General Practitioner perceptions and experiences of managing perinatal mental health: a scoping review

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Overall, mental health remains a significant contributor to disease burden affecting 1 in 4 pregnant women. Psychotropic medication prescribing occurs in almost 1 in 12 pregnancies, and appears to be increasing, along with the prevalence of mental health disorders in women of reproductive age. Perinatal mental health management is therefore not an unlikely scenario within their clinical practice. This scoping review aims to map current research related to GPs perceptions and experiences managing perinatal mental health, particularly exploring their experiences of diagnosis, medication use, guideline adherence and management of care. Method A comprehensive search strategy using nine electronic databases, and grey literature was undertaken between December 2021 and February 2023. Relevant studies were sourced from peer review databases using key terms related to perinatal mental health and general practitioners. Search results were screened on title, abstract and full text to assess those meeting inclusion criteria and relevance to the research question. Results After screening, 16 articles were included in the scoping review. The majority of articles focused on perinatal depression. Findings support that GPs are largely confident with diagnosing perinatal depression. However, over the last two decades, prescribing confidence in perinatal mental health remains variable with concerns for the safety profile of medication, low level of confidence in providing information and a strong reliance on personal experience. Despite the establishment of perinatal guidelines by countries, the utilisation of these and other existing resources by GPs appears to be infrequent. Many challenges exist for GPs around time pressures, a lack of information and resources, and difficulty accessing referral to services. Conclusion Recommendations following this scoping review include targeted perinatal education programs specific for GPs and embedded in training programs. The development of practice guidelines and resources specific to general practice that recognises time, services, and funding limitations. Future research is needed on how guidelines and resources can be developed and best delivered to optimise GP engagement to improve knowledge and enhance patient care. general practice perinatal mental health scoping review psychotropic medication Figures Figure 1 Introduction Mental health conditions are a common presentation for women of reproductive age and occur in over a quarter of women around the time of pregnancy (1), with perinatal mental health defined as the time period during pregnancy to one year after birth (2). General Practitioners (GPs) manage the bulk of preconception and early pregnancy care. They also manage the majority of patients with mental health disorders, including high prevalence disorders such as anxiety and depression, commonly with prescribed antidepressant medications (3). More and more, GPs also manage women with severe mental illnesses who may be planning to conceive or are pregnant as part of the shared care system which exists within our community mental health care system (4). Almost 1 in 12 pregnancies are associated with psychotropic prescribing and evidence suggests that this rate is increasing (5, 6) alongside the prevalence of mental health disorders in women of reproductive age (7). Estimates put around 15% of women of reproductive age in the United States (US) as being prescribed antidepressant medication (8) and combined with high rates of unplanned pregnancy in the general population rates of exposure to psychotropic medication may be higher than suggested. This makes reproductive planning and psychotropic medication counselling difficult in most cases, but vital when considering strategies to maximise mental wellbeing (9). Dealing with the scenarios of mental health, psychotropic prescribing and pregnancy is therefore unlikely to be an infrequent encounter within general practice and one many GPs would be familiar with. Prescribing practices, as part of the overall comprehensive care for pregnant women with existing mental illness, can have a significant impact, not just on the women’s mental health in terms of risk of relapse (10), but also on the risks to the pregnancy and the unborn child. It is a complex issue for women and health professionals. Available evidence from the United Kingdom suggests that many women ceased taking psychotropic medication when they learn they are pregnant, but it remains unclear what role GPs play in influencing this early decision (11). Research in women with anxiety and depression and medication use, suggest that GPs have a strong influence on early decision-making (12). Any discontinuation, switching, or lowering of doses of medication during planning or in the earlier stages of pregnancy needs to be carefully considered in the context of weighing up the risks and benefits of treatment, ideally as part of a shared decision-making process. This is often led by the woman’s GP, however, there is a need to explore what advice GPs give and what sources of information they use to aid this process. Clinical practice guidelines aim to reduce risk by outlining