ASSESSMENT OF MENTAL HEALTHCARE DURING PREGNANCY AND THE POSTPARTUM PERIOD IN PRIMARY CAREABSTRACT
Objective: To assess the mental healthcare actions provided by Primary Health Care professionals to women during the pregnancy-postpartum period in a municipality in the Central-South region of Paraná, Brazil.
Method: This qualitative evaluative study was conducted with 15 postpartum women. Data collection included semi-structured interviews, administration of the Edinburgh Postnatal Depression Scale, and documentary analysis of medical records. Data were subjected to descriptive analysis and thematic content analysis.
Results: A high frequency of psychological distress during the pregnancy-postpartum period was identified, contrasting with the absence of mental health records in medical charts and the scarcity of guidance and emotional support during prenatal and postpartum care. Care was shown to be centered on the biomedical model, with low nursing participation and limited use of qualified listening and psychosocial support strategies.
Conclusion: The findings reveal structural weaknesses in maternal mental healthcare within PHC, highlighting gaps in care and discontinuity of assistance. The need to improve professional practice, incorporate screening practices, and strengthen comprehensive care models capable of addressing women’s emotional needs during the pregnancy-postpartum period is emphasized.
DESCRIPTORS:
Primary Health Care; Mental Health Assistance; Postpartum Period; Depression, Postpartum; Women’s Health
RESUMO
Objetivo: Avaliar as ações de assistência em saúde mental prestadas por profissionais da Atenção Primária à Saúde a mulheres no período gravídico-puerperal em um município do Centro-Sul do Paraná.
Método: Estudo qualitativo, de caráter avaliativo, realizado com 15 puérperas. A coleta de dados incluiu entrevistas semiestruturadas, aplicação da Escala de Depressão Pós-Parto de Edimburgo e análise documental de prontuários. Os dados foram submetidos à análise descritiva e à análise de conteúdo temática.
Resultados: Identificou-se elevada frequência de sofrimento psíquico no período gravídico-puerperal, contrastando com a ausência de registros sobre saúde mental nos prontuários e com a escassez de orientações e de acolhimento emocional durante o pré-natal e o puerpério. A assistência mostrou-se centrada no modelo biomédico, com baixa participação da enfermagem e pouca utilização de estratégias de escuta qualificada e de apoio psicossocial.
Conclusão: Os achados revelam fragilidades estruturais na atenção à saúde mental materna na Atenção Primária à Saúde (APS), elucidando lacunas na assistência e descontinuidade do cuidado. Destaca-se a necessidade de qualificar a atuação profissional, incorporar práticas de rastreamento e fortalecer modelos de cuidado integral que respondam às necessidades emocionais das mulheres no período gravídico-puerperal.
DESCRITORES:
Atenção primária à saúde; Assistência à saúde mental; Período pós-Parto; Depressão pós-parto; Saúde das mulheres
RESUMEN
Objetivo: Evaluar las acciones de atención a la salud mental proporcionadas por profesionales de atención primaria a mujeres durante el embarazo y el período posparto en un municipio de la región Centro-Sur de Paraná.
Método: Este estudio cualitativo y evaluativo se realizó con 15 mujeres en el posparto. La recopilación de datos incluyó entrevistas semiestructuradas, la aplicación de la Escala de Depresión Posnatal de Edimburgo y el análisis documental de los expedientes médicos. Los datos fueron sometidos a análisis descriptivo y análisis temático de contenido.
Resultados: Se identificó una alta frecuencia de malestar psicológico durante el embarazo y el posparto, en contraste con la ausencia de registros de salud mental en las historias clínicas y la escasez de orientación y apoyo emocional durante la atención prenatal y posparto. Se observó que la atención se centraba en el modelo biomédico, con escasa participación del personal de enfermería y un uso limitado de estrategias de escucha activa y apoyo psicosocial.
Conclusión: Los hallazgos revelan deficiencias estructurales en la atención de la salud mental materna dentro de la Atención Primaria de Salud, evidenciando carencias en la asistencia y discontinuidad en la atención. Se subraya la necesidad de mejorar la práctica profesional, incorporar métodos de detección y fortalecer modelos de atención integral que aborden las necesidades emocionales de las mujeres durante el embarazo y el posparto.
DESCRIPTORES:
Atención Primaria de Salud; Atención a la Salud Mental; Periodo Posparto; Depresión Posparto; Salud de la Mujer
INTRODUCTION
The pregnancy-postpartum period is marked by several changes in women’s lives, especially psychological and emotional changes, and requires adequate and timely mental healthcare in order to contribute to reducing maternal morbidity and mortality1,2. The literature indicates that care during the pregnancy-postpartum period places greater emphasis on physical problems than on psychological and emotional well-being, which remains permeated by stigma and the invisibility of women during this period3,4. However, the emotional and psychological dimensions of pregnant and postpartum women deserve special attention, particularly given the possible discrepancy between idealized expectations and lived reality3.
