A systematic review of midwives’ training needs in perinatal mental health and related interventions

Background Midwives may be key stakeholders to improve perinatal mental healthcare (PMHC). Three systematic reviews considered midwives’ educational needs in perinatal mental health (PMH) or related interventions with a focus on depression or anxiety. This systematic review aims to review: 1) midwives’ educational/training needs in PMH; 2) the training programs in PMH and their effectiveness in improving PMHC. Methods We searched six electronic databases using a search strategy designed by a biomedical information specialist. Inclusion criteria were: (1) focus on midwives; (2) reporting on training needs in PMH, perinatal mental health problems or related conditions or training programs; (3) using quantitative, qualitative or mixed-methods design. We used the Mixed Methods Appraisal Tool for study quality. Results Of 4969 articles screened, 66 papers met eligibility criteria (47 on knowledge, skills or attitudes and 19 on training programs). Study quality was low to moderate in most studies. We found that midwives’ understanding of their role in PMHC (e.g. finding meaning in opening discussions about PMH; perception that screening, referral and support is part of their routine clinical duties) is determinant. Training programs had positive effects on proximal outcomes (e.g. knowledge) and contrasted effects on distal outcomes (e.g. number of referrals). Conclusions This review generated novel insights to inform initial and continuous education curriculums on PMH (e.g. focus on midwives’ understanding on their role in PMHC or content on person-centered care). Registration details The protocol is registered on PROSPERO (CRD42021285926)


Introduction
Perinatal Mental Health Problems (PMHPs) affect parents during pregnancy and the first year after childbirth and commonly consist of anxiety, non-psychotic depressive episode, psychotic episodes, post-traumatic stress disorder and adjustment disorder.Despite being often associated with poor parental and child outcomes (1), PMHPs remain predominantly unrecognized, undiagnosed and untreated (2).
Given their role in perinatal care providing multiple occasions to discuss perinatal mental health (3) -midwives may be key stakeholders to improve the detection, referral and management of PMHPs.Parents usually welcome midwives' interest in their mental health and report to prefer discussing mental health issues with obstetric providers than with mental health providers (4,5).Assessing perinatal mental health (PMH) and detecting symptoms of postpartum depression, anxiety and psychosis are part of the essential competencies for midwifery practice according to the International Confederation of Midwives (2019) (6).However, and despite being in general interested in assessing perinatal mental health (PMH) and wellbeing (7), midwives report feeling less comfortable with putting competencies related to PMH into practice compared to those related physical health (8,9).
To our knowledge, three literature reviews have been conducted on midwives' educational needs in perinatal mental health (7,10,11).These reviews reported a lack of knowledge, skills and confidence influential at different levels of the care pathway, e.g.detection, decision-making about referral and support.However, there remain some limitations to the current body of evidence.First, all reviews found low-to-moderate quality studies coming predominantly from high-income countries.Second, two out of three reviews (10, 11) -conducted in 2017 (n=17 articles) and 2022 (43 articles) -focused on perinatal depression or perinatal anxiety and did not cover the full range of PMHPs as well as related conditions (e.g.substance use disorder, serious mental illness (SMI)) or autism).The third review (7) conducted in 2017 (n=22 articles) covered a wider range of PMHPs using an integrative review design, the other two (10, 11) being systematic reviews.Third, previous reviews (7,10,11) focused on midwives' knowledge, skills and attitudes and context-related factors.However, it remains unclear whether improvements in these areas translate into in routine clinical practice (e.g.improved detection of PMHPs or facilitated decision-making about referral to mental health providers).Fourth, case identification -using formal or informal screening methods -have contrasted effects on referral rates (7) and patient outcomes [e.g.limited effects of screening on depressive symptoms (12,13)].Fifth, two systematic reviews reported on training programs in perinatal depression [n=7 studies (10), n=12 studies (14)].However, these reviews included mixed samples [e.g.37% midwives in Wang et al., 2022 (14) and 54% midwives in Legere et al., 2017 (10)] and did not target the same set of skills [e.g.improving knowledge and detection (10); providing evidence-based interventions (14)].Reviews either investigated midwives' training needs (7,11) or training interventions (10,14).The literature on training programs in PMH for student midwives and midwives remains scarce [n=4 studies (10)].A synthesis of evidence before this study is presented on Table 1.
The present review primarily aims to identify and review: 1) midwives' educational/training needs in PMH (i.e.beyond perinatal depression or anxiety to include PMHPs, SMI, substance use disorder, and autism); 2) the existing interventions and their effectiveness in improving detection and management of PMHPs.

