CFA using the standard ML method indicated a good model fit, χ2 = 21.207, p = 0.096; CFI = 0.999; SRMR = 0.027. More studies are needed to determinate the cut-off point and the maximisation of the scale's sensitivity and specificity in pregnant and postpartum Greek Cypriot women. CONCLUSIONS: GAD-7 is a valid and reliable measure and healthcare professionals should utilize GAD-7 as a standard instrument for the screening of anxiety symptoms in pregnant and postpartum Greek Cypriot women.

Experiences, concerns, and needs of pregnant and postpartum women during the Covid-19 pandemic in Cyprus: a cross-sectional study.

BACKGROUND: The current COVID-19 pandemic is a unique stressor with potentially challenging and negative consequences on the experiences of pregnant and postpartum women. International literature highlights the pandemic's negative impact on women's perinatal experiences. This is the first study in the scientific literature reporting on the impact of the COVID-19 pandemic, on the perinatal experiences of a large sample of women living in Cyprus. AIM: To examine the impact of the COVID-19 pandemic on the experiences, concerns and needs of pregnant and postpartum women in Cyprus. METHOD: The cross-sectional study was conducted from July 2020 to January 2021. A total of 695 women, 355 pregnant and 340 postpartum women (with infants up to 6 months of age), residing in Cyprus were surveyed. RESULTS: The great majority of the participants (80.9%) perceived the impact of the COVID-19 pandemic on their life as negative. The greatest sources of stress were identified and quantified for their impact on the participants. Our findings indicate that 74.1% of the pregnant women were concerned about changes due to COVID-19 measures impacting the presence of their family at the time of delivery, 57.2% about their newborn's health, and 43.1% about changes related to perinatal care. Postpartum women's concerns were mainly related to the welfare and health of their child (70.3%), whilst half of them (49.1%) expressed concerns about how they were going to care for their baby because of pandemic-related changes. Qualitative data revealed emerging themes as the basis of the pregnant and postpartum women's concerns and needs. CONCLUSIONS: The COVID-19 pandemic and the associated imposed measures and restrictions had adverse effects on pregnant and postpartum women's perinatal experiences in Cyprus. The women's concerns emphasized the need for the development of specialized, evidenced-based support systems which are essential particularly in pandemic-like situations, when pregnant and postpartum women are more vulnerable to isolation.

Rates of depressive and anxiety symptoms in the perinatal period during the COVID-19 pandemic: Comparisons between countries and with pre-pandemic data.

BACKGROUND: The COVID-19 pandemic was a significant threat to perinatal mental health. This study examined differences in clinically significant depression, anxiety, and co-morbid symptoms among pregnant and postpartum women across several countries and compared prevalence of perinatal depression and anxiety before and during the pandemic in each participating country. METHODS: Participants were 3326 pregnant and 3939 postpartum women (up to six months postpartum) living in Brazil, Chile, Cyprus, Greece, Israel, Portugal, Spain, Turkey, and the United Kingdom. An online survey was completed between June 7th and October 31st 2020, and included the Edinburgh Postnatal Depression Scale (EPDS) and the Generalized Anxiety Disorder Screener (GAD-7). The pre-pandemic studies were identified through literature review. RESULTS: Prevalence of clinically significant depression (EPDS≥13), anxiety (GAD-7 ≥ 10), and co-morbid (EPDS≥13 and GAD-7 ≥ 10) symptoms was 26.7 %, 20 % and 15.2 %, in pregnant women, and 32.7 %, 26.6 % and 20.3 %, in postpartum women, respectively. Significant between-country differences were found in all mental health indicators in both perinatal periods. Higher levels of symptoms were observed during (versus before) the pandemic, especially among postpartum women. LIMITATIONS: Participants were mostly highly educated and cohabiting with a partner. The online nature of the survey may have limited the participation of women from vulnerable socio-economically backgrounds. CONCLUSIONS: Our findings expand previous literature on the negative impact of the COVID-19 pandemic on perinatal mental health, by highlighting that this may be influenced by country of residence. Mental health care policies and interventions should consider the unique needs of perinatal women in different parts of the world.

The Mental Health of Women with Gestational Diabetes During the COVID-19 Pandemic: An International Cross-Sectional Survey.

