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Pensar Enfermagem / v.28 n.01 / February 2024
DOI: 10.56732/pensarenf.v28i1.285
Qualitative Original Article
How to cite this article: Almeida OM, Baratieri T, Krulikowski IBO, Natal S, Cavalcante MDMA,
Malaquias TSM. Evaluation of mental health care for postpartum women in primary care: an evaluative study.
Pensar Enf [Internet]. 2024 Feb; 28(1): 26-32. Available from: https://doi.org/10.56732/pensarenf.v28i1.285
Evaluation of mental health care for postpartum
women in primary care: an evaluative study
Abstract
Introduction
Pregnancy is a phenomenon laden with emotions in a woman's life, bringing with it
numerous hormonal, physical, and psychological changes, culminating in a series of
transformations in her body.
Objective
To evaluate the mental health care provided by primary care professionals to women in the
postpartum period.
Methods
An evaluative study of implementation analysis with a quantitative and qualitative approach,
conducted through a multiple case study. Data collection involved the analysis of medical
records and semi-structured interviews with 31 postpartum women and 24 healthcare
professionals. In the quantitative analysis, the degree of implementation was assessed
(classification: satisfactory, partial, incipient, and critical) determined by the Analysis and
Judgment Matrix composed of the dimensions “management” and “execution”, and their
respective sub-dimensions. Qualitative analysis occurred through content analysis.
Results
Through quantitative data, an incipient degree was observed in cases 1 and 3, and a critical
implementation degree in case 2. In the application criterion of the scale for postpartum
depression diagnosis, all cases scored zero. Considering the content of the statements, they
can be grouped into two categories: the presence of feelings of abandonment and sadness
in postpartum women, and the lack of assistance from healthcare professionals to
postpartum women.
Conclusion
It is concluded that women have postpartum health needs related to mental health;
however, there is a lack of assistance from primary care professionals.
Keywords
Primary Health Care; Mental Health Care; Primary Care Evaluation of Mental Disorders;
Postpartum Depression.
Milena Oliveira de Almeida1
https://orcid.org/0000-0003-1234-4356
Tatiane Baratieri2
https://orcid.org/0000-0002-0270-6395
Iria Barbara de Oliveira Krulikowsk3
https://orcid.org/0000-0002-4783-3523
Sónia Natal4
https://orcid.org/0000-0001-6155-4785
Marília Daniella Machado Araújo5
https://orcid.org/0000-0002-7685-6679
Tatiana da Silva Melo Malaquias6
https://orcid.org/0000-0001-5541-441X
1 Bachelor of Nursing. State University of Centro-
Oeste, Guarapuava, Brazil.
2 PhD in Public Health. State University of Centro-
Oeste, Guarapuava, Brazil.
3 Master’s degree in Nursing. State University of
Centro-Oeste, Guarapuava, Brazil.
4 PhD in Public Health. Federal University of Santa
Catarina, Santa Catarina, Brazil.
5 PhD in Nursing. State University of Centro-Oeste,
Guarapuava, Brazil.
6 PhD in Nursing. Universidade Estadual do Centro-
Oeste, Guarapuava, Brazil.