Search strategy
The protocol for this systematic review was reported according to PRISMA guidelines (15).The search strategy was designed by a biomedical information specialist (WMB) from the Medical Library of Erasmus MC, University Medical Center Rotterdam (16).We searched Embase, MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials, CINAHL and, PsycINFO for published, peer reviewed original articles.The search combined terms for (1) perinatal mental health problems, serious mental illness (i.e.schizophrenia, mood disorders, personality disorders, anxiety), eating disorders, substance use disorders or autism, and (2) midwives' knowledge, attitudes, skills or training needs, as well as existing training programs for midwives on PMH.We included  We hand-searched the reference list of three systematic literature reviews (7,10,11) for additional relevant articles.The full search strategy, search terms and syntax are presented in online Supplementary Table 1.

Inclusion/exclusion criteria
To be included, articles had to meet all the following criteria: 1) focus on midwives (included midwives, nurse-midwives, registered midwives, registered midwives tutors, registered midwives prescribers and registered advanced midwives practitionersreferred as "midwives" in this review); 2) reporting on midwives' training needs in PMH, PMHPs or related conditions or existing training programs that focus on the use of screening tools to detect PMHPs, on PMH in general or specific aspects of PMH; 3) using quantitative, qualitative or mixed-methods design.For training programs, we included uncontrolled and controlled studies (placebo, TAU or active comparators).
Our exclusion criteria were:

Selection and coding
The screening process was conducted in two separate stages: 1) Two authors (M.D. and J.D) independently screened the title and abstracts of all non-duplicated papers excluding those not relevant.Potential discrepancies were resolved by consensus; 2) Two authors (M.D. and J.D) independently applied eligibility criteria and screened the full-text papers to select the included studies.Disputed items were solved discussing together and reading further the paper to reach a final decision.Supplementary Tables 2, 3 present the list of included/ excluded studies.Inter-rater reliability was calculated (kappa=0.90).

Data extraction
Two authors (MD and JD) performed independently the data extraction.For each study, we extracted the following information: general information (author, year of publication, country, design, type of study, population considered, period), assessment tools or methods, cultural aspects, the main findings and variables relating to quality assessment.For studies reporting on training programs, we also extracted information about the intervention (nature, type, length, targeted skills or outcomes, format), outcome measures and effectiveness on midwives' knowledge, attitude, skills or routine use of screening tools to detect PMHPs or parents' outcomes (e.g.depressive symptoms).Tables 2-6 present the factors associated with knowledge, skills, confidence and decisions about screening, referral or support.Supplementary Tables 4, 5 present the detailed characteristics of the included studies.

Quality assessment
Quality assessment was realized using the Mixed Methods Appraisal Tool (MMAT) (61).MMAT is a validated instrument to assess the methodological quality of qualitative, randomized controlled trials, non-randomized trials, descriptive studies, and mixed methods studies.It is comprised of five 5-item subscales assessing different aspects of quality (e.g.appropriateness of the selected design/methods/measurements, integration of quantitative and qualitative parts for mixed-methods studies).Two researchers (MD and JD) independently assessed methodological quality using the MMAT and extracted MMAT scores for each article.Discrepancies were resolved through consensus.The MMAT overall quality score and detailed scores are provided in Supplementary Tables 4, 5.The study protocol was registered on PROSPERO on November 1, 2021 (CRD42021285926).

Results
Of the 9650 articles found during searches from inception to June 26 th 2023, 4969 references remained after removing all duplicates.Based on titles and abstracts, 4772 papers were excluded for lack of relevance.Our search strategy yielded 197 full-text articles.After conducting a full-text analysis of all these papers, we ended up with 66 relevant papers (47 on knowledge, skills or attitudes and 19 on training programs; PRISMA diagram on Figure 1).

