Study design

The study uses a qualitative approach and follows the research stages using the 8-step from the PEPPA framework¹⁶. This framework comprises a total of nine steps: 1) Define the patient population and describe the current model of care; 2) Identify stakeholders and recruit participants; 3) Determine the need for a new model of care; 4) Identify priority problems and goals to improve the model of care; 5) Define the new model of care and the APN role; 6) Plan implementation strategies; 7) Initiate the implementation plan; 8) Evaluate the APN role and new model of care; and 9) Conduct long-term monitoring of the APN role and new model of care¹⁶.

Qualitative data, participants and ethics

In PEPPA Step 1, five interviews were randomly selected from a parallel-running project, Perinatal Mental Health Care in Switzerland: Unravelling the Perspectives of Affected Women and Health Professionals (MADRE), within the Obstetrics Research Department of the Bern University of Applied Sciences Health (BFH)¹⁷. The MADRE study received ethics approval from the Cantonal Ethics Committee for Research, Health and Welfare Directorate of the Canton of Bern, Switzerland, on 21 March 2019 (reference number 2018–02345) ¹⁷. The women interviewed had a psychiatric (ICD-10-F) diagnosis within the categories of mood disorders, behavioral and personality disorders, or psychosis.

The perspectives of healthcare providers (PEPPA Step 3) were also obtained from notes taken during focus group interviews with different healthcare professionals for the MADRE study. The health professionals were interviewed in three focus groups, with six to eight health professionals participating in each interview. The health professionals included psychiatrists, psychologists, gynecologists, a social worker, a member of the child and adult protection authority, a counselor for mothers and fathers, an APN from the neonatal intensive care unit, the chairperson of the Swiss Postnatal Depression Association, outpatient midwives, family care midwife, and a pediatrician. All individual interviews were transcribed using f4transkript transcription software¹⁸ and analyzed using thematic analysis¹⁹.

In Step 1 of the original PEPPA framework, the authors used the ‘cancer journey’ model, a flowchart depicting interconnected stages from prevention to treatment, to identify gaps in current care and define interventions. This model was adapted to illustrate the treatment pathway and care for women with PMDs (Figures 1 and 2) and helped to discover the most important gaps and the needs in perinatal mental healthcare, and to determine the scope of the care model. The forthcoming results section will delineate various measures undertaken for Steps 4–7.

Figure 1

Adapted PMH care pathway

Figure 2

APM model of care

After a one-year pilot phase from 1 February 2021 to 31 January 2022, the screening project was evaluated (PEPPA Step 8) in the context of a BFH Master’s thesis. This evaluation study received ethics approval from the Cantonal Ethics Committee for Research, Health and Welfare Directorate of the Canton of Bern, Switzerland, on 27 August 2021 (reference number 2021-00909). The evaluation focused on screening frequencies, results, healthcare professionals’ perceptions of the new APM role, and recommendations for improvement based on practical experience. A multimethod approach, blending qualitative and quantitative designs, assessed the screening project. The steps and related methodological processes are presented in Table 1.

Steps 1 and 3: Qualitative results of the current model of care

Four themes emerged from the qualitative analysis: 1) Experienced inadequate psychiatric treatment in the perinatal period, 2) Community as an important support factor, 3) Experienced challenges, and 4) The need for a care plan provision orientation.

Experienced inadequate psychiatric treatment in the perinatal period

All women interviewed reported that they experienced inadequate mental healthcare during the perinatal period. The adapted PMH pathway shows the perceived inadequacies at the various levels of care (Figure 1). Gaps were evident throughout the entire treatment pathway. Healthcare professionals did not verbally provide information about PMH and PMDs, nor were appropriate informational materials made available. None of the interviewees received systematic mental health screenings, even when they reported mental health problems, nor did they receive referrals to psychiatry from an obstetrician or midwife, and the patients had to seek psychiatric help on their own. The women reported that healthcare professionals dismissed mental health changes during pregnancy as a natural occurrence and that they had to consult with different healthcare services until they received a specialized therapy appointment. They experienced long waiting periods for specialized services and were not provided with transitional support while they waited:

If women were undergoing psychotherapeutic treatment, challenges were identified, including a lack of interprofessional cooperation, insufficient continuity of care, and unclear responsibilities. Health professionals relied on women to manage information exchange, which proved difficult due to the numerous professionals involved.