Autor de correspondência
Milena Oliveira de Almeida
E-mail: themmoliveira@gmail.com
Received: 28.06.2023
Accepted: 24.11.2023
Pensar Enfermagem / v.28 n.01 / February 2024 | 27
DOI: 10.56732/pensarenf.v28i1.285
Qualitative Original Article
Introduction
Pregnancy is a phenomenon laden with emotions in a
woman's life, bringing numerous hormonal, physical, and
psychological changes, culminating in a series of
transformations in her body, leading her to start creating
expectations regarding her gestation.1
In the postpartum period (after childbirth), there are
modifications in this scenario, and these expectations give
way to feelings of fear, anguish, and apprehension, as new
mothers begin to fear that their desires may not be met,
generating frustrations and insecurities.2
Among the common complications in the postpartum
period, emotional changes stand out, with postpartum
depression (PPD) being a relatively common condition in
the first month after childbirth, with the possibility of
extending for longer periods3, and its prevalence is higher
in teenage mothers, ranging from 14% to 53%, and from
6.9% to 16.7% in adult women.1,4
All changes that occur in the postpartum phase require
special attention, as they can be even more recurrent in
cases of unwanted, unplanned, and repudiated by family
members pregnancies, social deprivation, or other factors
capable of emotionally destabilizing the woman, along with
hormonal factors.1
Thus, support for postpartum women becomes
fundamental, from their families and the community itself,
where healthcare services ensure quality assistance so that
they can overcome their obstacles, as otherwise, it may
result in complications that bring temporary and/or
permanent consequences, and in some cases, lead to death.2
Therefore, motherhood and its nuances must be
recognized as factors that directly impact women's mental
health.5 Thus, they require care, especially in the context of
Primary Health Care (PHC), as it is the closest point of
attention to this population and the care organizer, where
the assistance provided positively impacts their health, such
as reducing morbidity and mortality, contributing to care
and the right to autonomy, making postpartum care
necessary, provided it occurs in an organized, coherent, and
applicable manner.2
Hence, it is of utmost importance that all postpartum
women receive support from PHC professionals beyond
their momentary physical and biological well-being but for
the prevention of future complications. Another aspect that
gives relevance to this study is the fact that there are few
approaches focused on the professional's perspective on
women in the postpartum period during care. Thus, the
present study aims to evaluate the mental health care
actions developed by PHC professionals for women in the
postpartum period.
Methods
This is an evaluative study of the implementation analysis
type6, with a quantitative and qualitative approach,
developed through a multiple-case study7 guided by the
precepts of the Standards for QUality Improvement
Reporting Excellence (SQUIRE 2.0).
Three municipalities were selected, one from each state in
the Southern Region of Brazil, named Case 1, Case 2, and
Case 3, based on the following inclusion criteria: over
100,000 inhabitants, because most of them present
favorable characteristics for health management;8 PHC
coverage greater than 80%; over 80% of health teams
enrolled in the National Program for Improving Access
and Quality of Primary Care (Programa Nacional de
Melhoria do Acesso e da Qualidade da Atenção Básica -
PMAQ); over 80% of teams with "excellent," "very good,"
and "good" ratings in PMAQ. When more than one
municipality met the inclusion criteria, professionals from
the technical area of PHC and women's health, from the
respective State Health Departments, were asked to choose
the best case.
One family health team from each municipality with an
"excellent" or "very good" rating in PMAQ was
investigated. Informants included professionals from PHC
teams and postpartum women attended by these teams.
Professionals from the minimum family health team
(doctor, nurse, nursing technician/assistant, and
community health worker) with over one year of
experience in the same workplace were selected.
Professionals on vacation or on leave were excluded.
Regarding postpartum women, those who had undergone
at least one postpartum consultation up to 42 days and were
at most six months postpartum were selected to reduce
memory bias about the care received. The following were
excluded: those with whom contact was not possible or
who, due to some health condition, could not participate in
the study. The eligible women were surveyed, and
subsequent draw was conducted, interviewing participants
until data saturation was reached. The study included 4
nurses (one from Case 1, one from Case 2, two from Case
3), two nursing technicians (one from Case 1, one from
Case 2), 18 community health workers (six from Case 1,
nine from Case 2, three from Case 3), and 31 postpartum
women (ten from Case 1, eleven from Case 2, ten from
Case 3).
One nursing technician from Case 3 on vacation was
excluded, six postpartum women refused to participate,
and contact with three postpartum women was not
possible.
Data collection occurred in two stages: In the first stage,
interviews were conducted with professionals and
postpartum women, using a specific semi-structured script
with language adaptation for each participant category. The
scripts addressed questions directed at the investigation by
professionals about the history of mental health problems,
emotional state, family and social support during prenatal
and postpartum periods, guidance on common emotional
changes postpartum (directed to professionals and
postpartum women), and the use of a scale for PPD
diagnosis when identifying warning signs (for
professionals). Interviews were scheduled with
professionals at their respective workplaces, and women,
after contact by phone or home visit by community health
workers, chose the health unit or home for recorded
interviews, which were transcribed in full. In the second
28 | Almeida, M.