Study characteristics
The characteristics of the 66 included studies are presented on Tables 7, 8.Most studies were conducted in high-income countries (89.4%) and published after 2015 (50%).Study designs were quantitative (n=33; 50%), qualitative (n=22; 33.3%) or mixedmethods (n=11; 16.7%).Samples included qualified midwives (n=37; 56.0%), qualified midwives and other perinatal health providers (n=17; 25.8%) and student midwives (n=11; 16.7%).Qualified midwives had a variable level of training in PMH ranging from none to 90% (specified in 24 studies; most covered topics: general information about PMH and PMHPs; least covered topics: interviewing/counseling skills, psychopharmacology and suicide risk assessment).Eight studies (12.1%) reported on midwives' mental health nursing experience (ranging from 0.8% to 30%) or placement experience in a mental health setting or a mother-baby unit during their studies (ranging to 9% to 23.2%).Four studies (6%) mentioned family or personal experience of mental health problems ranging from 25% to 66.3%.Most studies covered the entire perinatal period (n=44; 66.7%) and reported on PMHPs (n=32; 48.5%).The definition of PMHPs was highly variable across the studies (e.g.inclusion of conditions usually not considered as PMHPs, such as schizophrenia, bipolar disorder, personality disorders, self-harm, suicide eating disorders or SUD in 16 studies; definition restricted to anxiety, depression, postpartum psychosis and/or posttraumatic stress disorder in 9 studies; unspecified in 7 studies).One third of the included studies used validated instruments to assess outcomes (n=16; 36.4%).Five studies (7.6%) investigated the influence of cultural aspects on the detection and management of PMHPs.
Of 15 studies reporting on a training program using a quantitative or a mixed-methods design, three used a waiting-list control group (20%; one randomized controlled trial (RCT)) and 13 (86.7%)were uncontrolled.Sample size was small in most studies (< 50 participants; n=9 studies).Nine studies (47.3%) reported contact with persons with lived experience when designing their training program.The training programs were heterogeneous in nature (initial training, n=6, 31.6%;continuous education, n=13, 68.4%), type, format and duration (ranging from 2 minutes to a fifteen-week module).All studies assessed training outcomes either immediately after (n=15; 79%) or up to 3 months after the intervention is delivered (n=4; 21%).

Quality assessment
The overall assessment score ranged from low (n=30, 45.4%; n=13, 68.4% for training programs) to high (n=11, 16.7%; n=2, 10.5%).For quantitative or mixed-methods studies, the reasons were convenience sampling (n=61 studies, 92.4%), sample size, low response rate (n=18 studies > 60%), limited use of validated outcome measures (36.4%), use of self-reported measures, absence or short duration of the follow-up period, limited integration of the results in mixed-methods studies and lack of controlled/RCT studies to evaluate the effectiveness of training programs.For qualitative studies, the reasons were interpretation bias (e.g.no investigator triangulation, the data being analyzed by only one researcher), absence of data saturation and lack of reflexivity.

Narrative review
Many studies found that midwives felt ill equipped to care for parents with PMHPs [e.g.ranging from 69.2% of 815 midwives in     (40).Self-reported barriers to discuss PMH issues or self-reported interviewing skills did not differ between nurses and midwives (25).Student midwives' knowledge, skills and attitudes in PMH did not clearly differ from those of qualified midwives (n=5 studies).On the job experience, learning from peers and attending to workshops/ conferences were midwives' main sources of knowledge (n=3 studies).
The factors positively associated with knowledge about PMHPs included the perception to be well equipped to provide PMHC (66.7% significance), previous training in PMH (50% significance), younger age (17), shorter work experience in general and as a midwife (20% significance), frequent contact with parents with PMHPs (50% significance) and type of practice (33.3% significance).Mental health nursing experience was positively associated with the perception to be well equipped to provide PMHC, but not with higher knowledge about PMH (8).No significant association was found between confidence in providing PMHC and other factors [e.g.age, personal experience of mental health problems, frequent contact with parents with PMHPs (29)], except for PMH education and case identification (8).Compared with suicide risk assessment and other conditions (e.g.postpartum psychosis, SMI, eating disorders or posttraumatic stress disorder; n=4 studies), midwives reported higher knowledge, better skills and more confidence in detecting and managing perinatal depression and anxiety.Midwives felt in general ill equipped to care for postpartum psychosis, eating disorders, posttraumatic stress and SMI (n=10 studies) and reported ambivalent or negative attitudes toward parents with these conditions (n=7 studies).Knowledge about PMHPs varied according to the assessment method [i.e. higher selfreport knowledge than researcher-rated knowledge (19, 43)] and the timing of perinatal period (i.e. higher in the postpartum than during pregnancy, n=5 studies).