Community as an important support factor

Women and health professionals mentioned the need to establish a support network for mothers experiencing PMDs. Specifically, the importance of the partner’s role in finding and contacting professional help became evident:

When resources were lacking, individual situations were more likely to deteriorate, as in the case of a woman who was admitted to a psychiatric hospital and had her child placed in a children’s home.

Challenges experienced

In some cases, the challenges experienced by the women took the form of feelings of stigmatization, such as being ‘labeled’ (WOM5, #00:27:05-0) or being treated like a ‘complete idiot’ (WOM4, #00:29:26-1) in the postpartum period. In other cases, they identified feelings of shame and guilt or described how they hid their condition out of fear of losing custody of their children. The fact that the topic was taboo among the mothers themselves was also identified as a challenge. Health professionals identified stigma as a key problem, which often resulted in women seeking help too late, related to the lack of early detection by professionals. The women described the health professionals’ lack of specific expertise as another challenge. They reported that the advice received from the health professionals was not helpful:

Women also reported that professionals in outpatient services rarely collaborated, reflecting the prevailing fragmented healthcare service. The reasons for the lack of interprofessional collaboration were economic (e.g. roundtable meetings were not billable), a lack of time and resources, a lack of knowledge about other services, and a lack of personal contact with other providers.

Need for a care plan strategy

It became evident that a care plan was required during the perinatal period. The interviewed women and healthcare providers expressed parallel concerns about optimized care (Table 2).

Step 4: Identify the priority problems and goals to improve the model of care

In February 2020, a strategy meeting convened with both hospitals’ defined stakeholders (Step 2) to discern priority tasks and goals. The results outlined above (Steps 1 and 3) were presented to all stakeholders and acknowledged as a comprehensive, thematically complete foundation. These findings served as a basis for discussing the prioritized goals and aspects of improved care provision (Step 4). Stakeholders reached a consensus that early PMD detection should be enhanced, PMH should be strengthened, interprofessional collaboration should be promoted, and the coordination of the care process should be optimized. Based on these priorities, the study advanced to Step 5.

Step 5: Defining the new model of care and the APM role

Given the distinctive position of the APM service at the intersection of psychiatry and obstetrics, it was crucial to clarify and define competencies. Following discussions with stakeholders, the decision was made that the APM service should focus on the dual aspects of health promotion and prevention. Consequently, the core competencies of the APM were established accordingly. For women with PMDs, the role of an APM is to perform tasks delegated by the psychiatrist and assist with coordinating the treatment process (Figure 2). APMs are not authorized to make any psychiatric diagnoses or offer any psychotherapeutic services. They must have at least a Master’s degree and in-depth expertise in the PMH and PMDs to be considered qualified. Hierarchically, APMs work under the leadership of a psychiatrist. In alignment with the goals defined in Step 4, the following core competencies are recommended as part of the APM’s role definition: 1) Education and prevention, 2) Consultation with affected women and families, 3) Referral to other health professionals, and 4) Coordination of treatment for women with a PMD. Figure 2 illustrates the core tasks of APM services in blue, along with collaboration and cooperation with the psychiatrist and outpatient providers (green) throughout the pathway.

Step 6: Planning implementation

Studies and guidelines recommend systematic PMH screening to ensure timely detection and treatment of patients at risk^1,2. This was also implied by the women and healthcare providers interviewed (Table 2). Therefore, systematic screening was planned as the initial implementation step. The screening pathway and the extended APM screening assessment were developed with stakeholders and reviewed by the medical directors.

Step 7: Initiate the implementation plan

The screening comprised two stages: an initial assessment using the Whooley questions (WQs). The WQs are a validated tool to identify the risk for perinatal depression²⁰. If either answer was positive, women were asked to complete the Edinburgh Postnatal Depression Scale (EPDS)²¹. A score exceeding ten on the EPDS warranted consultation with a psychiatrist. Due to the availability of APM services, pregnant or postpartum women had the option to undergo an extended screening assessment by the APM if they scored between 10 and 13 points. The results and potential further procedures were discussed with each woman during the APM consultation. Midwives and obstetricians conducted the initial screening during routine antenatal and postpartum consultations. To facilitate this, the APM informed, trained, and supported the medical and midwifery teams.

Step 8: First evaluation of the APM role and new model of care

During the pilot phase, 509 women were screened, corresponding to 45% of the women who regularly sought antenatal care. Of these women, 13% had positive WQ screenings (Step 1). Subsequently, more than half of the respondents (53%) had positive EPDS results and fulfilled the criteria for extended screening. Of these women, 14% met the criteria (10–12 points) for extended screening assessment by the APM, and 39% met the criteria for direct referral to a psychiatrist (≥12 points). However, most of the women (38%) who required a direct referral to the psychiatrist preferred an initial appointment with the APM. After extended screening with the APM, 35% of the women were referred to the psychiatrist, with an average waiting time of 7.6 days. The evaluation of the EPDS showed that about 13% of the women sometimes had thoughts of harming themselves (EPDS, item 10).

