Maternal health workers' knowledge, practices, and influencing factors in screening and managing perinatal mental health conditions in primary healthcare facilities in Addis Ababa, Ethiopia: a qualitative study

Background
Poor perinatal mental health is a significant public health issue, especially in low- and middle-income countries. In sub-Saharan Africa, perinatal mental health conditions affect more than one in five women. Ethiopia’s mental health strategy mandates the integration of mental health services into primary care. However, screening and treatment for perinatal mental health conditions remain largely limited due to various challenges, including weak integration into maternal and child health services. This study aimed to explore maternal health workers’ knowledge, practices, and perceived factors influencing the screening and management of perinatal mental health conditions in primary healthcare facilities.

Methods
This qualitative exploratory descriptive study was conducted between August 2023 and March 2024 in ten primary healthcare facilities and the responsible sub-city health department in Addis Ababa. We conducted 25 in-depth interviews with frontline maternal health workers, facility managers, and program coordinators. Interviews were audio-recorded, transcribed verbatim, and translated from Amharic to English. Data were analyzed using Braun and Clarke’s six-phase inductive thematic analysis approach, supported by ATLAS.ti software. Two authors independently coded the data, and themes were developed and refined through team consensus. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to guide reporting.

Results
We identified four interconnected themes. 1) Foundational knowledge, misconceptions, and attitudes towards perinatal mental health: maternal health workers demonstrated foundational knowledge of perinatal mental health conditions, but this was inconsistent. Notable misconceptions included the conflation of postpartum depression with the ‘baby blues’ and underestimating its local prevalence. Despite these gaps, participants held strongly favorable attitudes towards the integration of perinatal mental health services; 2) Current practices in screening and management of perinatal mental health conditions: practices were informal and reactive, as none of the ten facilities used validated screening tools or followed standardized protocols. Assessment relied on opportunistic observation and patient-reported complaints, while management was limited to basic counseling and unreliable referral pathways; 3) Perceived readiness and capacity gaps: there was a disconnect between managerial confidence and frontline workers’ self-reported unpreparedness. Managers assumed readiness, whereas frontline health workers reported significant capacity gaps in their ability to provide integrated perinatal mental health services; 4) Systemic and socio-cultural barriers to implementation: these included overwhelming workloads, inadequate infrastructure, a shortage of mental health professionals, pervasive stigma, and the spiritual attributions of mental illness, which collectively constrained effective care.

Conclusions
This study highlights critical gaps in maternal health workers’ capacity to provide perinatal mental health services, emphasizing the need for targeted training, standardized tools, and systemic support to effectively integrate perinatal mental healthcare into the routine maternal and child health services.