Detection/screening
The practices and policies around screening for PMHPs varied across studies.There was a considerable overlap between the factors influencing the decision to screen, refer and support parents with PMHPs.Midwives' attitudes toward their role in PMHC (e.g.personal interest in PMHPs and perception that it is part of their role) played a central role in decision-making about opening discussions about PMH (n=12 studies), referral (42, 57) and support parents with PMHPs (n=6).Cultural aspects and stigma toward parents with ethnic minority background (e.g.underestimation of depression and suicide risks) impacted midwives' ability to detect and manage PMHPs and parents' maternity care experiences (n=4 studies).Other common factors included lack of knowledge about PMHPs (n=20 studies), referral pathways (n=8) and treatment options (n=10), lack of time/ clear referral pathways (n=22) and stigma related to preexisting mental health problems/SMI (n=8).
Midwives considered routine universal screening as useful in two studies (5,56).Facilitators included self-efficacy in screening (n=10 studies), person-centered care (n=3), the presence of a specialist team (n=2 studies) and mandatory routine screening (n=2).Barriers to screening included longer work experience (42), lack of knowledge about screening tools (n=11 studies), local/ national guidelines on screening (ranging from 12.8% to 53%, n=4 studies), and negative attitudes toward the use of formal screening tools (n=12 studies).The relationship between personal/family experience of PMHPs was either positive [e.g.reduces stigma and allows to relate with parents (29)] or negative (45).For student midwives, the presence of specialist midwives was both a facilitator [e.g.provides referral options and placement opportunities (50)] and a barrier to screening [e.g.perception that it is not part of their role (43)].Of note, specialist midwives reported to lack confidence in opening discussions about PMH and to lack knowledge about SMI (21).
The reasons underlying negative attitudes toward the use of formal screening tools included perceiving the questions as intrusive (n=3 studies), not clearly understanding the purpose of doing so (n=3 studies), inexperience in conducting assessment and feeling compelled to undertake it as a standardized survey (23), the fear of "not doing it right" (n=2) and discomfort when disclosure occurs (n=7 studies).Some studies reported a flexible use of screening tools (e.g.modified wording or timing of the questions; n=4 studies) and one study outlined the importance of personcentered care in conducting assessment (23).Conversely, midwives who lacked clarity about their role in PMHC reported feelings of inadequacy resulting in a non-flexible use of screening tools and a distant and superficial manner of asking questions (23).Midwives reported to feel more comfortable in opening discussions about PMH during follow-up visits compared with the booking appointment (n=5 studies).Alternatives to formal screening included assessing previous psychiatric history/current symptoms (28), using general open-ended questions (n=5 studies), behavioral observation (n=4 studies) and labor debriefing (46).Training needs covered knowledge about PMHPs (n=9 studies), screening tools (n=4 studies) and cultural issues and interviewing/distress management skills (n=10 studies).

Referral/support
Midwives reported to feel confident in their ability to refer parents with PMHPs to other health providers including specialist mental health services (n=7 studies).The opposite was found for parents with postpartum psychosis, eating disorders or SMI.High self-reported confidence in referring parents to other providers did not in practice lead to a higher number of referrals (37).The proportion of midwives indicating to feel confident in supporting parents with PMHPs in self-report questionnaires ranged from 34% to 53% (n=5 studies).Accurate case identification (9), an established diagnosis of PMHP (53) and parents' preferences (53) influenced decision-making about referral.Other factors included the intention to collaborate with other providers (n=2) or conversely a lack of trust/a reluctance to disclose sensitive information to other providers (n=3 studies).