Qualitative Original Article
stage, data were collected through the analysis of medical
records of selected postpartum women.
For the data collection instrument, the Analysis and
Judgment Matrix (AJM) was developed, guided by Program
Theory2 and validated by the consensus conference
technique9 with experts in the field and stakeholders
(interested in the evaluation), including four women
representatives of the women's movement, five
professionals in the PHC and women's health area from the
management of the states of Paraná, Santa Catarina, and
Rio Grande do Sul, and three professionals with experience
in PHC. The AJM was used to assess and determine the
degree of implementation of postpartum care, composed
of seven sub-dimensions (longitudinality; access; physical
health; mental health; domestic violence; breastfeeding; and
family planning), with the mental health sub-dimension
analyzed in this study.
The value judgment for each criterion/indicator of the
AJM was made through triangulation of different sources
of evidence, assigning a score. The ratio of the sum of
observed score (OS) in the sub-dimensions to the expected
score (ES) determined the value judgment for the degree of
implementation: DI (degree of implementation) = (Σ OS ∕
Σ ES) × 100. The proportions were stratified into quartiles
for the classification of the Degree of Implementation,
namely: satisfactory implementation (76% to 100%); partial
implementation (51% to 75%); incipient implementation
(26% to 50%); and critical implementation (below 26%).10
A pilot case study was conducted in a municipality that was
not part of the main study.
After the implementation analysis, a categorical content
analysis was conducted to understand in-depth the results
of the implementation analysis. Subsequently, readings of
the obtained data were performed to identify and interpret
the needs, weaknesses, and potentialities of health care. The
material was read, coded, enumerated, classified, and
aggregated to arrive at an understanding and proceed with
the interpretation and categorization of the results,
considering the identification of units of interest, common
aspects among them, and inferences.11 The study was
approved by the Research Ethics Committee of the Federal
University of Santa Catarina (opinion No. 3.036.173/2018,
CAAE: 02774918.80000.0121).
All research participants signed an Informed Consent
Form, emphasizing their commitment to preserving the
collected data and the identity of the participants. Thus,
participants are represented by acronyms.
To preserve the participants' identity, they were coded
according to the Case (Case) and the letter referring to the
participant group (P - professional; W - woman) followed
by the number corresponding to the interview sequence.
Results
The results demonstrate that mental health care in the
postpartum period, during the evaluated period, showed
incipient implementation for Cases 1 and 3, with Case 2
presenting a critical implementation degree, as it obtained a
score below 26%. In the criterion/indicator “investigation
of the history of complication/mental health problems
during prenatal and postpartum”, Case 1 had the highest
score. In the criterion/indicator “guidance on common
emotional changes postpartum”, Cases 1 and 2 obtained a
score of zero. Regarding the criterion/indicator
“application of a scale for PPD diagnosis when identifying
warning signs”, all cases scored zero, meaning they did not
meet the parameters. See Table 1.
After the implementation analysis, an in-depth interview
analysis was conducted, and the emerging analytical
categories refer to aspects that drew the researchers'
attention regarding mental health care in the postpartum
period, enabling the identification of main care gaps.
Feelings of abandonment and sadness in the
postpartum period and unawareness of emotional
changes
Feelings related to abandonment and sadness stand out in
the interviews due to the high number of times they appear
in the statements of postpartum women. In all three cases,
out of the 31 interviewees, 13 reported feeling sad at least
once after childbirth, where they felt the urge to cry, or
cried at least once during the period.
I felt sad as soon as he came home, I don't know why, but I was
always wanting to cry. (C1M4)
I've really had symptoms. It's something in the chest, you know, then
I have to change my thinking, start doing something, feeling like crying.
(C1M1)
While such feelings are present in the postpartum period,
postpartum women lack knowledge on the subject, leading
them not to seek help for this moment in their lives.
I don't know if it's postpartum depression, but I think it was because
I felt like crying, chest pain, anguish, and I couldn't do anything
because of the stitches, and it gave me more anguish because my mother
did things, and I couldn't do it, in this case, giving her a bath, whether
we like it or not, the first child, we want to do everything. And I was
a bit down, sad, weepy. (C1M10)
I handled this alone, didn't talk to anyone, not even with my husband.