The qualitative evaluation of the pilot study with seven health professionals revealed that cooperation between different specialists, especially the APM, was perceived as helpful and supportive. Especially in difficult situations, staff midwives often turned directly to the APM for support. The obstetrician appreciated the APM’s competence and described a feeling of great relief that allowed him to focus on medical issues during consultations. From the perspective of the professionals, the women and their relatives reported that they viewed addressing mental health issues positively. The professionals reported that due to the routine screening process, their awareness of PMH issues had increased. However, they noted that challenging communication situations with migrant women constituted a barrier to successfully implementing the systematic screening. Additional barriers were limited time resources during counseling and additional documentation efforts related to the evaluation.

Responsibility and liability in the APM model

The developed APM service serves as a bridge between obstetrics and psychiatry, and accordingly, it is based on a delegation model. The assigned APM competencies lie within health promotion and prevention (Figure 2). When working with a woman with a PMD diagnosis, the APM works with other involved health professionals to coordinate the woman’s care and treatment (Figure 2) and regularly consults with a psychiatrist. It has been shown that for patients with mental health disorders, collaboration between various health professionals from different disciplines is effective and helpful^25,26. Further, such collaboration has been recommended specifically for PMH care^27,28. In this study, cooperation with the University Hospital of Psychiatry and Psychotherapy played an important role in developing the presented APM role, as the hospital’s psychiatrist acted as the APM’s clinical supervisor. With regard to delegation models, trust is identified as one of the key factors in fostering a sustainable working relationship between the APM and various stakeholders²⁹. To ensure confidence, involving stakeholders and clarifying and defining competencies was crucial.

After role development, it became evident that immediate implementation of all aspects of the developed model in the clinic would not be feasible. This aligns with the typical clinical implementation processes, as noted by the authors of PEPPA¹⁶. The full development of a new role within a new model requires flexible oscillation between Steps 6 and 7 to stabilize the structure and implement long-term monitoring of the role and care model¹⁶. Based on the available personal and structural resources and strong agreement with stakeholders, the first implementation step was the systematic PHM screening. This approach aligns with international recommendations to o prioritize the early detection of PMDs^1,2. Healthcare professionals have reported that, since the implementation of screening in clinical care, they have become more aware of potential PMDs and feel more secure when systematically assessing PMH. Implementing screening can also enhance awareness of mental health among healthcare professionals and women themselves³⁰.

Success factors for the implementation of new care models

The education and training of professional teams and the provision of necessary resources are crucial for the successful implementation of midwifery projects³¹. Therefore, a manual was provided to ensure standardized screening procedures, and all staff were informed and trained about the process by the APM. Despite the successful introduction of the APM, the first screening with the WQs was only performed in 45% of women, possibly due to incomplete integration into daily routines. A similar phenomenon was observed in another study, where the number of screenings started to increase in the second year after implementation³². Therefore, continuous evaluation of the screening is recommended. According to a recent study, the screening program described here meets the current recommendations³³. In addition to the resources required for screening, these recommendations include timely diagnosis, appropriate treatment, and comprehensible action paths within the health organization. In the long-term, systematic screening for PMDs is expected to lead to improved health outcomes for women and their children^33,34. It can potentially reduce exceedingly high long-term costs related to unidentified PMDs³⁵. Recently published data about the causes of maternal mortality in the perinatal period from the USA and UK highlight the negative consequences of untreated maternal mental health conditions, which are considered the main causes of maternal deaths during this period in both countries^36,37. Although motherhood is not generally associated with suicide in society, 13% of the women in our sample reported suicidal thoughts. This finding underlines the importance of screening as an early detection method followed by early treatment.

Strengths and limitations

A major strength of this study is its systematic role development based on data from the MADRE project. Furthermore, this is the first time the PEPPA framework model has been used in the midwifery sector in APM development, implementation, and evaluation. Additionally, continued cooperation with the University of Applied Sciences ensures the further development and evaluation of the program. The study’s limitations include the small amount of data collected during role development and the specificity of the data to a particular location within a university hospital. Nevertheless, this study is a model for others seeking to develop APM services in their contexts.