In this context, it is noteworthy that perinatal depression is one of the most common complications during pregnancy and postpartum, affecting approximately one in seven women1. The literature reports a prevalence of 24.7% of postpartum depression (PPD) in low-income countries5, which may reach 56% among Latina women6. Despite this high prevalence, the literature highlights weaknesses in the Health Care Network during the pregnancy-postpartum period2,7, especially within Primary Health Care (PHC), where professionals often lack knowledge regarding the adequate and timely diagnosis of PPD77,8.
Despite the high prevalence and negative repercussions of perinatal depression, the literature demonstrates weaknesses in the Health Care Network during the pregnancy-postpartum period2,7, revealing inadequate care for women during this stage and lack of knowledge among PHC professionals regarding the adequate and timely diagnosis of PPD7,8.
In recent years, studies have advanced in identifying structural and organizational barriers within PHC, as well as in analyzing professional performance regarding maternal mental health; however, evaluative studies still remain limited4. Such studies are mostly concentrated in capitals or large urban centers, focus only on professionals’ perceptions, or use aggregated secondary sources without direct access to clinical records8,9. Thus, the concrete experiences of women receiving care, as well as the actual quality of mental health records during prenatal and postpartum care, remain underexplored. Furthermore, recent studies have not addressed the specificities of small municipalities, where structural limitations, lower management capacity, and difficulties accessing specialized services create a distinct and poorly investigated scenario10,11.
Therefore, the present study advances knowledge by integrating two dimensions that remain insufficiently articulated in the national literature: the perspective of the women themselves, which allows understanding their needs, perceptions, and expectations regarding the care received; and the analysis of clinical records from healthcare visits, providing concrete evidence of how mental healthcare is operationalized within PHC.
Considering the above, this study contributes to advancing the field by deepening the understanding of women’s needs and perceptions, as well as the records produced during the pregnancy-postpartum period in a small municipality, thereby supporting public policies and strategies aimed at strengthening mental healthcare in these specific contexts.
This study aimed to assess the mental healthcare actions provided by PHC professionals to women during the pregnancy-postpartum period in a municipality in the Central-South region of Paraná. The hypothesis was that such care is provided superficially, without systematic mental health approaches during consultations and with limited professional knowledge regarding the use of instruments for identifying PPD.
METHOD
This is an evaluative study with a qualitative approach, grounded in Patton12 and conducted according to the COnsolidated criteria for REporting Qualitative research recommendations. The research setting was a small municipality in the Central-South region of Paraná, Brazil, with 29,924 inhabitants and an annual average of 455 live births13,14. The local Health Care Network consists of 12 Basic Health Units (BHUs); however, the municipality does not have a specialized mental healthcare service, referring patients to a regional reference service. Three BHUs with the highest number of registered pregnant women were selected for data collection.
The population consisted of postpartum women aged ≥18 years who had attended at least one postpartum consultation at their reference BHU and were between 42 days and six months postpartum. Women whose children were not born alive were excluded. Eligible participants were identified with the support of BHU nurses. Of the 37 women initially contacted, 15 comprised the final sample. Losses occurred due to refusal (n=2) and inability to establish contact (n=20). Sample size was defined according to the theoretical-empirical saturation criterion, independently verified by two researchers12.
Interviews were scheduled according to the order in which participants returned telephone contact attempts. Upon contact, women were allowed to choose the most convenient time and location.
Data collection took place between January and March 2024 through four distinct stages. Initially, a questionnaire was administered containing sociodemographic information (age, marital status, education level, number of children, presence of family conflicts) and clinical and obstetric profile data (number of pregnancies, diseases and health conditions, planned pregnancy, and complications during pregnancy, childbirth, and/or postpartum).
Subsequently, semi-structured interviews were conducted using a script developed based on the Theory of the Postpartum Care Program4. Questions addressed the history of mental health problems, participants’ emotional status, family and social support received during prenatal and postpartum care, as well as guidance provided regarding common emotional changes during the postpartum period. The guiding question used was: “Tell me how your care provided by the BHU (health center) team was from prenatal care until now”.
The interviews were conducted by a previously trained nursing undergraduate student in private settings, seven at the BHUs and eight at participants’ homes, with an average duration of ten minutes. All interviews were audio-recorded and fully transcribed.