It was painful not being able to talk, not even with the doctor, I didn't
talk because I thought it was something of mine, I thought it was
fussiness, some people won't understand, so you have to keep it to
yourself. (C1M4)
The absence of a support network for women during the
phase of emotional changes, especially due to the lack of
knowledge about the processes experienced in the
postpartum period, is observed. There is a need for the
involvement of family, friends, and healthcare
professionals so that women feel supported and can
overcome this period, being able to differentiate between
common changes of the period and when there are warning
signs.
Pensar Enfermagem / v.28 n.01 / February 2024 | 29
DOI: 10.56732/pensarenf.v28i1.285
Table 1: Analysis and Judgment Matrix of Mental Health Care for Postpartum Women in PHC - Southern Region,
Brazil, 2019
Critério ou indicador*
Rationale
ES*
*
OS**
Case 1
OS**
Case 2
OS**
Case 3
Investigation of family
and social support during
prenatal and postpartum
care
Understanding and involving the members of a woman's support
network in her care, from the beginning of pregnancy, provides
opportunities for everyone involved to gain an understanding of the
impact of motherhood on woman’s emotional health and well-being.
It also addresses the psychosocial factors affecting family
relationships. This network should be investigated at each postpartum
contact.12
1
0.4
0.2
0.7
Investigation of the
history of mental health
issues during prenatal and
postpartum care
All pregnant women should be asked about a family history of bipolar
disorder or postpartum psychosis, whether the woman has or had any
mental illness, and the existence of previous treatments for mental
health problems.12
1
0.8
0.4
0.6
Investigation of
emotional state during
postpartum care
The healthcare professional should ask brief, focused questions with
simple (“yes” or “no”) responses addressing women's moods to detect
signs of Postpartum Depression (PPD): “During the last month, have
you frequently felt bothered by feeling depressed or hopeless?” and
“During the last month, have you been bothered by having little
interest or pleasure in doing things?" If yes, inquire, “Is this something
you would like help with?”.13
1
0.2
0.2
0.5
Guidance on common
emotional changes
postpartum
Between 10 and 14 days after childbirth, healthcare professionals
should inquire about the resolution of symptoms of transient
postpartum depression (maternal blues). In the first two weeks, they
should provide guidance on major emotional changes (fragility,
hyperemotionality, mood swings, lack of self-confidence, feelings of
incapacity), indicating that these are transient symptoms resulting
from the physical, emotional, and social changes inherent to
the period.13
1
0
0
0.5
Application of a scale for
PPD diagnosis when
identifying warning signs
Non-specialist PHC professionals through the application of validated
instruments can identify symptoms of PPD. The Edinburgh Postnatal
Depression Scale is the most commonly used.12-13
1
0
0
0
5
1.4
0.6
2.3
ID = (ΣOS∕ΣES*100)
100
%
28%
16%
46%
*Source of evidence: Interviews (professionals and users); medical records.
*Parameter: Fully meets (1) Partially meets (0.9 to 0.1) Does not meet (0).
**ES: Expected score; OS: Observed score.
Lack of healthcare professionals' assistance to
postpartum women after childbirth
The first category identified that women experienced
emotional changes in the postpartum period and, in
general, were unaware of the subject. Despite this, out of
the 31 postpartum women interviewed, 21 were not even
asked about mental health, nor were they explained what
PPD would be. Of these, eight reported that they were
asked about their feelings when they had a history of
emotional changes, such as recent family death or a
previous diagnosis of mental disorder.
No one ever said it was normal." (C1M4)
"No. Chest pain, no, but I cried. Oh, I think it was about three days
after we got home. They didn't even guide me on that in the hospital."
(C1M1)
"Sometimes I get sad. In general, people don't ask much about you;
it's more about the baby." (C1M10)
From this analysis, it is evident that healthcare professionals
according to the postpartum women’s statements did not
perceive emotional changes. Still, when questioned, they
reported that such information is provided, showing
contradictions between reports.