the research literature with the latest evidence and recommendations. Over the last three decades investment into research, education and raising awareness of perinatal mental health has occurred. Countries like Australia, the United Kingdom (UK) and United States have developed resources which focus on the area of perinatal mental health to assist community members and health professionals alike including clinical practice guidelines. Further, we need to understand the use of these resources and clinical practice guidelines by general practitioners and how GPs can best be supported in our health system to facilitate best practice prescribing to improve health outcomes for women with mental illnesses and their babies. A scoping review was deemed the most appropriate method of assessing the literature in trying to examine broadly General Practitioner experiences of managing perinatal mental health. Scoping reviews are often used to map existing research by synthesizing the evidence within a given field in terms of its nature, features, and volume and thereby identify gaps and make recommendations for future research (13). This method is useful when the nature of the research question is complex or heterogenous. The following research question guided our review: What is known from the existing literature of General practitioners’ (or equivalent) perceptions and experiences when managing perinatal mental health conditions, specifically related to: diagnosis medication utilisation guideline adherence and management of care Method Guidelines set out by Arksey and O’Malley (14) created the methodological framework for this review. To ensure a rigorous scoping review, five stages were adhered to: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the result. Search Strategy A comprehensive search strategy using nine electronic databases was undertaken between December 2021 and January 2022, with a final rerun of the search strategy completed in February 2023: GlobalHealth, PubMed, Informit Health Collection, EMBASE, MEDLINE, PsycINFO, Scopus, Best Practice, ClinicalKey; along with a search of alternative grey literature sources e.g., Google Scholar. No limits were set on date, language, or methodological design. The key words and derivatives were created by the authors and tailored for the specific requirements of each database ( see Appendix A ). Key terms were related to the perinatal period, psychotropic prescribing, best practice guidelines and mental health. The reference lists of included articles were also manually searched for any relevant research, as well as looking at articles which had cited the included articles. Citation Management All citations were imported into a software-based reference manager EndNote. Duplicates were removed with the aid of EndNote’s software, with further duplicates removed later in the review process. Eligibility Criteria All articles were screened in a two-stage process; titles and abstracts were screened for relevance, followed by a full-text review. If studies appeared to describe the management of mental health within the perinatal period, they were eligible for inclusion. Studies that were not written in English, and did not have an available translation, were excluded. Systematic reviews of perinatal mental health were excluded. Studies that appeared to assess general medication management within the perinatal period or general health within the perinatal period were excluded, along with studies that did not have a clear GP or equivalent role e.g., a family physician is the US equivalent of a GP. Studies that included other roles in addition to the GPs, such as psychiatrists, needed to provide a clear separation of findings to be included in the study, i.e., is researchers reported scores in aggregate, the article was excluded. Conference proceedings without full text articles were excluded. Articles that focused on the use of alternative or complementary medicines were also excluded. Article screening was completed by SS and reviewed by JF. Data Charting To complete a narrative review and synthesis of the articles, a data charting form was created in Excel to capture relevant information needed for analysis. Characteristics of the articles were extracted by SS and reviewed independently by JF. The information captured in the forms included the following: author(s), year and journal of publication, study location key words and aim of the study research method type and operationalisation of this method number of participants key results and points of discussion From the information extracted, thematic process was adopted to highlight common themes within the articles included in the scoping review. These themes would then explain what the current landscape of GP experiences is when managing perinatal mental health, while also highlighting areas where there is a lack of research or limited understanding. Results Overview of the current literature The original search was conducted over December 2021 and January 2022 and yielded a total of 1,170 potential articles. After two-stage screening, 16 articles were included in the scoping review. The flow of articles from initial identification to inclusion are represented in Of these, 44% were carried out in the UK, followed by 18% in Australia, including one Australian and