Training outcomes
All training programs reported improved self-rated knowledge, skills, attitudes and confidence in screening, referring and supporting parents with PMHPs (n=19).Few significant positive training effects were reported due to small-sized samples and lack of controlled/RCT studies.Results included positive effects on empathic communication skills (62,63), case identification (64,65) and the detection of PMHPs in maternity wards (66-68).Contrasted results were found on the number of referrals [n=2 studies; 50% significance; positive effect on self-reported referrals in Pearson et al. (2019) (69) and no significant effect in Wickberg et al. (2005,70)].No significant effects were found on depressive symptoms (70) and attitudes toward providing psychological support to parents with PMHPs (63).Participants' satisfaction rates were high, the insight provided by parents with lived experience of PMHP being determinant for student midwives (n=4 studies).Barriers included an excessive workload (71) and for student midwives, elective participation and late delivery within midwifery studies (72).No difference related to the format of the intervention was reported.

Discussion
To our knowledge, this systematic review of 66 studies is one of the first exploring both the training needs in PMH identified by student midwives and midwives and the training programs designed for this population.Overall, a main finding of this systematic review is that although detection, referral and support of parents with PMHPs are part of the essential competencies for midwifery practice according to the ICM (2019) (6), their effective translation into routine clinical practice may depend on midwives' understanding of their role in PMHC, i.e. finding meaning in opening discussions about PMH with all parents and the perception that this is part of their routine clinical duties.This suggests that this factor should be targeted by raining interventions aiming at improving detection and management of PMHPs, above and beyond knowledge, confidence, and skills.
Extending the findings of previous reviews (7,10,11), we found that although most midwives consider they have a role in PMHC (this aligning with ICM essential competencies for midwifery practice; 2019 (6)), their understanding of that role remains often unclear.Several potential explaining factors have been identified.First, while this topic may be central for a meaningful engagement into providing PMHC, only a few training programs explored the role of midwives in PMHC (71,73).Second, there is a view -in particular in student midwives -that addressing PMH needs is less a priority than addressing physical health needs and that other providers should assume this responsibility (31, 35, 39, 43, 50, 52).The interaction between this view, mental illness stigma and racism toward parents with ethnic minority background contributed to poorer maternity experiences and under-detection of PMHPs (19,35,73).
Third, some midwives consider their role as limited to assessing PMH and wellbeing and as appropriate, referring to other health providers (9, 18, 55, 57, 58), whereas others have a broad perception of their role that include providing support, psychoeducation and with adequate training counseling interventions (21,24,25,42).Recent meta-analyses showed positive effects of midwife-led counseling on anxiety and depressive symptoms after at least 3 days of training (14,74).This concurs with recent calls for a better integration of mental health and perinatal health care and an extension of the scope of midwifery practice to include strengthsbased case management and psychological interventions for parents