It depends on the postpartum woman's needs, then I'll see if she's okay,
receives guidance, has few or no doubts, has no need for anything, I
don't refer. Now, the one I feel has something more, I propose myself.
(C2P5)
I usually provide guidance. I have a tendency to see what comes from
her demand, even not to induce a behaviour. But I usually take care
of the emotional part, from the beginning of gestation. And I reinforce
the issue of guilt, not feeling guilty. Trying to explain the difference
between this anguish, which is normal, a certain melancholy in the
30 | Almeida, M.
Qualitative Original Article
postpartum, which is normal, she may be more tearful, but trying to
differentiate from postpartum depression. (C3P4)
The healthcare professionals use a non-verbalized
approach in their interactions, meaning they do not directly
ask questions related to feelings of sadness and
abandonment. This led postpartum women to be unaware
that they were being assessed, as there were no inquiries
about these matters. Professionals reported conducting a
preliminary analysis, where they visually assess the
postpartum woman's state, determining if she appears sad,
disheartened, or tearful. Only if these signs are noticed, they
inquire about their feelings and provide guidance, limiting
the opportunity for all women to speak, regardless of their
situation.
It is emphasized that this analytical approach, as per the
reported accounts, means many women with emotional
changes do not receive a comprehensive examination from
the professional, as crucial information ends up being
overlooked.
To assist in this assessment, healthcare professionals were
questioned about their prior knowledge and/or use of any
type of tool to identify the PPD. Upon analysing the
interviews, it becomes clear that scales were not used in any
of the three cases in the study.
Unfortunately, I don't use a scale. I don't think I even knew we had
one. I confess to you that I never even asked myself. Nowadays,
everything is stratified, but for this one, I didn't even think about it.
(C1P5)
No, we rely more on conversation. (C2P3)
I've heard of the scale, but I don't use any. (C2P4)
Despite the indispensable need for using such a tool to
stratify risk and provide quality care, it was noted that the
interviewed professionals lacked knowledge about it. They
mentioned that consultations are based on observing the
emotional state of the postpartum woman, as evident in
their accounts. This reveals that postpartum women ended
up mediating the consultations.
The lack of information, caused by a lack of assistance,
leads to frustration due to not knowing what to do in
moments when there are many doubts and no answers.
Another important aspect identified in the interviews was
that among the postpartum women who did not receive
information about what to do regarding their feelings, some
reported that one of the ways to obtain information was
through internet searches or by consulting with family
members.
Here, no one guided me. I think it was mentioned at one of the
meetings here. When this happened to me, I didn't know, so I started
researching postpartum depression symptoms on the internet, and I had
all of them. Then I called and told my mom, and she said it was
normal, that she also had it and such. My mom helped me. I didn't
get to mention this during the consultation. (C2M10)
As we know, it is necessary to filter the vast amount of
information found, as not everything on the internet is
scientifically substantiated—valid arguments with proven
efficacy. In other words, one can encounter the so-called
"fake news," false information circulating in the media that
can have negative influences on users.
This could be minimized if there were information
dissemination within the health unit itself, including
guidance on accessing reliable sources on the internet.
Discussion
With the birth of the baby, the woman and her family begin
a new daily routine, which can be frustrating due to the
challenges of the mother-child relationship, family nucleus
reorganization, anxiety, and breastfeeding, which may
require many readjustments to this new moment in her
life.14
In this aspect, the present study identified that women go
through feelings of abandonment and sadness during the
postpartum period, and often, due to a lack of knowledge
on the subject, they do not share their suffering and do not
receive family and professional support.
A study indicates that experiencing sadness in the last
trimester of pregnancy and a history of depression in the
family are associated with a higher prevalence of PPD15,
reinforcing the recommendations of the present study
regarding the investigation of the history of mental
distress/illness during prenatal and postpartum periods.