Background: There is evidence that women with gestational diabetes are at increased risk of the common mental disorders of anxiety and depression. The COVID-19 pandemic may have exerted an additional burden on the mental health of this population. The aim of this analysis was to compare levels of symptoms of common mental disorders and experiences during the COVID-19 pandemic between pregnant and postnatal women exposed and unexposed to gestational diabetes. Methods: Cross-sectional study utilizing quantitative data from an online survey administered across 10 countries to women who were pregnant or up to 6 months postpartum from 15 June to October 31, 2020. Women self-reported gestational diabetes and completed the Edinburgh Postnatal Depression Scale and GAD-7 (Generalized Anxiety Disorder 7 items) measures. The COPE-IS (Coronavirus Perinatal Experiences-Impact Survey) tool was also administered. Complete case analyses were conducted on a sample of 7,371 women. Results: There was evidence of an association between gestational diabetes and increased levels of depression symptoms, which was robust to adjustment for age, education, and employment status. There was only evidence of an association with anxiety in postnatal women. There was also evidence that women with gestational diabetes, particularly those in the postnatal period, experienced higher levels of pandemic-related distress, although they did not experience higher levels of COVID-19 infection in this sample. Conclusions: The increased risk of common mental disorders in women with gestational diabetes underscores the importance of integrated physical and mental health care for pregnant and postnatal women both during and beyond the pandemic. Clinical Trial Registration no. NCT04595123.

Clinical practice guidelines with recommendations for peripartum depression: A European systematic review.

OBJECTIVE: This study aims to systematically review all Clinical Practice Guidelines (CPGs) with recommendations for peripartum depression in European countries. METHODS: A systematic review according to the PRISMA statement was conducted. CPGs focussing on peripartum depression or with at least one specific recommendation for peripartum depression from European countries were selected. Searching was conducted in electronic databases (MEDLINE and PsycINFO), and by contacting professional societies and international experts until November 24th, 2021. Characteristics of the included CPGs and their recommendations were extracted. A methodological quality assessment was conducted using the AGREE-II tool. RESULTS: A total of 239 records were identified after duplicate removal. Of these, 54 were examined for full-text inspection. The final selection yielded 14 CPGs from 11 European countries in 10 languages. Of them, 11 provided recommendations on pharmacological treatments, 10 on psychological treatment (e.g., cognitive-behavioural therapy), 10 on screening, 8 on diagnosis, 6 on other treatments (e.g., physical exercise), 5 on prevention, and 5 other recommendations (e.g., provide information). Regarding the overall methodological quality, only five (35.7%) guidelines were rated as of adequate quality, reaching a score ≥ 70% in the overall assessment of the AGREE-II instrument. Of the six AGREE-II domains, applicability scored the lowest and clarity of presentation scored the highest. CONCLUSION: The absence of CPGs in most European countries, the discrepancy in recommendations and the low methodological quality of the guidelines may lead to disparities and inequalities in peripartum depression management in Europe. The COST Action Riseup-PPD highlights key considerations for future guideline developers.

Women's experiences of VBAC in Cyprus: a qualitative study.

BACKGROUND AND AIM: In 21st century, there has been an increasing interest in vaginal birth after previous caesarean section (VBAC) in Cyprus, a country with a very high operative birth rate. Research-based evidence of women's VBAC experiences in Cyprus is non-existent, despite its significance for the well-being of mothers and families. The aim of this study is to gain insight into the women's lived experience of VBAC in Cyprus. In this study women's experiences of VBAC are explored for the first time in Cyprus. METHOD: The study is qualitative and exploratory in nature. Data were collected through semi-structured interviews with 10 women, who experienced vaginal birth after a previous caesarean section (VBAC) in Cyprus. A descriptive phenomenological approach was employed for the analysis of data. RESULTS: Analysis of data yielded four major themes: (a) medicalization of childbirth, (b) preparing for a VBAC, (c) birth environment, and (d) healing through VBAC. On the whole, the women interviewed described their previous experience of CS as traumatic, in contrast to vaginal childbirth. VBAC was considered an utterly positive experience that made the women feel empowered and proud of themselves. CONCLUSION: This study offers valuable insight into a newly researched subject in Cyprus, which is necessary for advancing perinatal care in Cyprus. The findings indicate that women need evidence-based information, guidelines on birthing options, good preparation with tailored information and personalized care for a successful vaginal birth after a previous caesarean section. Proper, non-biased, consultations are a main factor that affects women's choice of mode of birth. The introduction of new, women-friendly perinatal strategies that respect and promote childbirth rights is imperative in the case of Cyprus. All women have the right to exercise informed choice and the choice to alternative birthing options.