In the next stage, participants received the Edinburgh Postnatal Depression Scale (EPDS) for self-administration. The version of the EPDS used in this study was validated for the Brazilian population by Santos et al.15 and consists of ten items investigating feelings related to the postpartum period, such as mood, guilt, anxiety, fear, sadness, and self-harm thoughts. A cut-off score equal to or greater than 12 was adopted, indicating the likelihood of PPD, although not defining its severity16.
Finally, data were collected from participants’ medical records using a form containing: consultation date, professional responsible for care, type of consultation (prenatal or postpartum), and a space for the faithful transcription of records made by professionals. This stage enabled the identification of records related to mental healthcare provided during the pregnancy-postpartum period.
Quantitative data were described using absolute numbers. Interviews and medical records were analyzed through categorical content analysis17, involving pre-analysis, exploration, and interpretation. In vivo coding18 and categorization guided by the Theory of the Postpartum Care Program4 were used, which directs comprehensive care in PHC considering access, longitudinality, coordination, and comprehensiveness.
The project was submitted to the Research Ethics Committee of Universidade Estadual do Centro-Oeste. To ensure participants’ anonymity, codes beginning with the letter “P” (for postpartum woman) followed by the corresponding interview number were used.
RESULTS
Fifteen postpartum women participated in the study. Among them, ten were aged 25 years or older, 11 had a partner, 11 had at least incomplete high school education, 11 had two or more children, and 13 reported not experiencing family conflicts.
Concerning clinical and obstetric profile, nine had planned pregnancies, two experienced complications (including preterm birth), and six reported a previous diagnosis of anxiety; two reported depression. In the EPDS, five participants obtained scores ≥12 and were referred for follow-up at the reference unit, whereas the others scored below the cut-off point.
From the analysis of qualitative data using in vivo coding, it was possible to identify three analytical categories: 1. Experiences of psychological distress during the pregnancy-postpartum period: silenced sadness, anxiety, and depression; 2. Weaknesses in mental healthcare during the pregnancy-postpartum period; 3. Satisfaction adapted to the biomedical model: positive perception despite care gaps related to emotional and subjective needs.
The synthesis of the analytical process is represented in the coding tree shown in Figure 1.
Experiences of psychological distress during the pregnancy-postpartum period: silenced sadness, anxiety, and depression
Participants’ reports revealed the recurrent presence of psychological distress during pregnancy and postpartum, expressed through in vivo codes such as “sad”, “I only cried”, and “it was very complicated”. These feelings were associated both with physical and emotional changes and with social and family demands, which intensify throughout this period.
Many women reported experiences marked by sadness and emotional overload, permeated by a sense of invisibility regarding their own needs in the face of the maternal role.
I do feel sad sometimes, because now I only think about them, you know? I no longer have that feeling of thinking about myself [...] I only think about them now, about raising my children (P3).
Unplanned pregnancy emerged as an aggravating factor for distress, especially at the beginning of pregnancy, when feelings of rejection, ambivalence, and fear became more evident.
It was really very difficult; I did not want to get pregnant by him. [...] At first, I only cried (P4).
The final weeks of pregnancy were also described as a period of great physical and emotional exhaustion, revealing the intensity of discomfort and vulnerability experienced by women.
I cried out of nervousness [...]. In the last few days, it was very complicated (P12).
In addition to these feelings, explicit references to anxiety and depression emerged, including previous or ongoing episodes.
I have already had depression [...] (P2).
[...] part of it is because of the anxiety I have always had (P7).
Despite the variety of symptoms, the clinical management reported by participants was restricted to medication use, without mention of psychotherapeutic interventions or non-pharmacological resources.
Even though I’d been taking sertraline for about three years already [...] I can’t stay without this medication. I become very stressed (P4).
This set of reports indicates that psychological distress was present and recognized by the women themselves; however, it was not connected to a care network capable of providing emotional support or a diversity of therapeutic approaches.
Weaknesses in mental healthcare during the pregnancy-postpartum period
Analysis of the interviews showed that, despite the presence of significant emotional symptoms, the mental healthcare provided by PHC services was incipient, fragmented, and predominantly centered on medication prescription. Women reported not being asked about their feelings during prenatal or postpartum care.
They did not ask me anything [...]. I have already had depression, but I do not think they even remembered it (P1).
No, they did not ask anything about that [...] not even after I had her (P3).
Even women with a history of depression or anxiety reported a lack of systematic follow-up.
The only thing the doctor told me was to take sertraline. I was already taking it before (P12).
Of the 15 participants, 13 stated that they had not received any guidance regarding mental health. For many, the topic was never even addressed by professionals.
The worst part is that we know, right, that this can happen [...] but not there (P14).