The literature points out that emotional, instrumental, and
informational support from the partner is fundamental,
finding that the more support, the lower the prevalence of
PPD16 (Ramos, 2022). Similarly, support from the
healthcare team to women during prenatal care reduces the
prevalence of PPD by up to 23%.15
There is a need for planning and organization regarding
these issues, as this allows doors to open for
comprehensive care that meets the health needs of these
women. Access to healthcare services contributes to
reducing maternal mortality and ensuring comprehensive
women's health care.17
In this process, it is essential to identify the weaknesses that
may exist in prenatal care and point out possible strategies
for the effectiveness of care provided until the postpartum
period.17
One strategy that could be used for a broader assessment
of the subject is the application of simple questions that
identify possible emotional changes, namely: “During the
last month, have you felt depressed or hopeless frequently?
Did this bother you? During the last month, have you had
little interest or pleasure in doing things? Did this bother
you?”.13
Additionally, it is worth mentioning the Edinburgh
Postnatal Depression Scale, one of the main instruments
for identifying PPD in the context of PHC, as it is quick to
apply, simple, and easy to understand. It can be self-
Pensar Enfermagem / v.28 n.01 / February 2024 | 31
DOI: 10.56732/pensarenf.v28i1.285
Qualitative Original Article
administered or administered by third parties (health
professionals), associated with its value in identifying risk
factors for PPD, as the psychosocial factor is relevant.14
The application takes approximately five minutes,
categorized with ten items divided into depression and
anxiety factors, measuring the presence and intensity of
symptoms in the last seven days. There are also differences
related to the most indicated cutoff point for identifying
PPD, which can be explained by methodological and inter-
regional variations.14
Thus, it becomes indispensable to identify these signs in the
patient's own speech through anamnesis, and in the face of
a positive response, the Edinburgh Postnatal Depression
Scale can be applied, used to identify PPD.18
It is crucial that healthcare professionals, especially nurses
who are closer to women throughout the gestational and
postpartum periods, have knowledge about PPD and can
identify factors or conditions that may worsen their health.
This enables them to assist women at the onset of
symptoms and refer them to specialized care when
necessary.
The literature points out that a certain lack of preparedness
among healthcare professionals who do not have a well-
defined definition of PPD or other mental disorders may
emerge in the postpartum period. This difficulty
complicates relating such disorder to factors that may cause
greater harm to the postpartum woman.19
Regarding internet searches to address their doubts,
considering that, although there are numerous websites
containing health-related information, the users' ability to
find scientifically robust health interventions is not fully
known.20
Therefore, it is important for professionals to recognize
this reality and assist women in making the best choices in
seeking information, in addition to incorporating digital
communication tools in care, such as teleconsultation,
emails, apps, among others.21
Conclusion
The study's main contributions demonstrate that mental
health care is fragile, and there is a need for improvement
and strengthening of PHC professionals since they are the
primary providers of postpartum care, especially nurses,
who are qualified to provide quality and timely postpartum
consultations. There is need for investment in the
continuing education of professionals so that they promote
health education practices related to the topic.
Study limitations
This study has the limitation of not allowing a
comprehensive analysis covering all Brazilian municipalities
and states as a whole. In other words, it does not permit the
generalization of data beyond the investigated reality.
Authors’ contributions
Almeida, O. M: Conception and design of the study, data
collection, data analysis and interpretation, statistical
analysis and writing of the manuscript.
Baratieri, T: Study conception and design, data collection,
data analysis and interpretation, statistical analysis, obtaining
funding and writing the manuscript.
Natal, S: Conception and design of the study, analysis and
interpretation of the data, statistical analysis, and critical
revision of the manuscript.
Krulikowski, I. B. O: Analyzing and interpreting the data,
statistical analysis and writing the manuscript.
Cavalcante, M. D. M. A: Data analysis and interpretation,
statistical analysis, and critical revision of the manuscript.
Malaquias, T.S.M: Data analysis and interpretation,
statistical analysis, and critical revision of the manuscript.
Conflicts of interest and Funding
No conflicts of interest were declared by the authors.
Acknowledgments
To the Araucária Foundation for its financial support,
making it possible to provide support throughout the
development.
Sources of support / Financing
The first author received a Scientific Initiation scholarship
from the Araucária Foundation for Scientific and
Technological Development of the State of Paraná (FA).
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