Impact of the Covid-19 pandemic on perinatal mental health (Riseup-PPD-COVID-19): protocol for an international prospective cohort study.

BACKGROUND: Corona Virus Disease 19 (COVID-19) is a new pandemic, declared a public health emergency by the World Health Organization, which could have negative consequences for pregnant and postpartum women. The scarce evidence published to date suggests that perinatal mental health has deteriorated since the COVID-19 outbreak. However, the few studies published so far have some limitations, such as a cross-sectional design and the omission of important factors for the understanding of perinatal mental health, including governmental restriction measures and healthcare practices implemented at the maternity hospitals. Within the Riseup-PPD COST Action, a study is underway to assess the impact of COVID-19 in perinatal mental health. The primary objectives are to (1) evaluate changes in perinatal mental health outcomes; and (2) determine the risk and protective factors for perinatal mental health during the COVID-19 pandemic. Additionally, we will compare the results between the countries participating in the study. METHODS: This is an international prospective cohort study, with a baseline and three follow-up assessments over a six-month period. It is being carried out in 11 European countries (Albania, Bulgaria, Cyprus, France, Greece, Israel, Malta, Portugal, Spain, Turkey, and the United Kingdom), Argentina, Brazil and Chile. The sample consists of adult pregnant and postpartum women (with infants up to 6 months of age). The assessment includes measures on COVID-19 epidemiology and public health measures (Oxford COVID-19 Government Response Tracker dataset), Coronavirus Perinatal Experiences (COPE questionnaires), psychological distress (BSI-18), depression (EPDS), anxiety (GAD-7) and post-traumatic stress symptoms (PTSD checklist for DSM-V). DISCUSSION: This study will provide important information for understanding the impact of the COVID-19 pandemic on perinatal mental health and well-being, including the identification of potential risk and protective factors by implementing predictive models using machine learning techniques. The findings will help policymakers develop suitable guidelines and prevention strategies for perinatal mental health and contribute to designing tailored mental health interventions. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04595123 .

Variation in caesarean section rates in Cyprus, Italy and Iceland: an analysis of the role of the media.

INTRODUCTION: Cyprus has Europe's highest rate of births by caesarean section (CS). In 2015 56% of all babies were born by CS. This compares with 36% in Italy, and 16% in Iceland, which is among the lowest rates in Europe. There is some evidence that CS rates are partly driven by maternal request and media representation. The aim of this review is to explore the depiction of childbirth by CS in the media, and more specifically in newspapers, television, web and informational leaflets in Cyprus, Italy and Iceland. EVIDENCE ACQUISITION: A thematic review of the depiction of CS in the media of Cyprus, Italy and Iceland was carried out through an examination of newspapers, television, web, and informational material published or presented in the included countries in 2017. Materials were identified by searches in PubMed and Google Scholar, using pre-determined key words, inclusion and exclusion criteria, and inclusion was agreed by at least two of the authors. Key themes in each data source were triangulated with each other and between the three countries. EVIDENCE SYNTHESIS: The review comprised 81 articles, 10 videos, six birth shows, two informational leaflets and one scientific paper. The central themes were: 1) CS as risky and unnecessary intervention, failure of maternity system; 2) CS as a necessary, life-saving intervention; 3) the ethical dimensions of CS; 4) the changing landscape of childbirth and medicalization; and 5) informed choices. In both Cyprus and Italy, the media focus was on a need to reduce high levels of CS. The focus in Iceland was on normal birth and midwife led care. The differing media messages in the three countries could partly explain the differing CS rates, suggesting that high CS rates are a social phenomenon, rather than a result of clinical need. The media may have a significant influence on the beliefs and choices of maternity service users, their families, and society in general, as well as health professionals and policy makers. CONCLUSIONS: Those working in the media have an ethical responsibility to critically examine the impact of high national CS rates, and to report on solutions that could optimize both the safety and the wellbeing of mothers and babies.