Analysis of medical records confirmed this gap. There was an almost complete absence of records related to mental health, both during prenatal care and postpartum care. Even with electronic medical records available, several fields were left blank or filled exclusively with biological information. There were no references to emotional symptom screening, psychosocial support, or referrals.
Paper-based medical records showed similar weaknesses, such as blank fields, incomplete notes, and absence of descriptions regarding the interventions adopted. Only three medical records contained sertraline prescriptions, without any additional details.
Attention was also drawn to the low participation of nursing professionals in follow-up care: only 26% of consultations had nursing records, revealing underutilization of the nursing consultation as a comprehensive care tool.
This set of findings demonstrates a disconnect between the suffering experienced by women and care practices, highlighting that mental health has not been systematically incorporated into PHC actions during the pregnancy-postpartum period.
Satisfaction adapted to the biomedical model: positive perception despite care gaps related to emotional and subjective needs
Despite the weaknesses identified, most participants assessed the care received as satisfactory, using terms such as “good” and “great”.
I think everything is really good (P9).
The care so far has been good [...] they notify us, schedule appointments, send messages (P5).
I have nothing to complain about [...] it was great (P1).
The response pattern suggests that the perception of satisfaction is strongly associated with the biomedical problem-solving capacity of the service - access to tests, appointments, vaccination, and medication prescriptions. However, subjective, emotional, and relational aspects were not recognized as part of the scope of care, revealing a limited understanding regarding rights and possibilities for mental healthcare assistance.
This dissociation between experienced suffering and the absence of criticism regarding the care received indicates a form of “adapted satisfaction”, in which women positively assess what they know as a possible service offering, rather than what would actually be appropriate from the perspective of comprehensive care.
This contrast became evident in the statement of a single participant who recognized the insufficiency of emotional support.
It is good in some ways [...] it was very complicated, I almost relapsed (P12).
This statement reflects a broader awareness regarding rights and needs, emphasizing that the absence of mental healthcare is not perceived by all women, but tends to be naturalized by most of them, especially in municipalities with limited availability of specialized services.
Thus, the results reveal not only care gaps, but also the need to promote mental health literacy among users, expanding their ability to identify demands and claim adequate care within PHC.
DISCUSSION
Participants’ sociodemographic characteristics reinforce evidence that factors such as education, income, and living conditions directly influence access to, understanding of, and use of health information, especially in the field of perinatal mental health4. In small municipalities such as the setting of this study, these variables are compounded by PHC structural and organizational limitations, creating additional barriers to comprehensive care.
Most women reported having a partner, which may represent a protective factor due to the emotional support provided19,20. However, such support is not always effective, making it essential for professionals to understand family dynamics and adopt welcoming strategies that include women’s support networks21. Therefore, family members and/or partners must be involved throughout the pregnancy-postpartum period4.
The presence of anxiety and depressive symptoms among participants confirms the relevance of perinatal mental disorders5. However, the records analyzed showed interventions that were essentially medication-based, without references to psychotherapeutic, integrative, or psychosocial support approaches. This absence reflects persistent weaknesses within PHC, which still operates predominantly under a biomedical model and incorporates few practices recommended by maternal mental health policies.
Women with suggestive EPDS scores were referred for follow-up; however, continuity of care proved fragile. Considering that factors such as psychiatric history, initial depressive symptoms, and comorbidities represent increased risk for PPD22, systematic follow-up should be robustly structured, especially given the increase in suicide as a preventable cause of maternal mortality23.
The postpartum period is marked by emotional vulnerabilities, insecurities, and social pressures related to the maternal role19. This experience is aggravated by gender expectations that place sole responsibility for childcare and household duties on women24. Incorporating a gender perspective into health actions is essential to recognize inequalities and guide more equitable care strategies.
Although the EPDS is widely recommended for screening, the use of this instrument should be linked to effective interventions for the timely identification of PPD risk4. Integrative approaches such as yoga practices, acupuncture, aromatherapy, and psychotherapy have shown effectiveness in reducing symptoms and promoting well-being25, but were not identified among PHC actions in this study. The absence of these practices highlights an important care gap.
The results of this study show that women have important mental healthcare needs. Therefore, the care provided should include investigation of emotional status, provision of qualified guidance, and implementation of appropriate interventions and referrals according to identified demands4.
Analysis of medical records revealed incomplete documentation and absence of essential information regarding psychosocial support, referrals, and interventions. In addition to compromising continuity of care, this gap represents an ethical and legal failure in professional practice26. In this context, the nursing consultation is an essential tool for comprehensive care, enabling welcoming practices, qualified listening, and psychosocial approaches, as well as documentation of essential information for continuity of care and the use of standardized instruments for screening and assessing patients’ health needs27.
Therefore, it is essential that PHC professionals, especially nurses, develop their practice in a qualified manner, in accordance with PHC attributes and with the guarantee of women’s rights, focusing on expanding active listening, using screening instruments for depression and anxiety4, maintaining adequate documentation, and providing timely referrals. The absence of these practices represents a systemic failure that may compromise both women’s care and the effectiveness of maternal mental health policies.
The predominance of a biomedical model centered on identifying pathologies and prescribing medications limits PHC’s ability to provide comprehensive and person-centered care28. This weakness is aggravated by structural barriers, lack of specific training, and stigma surrounding mental health9. Furthermore, many women avoid reporting psychological distress due to fear of judgment, reinforcing the need for sensitive and stigma-free welcoming practices21.
Adequate care is expected to improve women’s satisfaction; therefore, women need to be aware of their rights, which must be guaranteed by PHC professionals4.
This study makes an original contribution by integrating two complementary sources of information - women’s perceptions and analysis of clinical records - enabling the identification of discrepancies between what is experienced by users and what is effectively documented and performed by healthcare services. This approach, still scarcely explored in the Brazilian context, allows a broader and more reliable understanding of the quality of care provided.
Another innovative aspect was the focus on a small municipality, a setting frequently neglected in the literature on perinatal mental health. By highlighting how structural limitations and the limited availability of specialized services impact care, the study contributes to understanding territorial inequalities and to developing policies sensitive to local contexts.
The findings reinforce the need to strengthen PHC professionals’ training for timely identification of health problems, qualified use of the EPDS, development of psychosocial interventions, and proper documentation of information. In addition, it is essential to improve care pathways and coordination with specialized services, ensuring longitudinal follow-up and interventions aligned with women’s needs.
Assessment from users’ perspective is central to improving work processes, strengthening bonds, and guiding more effective and equitable maternal mental health policies29. Without integration among screening, qualified listening, and structured therapeutic actions, PHC cannot adequately respond to the emotional demands of the pregnancy-postpartum period.
Some factors should be considered when interpreting the findings: conducting interviews in environments linked to the health unit may have inhibited deeper criticism of the service, producing responses potentially influenced by social desirability bias; the short duration of interviews may have limited exploration of more complex subjective dimensions of the pregnancy-postpartum period; and reliance on physical and electronic medical records, which were frequently incomplete, restricted analysis of the comprehensiveness of care provided. Furthermore, the fact that data collection relied on the support of BHU nurses in identifying participants may have introduced some selection bias. Despite these possible limitations, the methodological rigor adopted and the triangulation among interviews, the EPDS, and medical records confer robustness to the results and contribute to a critical understanding of mental healthcare during the pregnancy-postpartum cycle within PHC.
CONCLUSION
This study revealed structural and procedural weaknesses in mental healthcare provided to women during the pregnancy-postpartum period within PHC, expressed through the absence of systematic documentation, predominance of biomedical interventions, and limited incorporation of psychosocial practices. Even in the presence of symptoms suggestive of psychological distress, the care provided did not fully address women’s subjective needs, reflecting a care model still centered on the biological dimension.
The originality of this study lies in the integrated analysis of users’ perceptions and medical record documentation, allowing identification of divergences between expected care, experienced care, and documented care - an aspect still scarcely explored in the literature, especially in small municipalities.
The findings reinforce the need to strengthen training and continuing education for PHC professionals, improve the use of validated screening instruments, and expand psychosocial interventions aligned with the biopsychosocial model. These results provide support for reorganizing maternal mental health practices and policies within the Brazilian Unified Health System toward more comprehensive, sensitive, and rights-oriented care.
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NOTES
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ORIGIN OF THE ARTICLE
Extracted from the Course Completion Project “Avaliação da Assistência em Saúde Mental Durante a Gestação e Puerpério na Atenção Primária”, presented to the Nursing Department, Universidade Estadual do Centro-Oeste, in 2024.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Estadual do Centro-Oeste, according to Opinion 6,541,332 registered in CAAE 76020323.7.0000.0106.
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TRANSLATED BY
Letícia Belasco.
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DATA AVAILABILITY
The entire dataset supporting the results of this study is available upon request from authors Milena Oliveira de Almeida and/or Tatiane Baratieri, who hold the data. The dataset is not publicly available due to potential privacy concerns for the research participants.
The entire dataset supporting the results of this study is available upon request from authors Milena Oliveira de Almeida and/or Tatiane Baratieri, who hold the data. The dataset is not publicly available due to potential privacy concerns for the research participants.