Canadian joint study. The final six studies were undertaken in six separate locations worldwide. Methodological designs consisted of qualitative, quantitative survey and mixed methods and the studies are shown in Table 1 . No quality appraisal of the literature was undertaken in this review, only the extent and range of the literature is presented. To ensure all recent research was captured, the literature search was conducted again in February 2023; the search yielded no new articles which detailed GPs perspectives on prescription of psychotropic medication in the perinatal period. All studies were required to assess the experiences and perceptions of general practitioners or equivalent. However, studies within the review also assessed the perceptions of health care visitors, obstetricians and gynaecologists, women, and psychiatrists. For the purposes of this review, the focus will remain on GP experiences and responses. The majority of the articles focused on perinatal depression (15-25), depression and anxiety (26, 27), identifying psychosocial vulnerability (28), post-traumatic stress disorder (29) and overall perinatal mental health (30). Characterisation of General Practitioner’s Experiences Diagnosis The literature supports findings that GPs appear confident in the diagnosis of mental health difficulties, with particularly awareness of postnatal/perinatal depression (16) rather than other less common diagnoses (29). GPs acknowledge that perinatal mental health was an important area (24) though not without challenges. There was reported hesitancy for some GPs to diagnose due to perceived associations with ‘labelling and stigma’ (17, 18), women’s hesitancy in seeking help or disclosing issues again reported due to a perceived lack of acceptance of a problem, stigma and the interaction between the GP and patient (16, 18, 30), and inconsistencies of how symptoms are viewed between GPs and patients. This was particularly challenging in women from Culturally and Linguistically Diverse groups (19, 30). A biopsychosocial approach to diagnosis was used most commonly by GPs, using perceived vulnerability and instinct, risk factors including social determinants, psychiatric and somatic conditions, supportive networks and inherent resilience (17, 28) with diagnosis conceptualised using this approach (18, 30). Although GPs liked the idea of screening tools, there appeared to be a lack of use of these formal screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS), to routinely screen women (17-19, 24). These tools were seen as being more helpful in the postpartum period (24) and used more as an aid to diagnosis or as part of the referral process (30). GPs felt that consistency of care was vital in supporting diagnosis (17-19, 26, 28-30) but also for management. Treatment There was variability in GPs confidence in prescribing psychotropic medication. GP initiated antidepressant use in the perinatal period was high (26). However, prescribing antidepressants as new onset in the perinatal period is viewed as second or third line in GPs, with psychological treatments and support structures taking precedence (15, 16). This was potentially influenced by a lack of resources being available including access to care (16, 19, 21, 22, 30). Decisions around treatment choice were influenced partially by patient factors (15) with a focus on patient centred care (30). This was not without challenges as women were reported to stop medication abruptly on confirming a pregnancy (22). There remained uncertainty around the safety profile of medication and low confidence in giving advice (15, 21, 22, 25, 26, 30). Some GPs viewed treatment in pregnancy as very different compared to those who were not pregnant due to a perceived heightened vulnerability in pregnancy in general and concerns over legal liability regarding medication use in pregnancy (15, 30). Inconsistent prescribing patterns (21, 25) were reported, with question concerning the undertreatment of women in the perinatal period (22). The literature reported a strong reliance on GPs personal experience or experiences of colleagues in influencing their management (21, 22, 30) combined with a low use of guidelines (21, 22) to aid in prescribing practices. Resources A limited knowledge of and access to educational opportunities, clinical exposure and appropriate resources impacted GPs in their practice (23, 26, 30). Training was seen to increase the use of screening tools (24). There was variable confidence in providing reliable information and resources to guide women in the decision making around these medications (22) and a lack of access of up to date safety data (25). Pharmacy services were commonly used by GPs, as well as routine pharmacopeia’s, the internet (25) with often limited written information on medication provided (26), and then mainly sourced from MIMS and product information. The limited use of guidelines corresponded to reports of GPs feeling overwhelmed by the quantity of guidelines for various medical conditions (22, 25), the lack of clear and specific direction (22, 30), often being too restrictive for individual circumstance (22), and too large in content to be useful (30). Systems Systemic limitations add difficulty. Many challenges exist for GPs around duration of consultations and how much can be covered. