Midwives' and Public Health Nurses' Understanding and Support to Mothers With Postpartum Depressive Symptoms: A Qualitative Study

BACKGROUND: Postpartum depressive symptoms (PPDS) are common yet under-recognized in routine maternal care, particularly in low- and middle-income settings where screening and maternal mental health services remain poorly integrated. We explored midwives' and public health nurses' (PHNs) understanding of PPDS and how they identify, support, and refer mothers in postnatal and child welfare services in Ghana. METHODS: We conducted a qualitative study using in-depth interviews with 33 midwives and PHNs in postnatal and child welfare clinics at three public facilities in Ho Municipality, Ghana, between September and November 2024. Interviews explored understanding of PPDS, identification and support practices, referral experiences, and barriers to care. Data were analyzed inductively using Braun and Clarke's thematic analysis. RESULTS: Clinical boundaries between PPDS and expected postpartum emotional changes were unclear, with providers relying on emotional and behavioral changes rather than standardized screening. Recognition relied on provider observation because mothers were perceived to rarely disclose distress owing to stigma, expectations of maternal strength, and fear of judgment. Care was largely relational within weakly integrated maternal mental health systems. The lack of access to standardized screening tools, limited training, inadequate privacy, poor documentation, and inconsistent referral pathways hindered identification and follow-up. CONCLUSION: Midwives and PHNs play a central role in identifying and supporting mothers with PPDS, but their ability is constrained by clinical uncertainty, limited maternal disclosure, and weak integration of maternal mental health into routine care. Strengthening routine screening, provider training, confidential consultation spaces, and referral pathways could improve the identification and management of PPDS.