This paper utilizes qualitative semi-structured interviews with healthcare workers and pregnant women, to identify the facilitators and barriers to mental health care for pregnant women attending MOUs in Cape Town. While healthcare workers and pregnant women acknowledged the importance of detecting women with symptoms of depression and anxiety, or experiences of domestic violence, detection rates were low. Barriers contributing to the low detection rates included patients’ concerns about the lack of confidentiality and feelings of shame related to experiences of domestic violence; and healthcare workers discomfort in dealing with mental health issues, their limited time available and heavy patient load. Interviews with healthcare workers highlighted the lack of standardised referral pathways and the poor uptake of referrals by women with symptoms of depression and anxiety, or experiences of domestic violence.
Several system-, provider- and patient-level facilitators and barriers were identified. The availability of a mental health screening tool, included in the updated MCR  was identified as a system-level facilitator, as it enabled nurses to screen pregnant women for CMDs as part of their routine consultations. However, several system-level barriers linked to the MCR were also identified: the screening tool contains a caveat, indicating that the screening should only be conducted if “resources are available for referral, e.g. mental health nurse, social worker, NPO, medical officer, counsellor, psychiatrists or other services”; the MCR only allows for the screening tool to be completed at the first consultation; and no questions are available to detect experiences of domestic violence . As depression and anxiety may develop  and remit  at any point during the perinatal period, only administering the screening tool at the first clinic visit, would result in missed opportunities for care for women who develop symptoms of depression or anxiety later in their pregnancy, or after birth. While the MCR provides a list of counselling topics, including one for domestic violence, the lack of a screening question for detecting domestic violence could be responsible for the poor detection rates found in communities where domestic violence is prevalent [24, 38], as studies suggest that routine screening for domestic violence in primary healthcare settings improves detection [39, 40]. The final system-level barrier contributing to the low detection and referral rate, was the lack of standardised referral pathways. We found that both healthcare workers and pregnant women were unclear about how and where to access care. As the mental health screening tool was only to be conducted when resources were available, healthcare workers who were unaware of resources available in the facility, were free to opt out of providing the screening service to perinatal women.
Provider-level facilitators included the perceived importance of detecting pregnant women with CMDs and experiences of domestic violence, and the treatment of women who screened positive. In this study, healthcare workers acknowledged the importance of providing a screening, referral and counselling service. However, several provider-level barriers were identified. ANC nurses who were tasked with conducting the screening felt that they were not the right cadre of staff to provide the service, citing their large patient load, the additional time needed to screen patients, their lack of awareness of the referral pathway, and their discomfort with mental health issues as the primary reasons for their reluctance. Studies investigating the challenges to providing quality healthcare in South Africa have highlighted the shortage of healthcare workers, especially at the nursing level in urban areas . As it is unconstitutional to deny anyone access to basic healthcare in public healthcare facilities in South Africa , these facilities are often overcrowded with inadequate staff and resources available to provide quality care to all . However, this situation is not unique to South Africa. In Zimbabwe, provider-level barriers to screening perinatal women attending PHC facilities for depression included nurses’ lack of time and inadequate training, and lack of privacy making patients less likely to disclose psychological distress . While the lack of privacy was not identified as a barrier in the facilities included in this study, it is a challenge in other PHC facilities in South Africa . Similar findings were reported in a review of studies exploring healthcare workers perceived barriers to screening, referral and management of mental health issues in perinatal women , and in reviews of barriers to IPV screening as perceived by healthcare providers [46–48]. Studies highlighted time constraints, lack of knowledge and training, and insufficient awareness of referral pathways as key provider-level barriers to screening.
Patient-level facilitators included the perceived importance of screening and counselling, while the patient-level barriers included concerns regarding confidentiality when disclosing sensitive information. High levels of mental health stigma have been reported in South Africa. In a qualitative study exploring the experiences of mental health stigma among healthcare providers and users in the North West province of South Africa , the authors reported that users were exposed to stigmatising attitudes of family members, neighbours, friends, church members and the general community. Similarly, a study in Massachusetts USA reported that perinatal women were reluctant to disclose their mental health issues due to stigma and the fear of being judged as an unfit parent, resulting in missed appointments and poor uptake of services .
Our study has strengths and limitations. We have both the perceptions of service providers and service users from the same clinics. However, our service users were interviewed when attending the clinic for their first antenatal appointment, making it difficult to link their perceptions of care with the specific healthcare providers we interviewed. Our study may be limited by social desirability bias, especially regarding the pregnant women’s responses to questions on domestic violence, and service providers’ responses to their role in providing care.
Several strategies can be used to mitigate the challenges we have identified and strengthen the health system. ANC nurses require training on administering the screening tool to decrease their feelings of discomfort with mental health issues. As nurses’ time with patients is limited, the mental health screening questionnaire could be administered in a patient centred manner . ANC nurses could be trained to routinely enquire about their patients’ feelings and anxieties while examining them, instead of completing the screening tool as a ticking exercise while completing the required documentation linked to the consultation. Standardised referral pathways and processes, specific to each facility, need to be developed and disseminated widely to ensure that both healthcare workers and patients are aware of the services available and how to access them. To lessen the burden of specialised mental healthcare providers such as social workers and mental health nurses, a cadre of lay healthcare workers could be identified and trained to provide basic evidence-based problem-solving counselling  to women with mild symptoms of depression or anxiety. The limitations of the MCR will need to be addressed at a policy level to encourage healthcare providers to detect symptoms of depression, anxiety and experiences of domestic violence in all pregnant women, at all clinic visits. Intervention studies aimed at strengthening the healthcare system with regards to detection, referral and treatment at MOUs in South Africa are needed.