Implications for training interventions
While the need to improve midwives' initial and continuous education in PMH is now well established (7, 10), student midwives, midwives and even specialist midwives continue reporting to feel ill prepared to care for parents with PMHP in particular in case of cooccurring SMI (9,21,24,33,34,36).Moreover, the proportion of midwives who received education in PMH -in particular in topics such as mental health/suicide risk assessment -remains consistently low.Given suicide is the leading cause of maternal mortality in the 1 st year postpartum in high-income countries, this is concerning (1,80).
Aligning with previous research (7,10,11), this systematic review found that education/training programs had positive effects on proximal outcomes (e.g.midwives' knowledge, skills, attitudes and confidence in providing PMHC) and contrasted effects on distal outcomes (e.g.screening in maternity wards, the number of referrals or depressive symptoms).This could be related to methodological bias (e.g.lack of RCT or quasi-experimental studies).There is a need for high-quality studies on interventions designed following the Medical Research Council framework for complex interventions (81), which proposes among other core elements to: 1) take into account the context of delivery; 2) use a clear theoretical basis (e.g.how the intervention is expected to produce positive effects and under which conditions) and; 3) promote a meaningful engagement of persons with lived experience among other relevant stakeholders.
According to Wadephul et al. (2018) (82) framework for assessing midwifery practice in PMH, knowledge, confidence, attitudes and organizational factors influence midwives' ability to detect and manage PMHPs.However, higher knowledge about  PMH does not necessarily translate into higher confidence in providing PMHC and the opposite (8).As reported in one of the articles included in this review (42) and aligning with the theory of planned behavior (82), additional factors such as individual values, e.g.personal interest in PMH, and behavioral intent (e.g. the intention to open discussions about PMH) could influence detection and decision-making about referral and support in PMHPs and thus be relevant for midwifery education.
To improve midwives' engagement into PMHC, training programs should put PMH in context (e.g. the positive outcomes that could be achieved with appropriate support) before covering topics related to specific knowledge or skills (5,38,49,50,53,54).Instead of focusing only on biomedical aspects (e.g. the signs, risk factors, consequences and treatments of PMHPs), programs should propose a continuum approach of PMH that covers the positive aspects of the person's life including wellbeing and personal recovery (83)(84)(85)(86).
Extending the findings of previous reviews (7,10,11), training programs should target student midwives, midwives and specialist midwives and cover interviewing and distress management skills with a focus on specific aspects (e.g.opening discussions without feeling intrusive, using flexibly screening tools and reacting in case of a positive answer) (5,21,38,45,49,50,53,54).In addition, training programs should include clinical supervision by mental health providers during and after intervention delivery (14).Future studies should include a longer follow-up period, as the embedding of practice change requires a minimum of nine months after the intervention is delivered (87).
Finally, while contact with persons with lived experience is one of the most effective strategies to reduce mental illness stigma in the general public and in frontline health providers (88,89), this review found a very low proportion of training programs that engaged persons with lived experience in the conception and delivery of the intervention.Initial and continuous midwifery education curriculums on PMH should involve persons with lived experience -co-design and co-intervention -and include content about personal recovery/person-centered care (72, 73,81,84,[90][91][92].

Limitations
There are limitations.First, despite a growing number of published studies on midwives' training needs in PMH and training interventions designed for this population (n=66 studies in this review vs. n=22 (7); n=17 (10); n=43 (11);), the quality of the included studies remains low to moderate, a concerning finding given the clinical relevance of this topic that is also a considerable limitation.Among other methodological bias, the absence of a clear theoretical basis for designing interventions (81), the small or unjustified sample sizes, the lack of RCT/quasi-experimental studies, the absence of control groups (or active comparators in controlled studies) and the absence or short duration of follow-up makes unclear whether interventions have positive effects on proximal or distal outcomes.Future high-quality studies on this topic are therefore needed.Despite these limitations, the inclusion of quantitative, qualitative and mixed-methods studies provided a complete synthesis of the available evidence and consistent messages emerged across studies.Second, relevant studies may have been missed since we excluded studies published in other languages than English or French and did not include the grey literature in our searches.

Conclusion
This review generated novel insights to inform initial and continuous midwifery education curriculums on PMH (e.g.codesign with persons with lived experience, focus on midwives' understanding on their role in PMHC or inclusion on content on person-centered care).

TABLE 1
Evidence before this study.

TABLE 2
Factors influencing the level of knowledge and skills.

TABLE 3
Factors influencing confidence and the perception of being well-equipped.

TABLE 3 Continued
felt less confident in the detection, referral or management of PMHPs (n=3) and had more negative attitudes toward their role in perinatal mental healthcare (PMHC) (57) or suicide prevention

TABLE 4
Factors influencing decisions about screening.

TABLE 5
Factors influencing decisions about referral.

TABLE 6
Factors influencing decisions about support.

TABLE 7
Research characteristics of the 66 studies included in the review.

TABLE 7 Continued
* Inclusion of conditions usually not considered as PMHPs.***total > 100% because some studies covered more than one condition. *

TABLE 8
Research characteristics of the training programs included in the review.
*total > 100% because some studies used co-construction and testimonies.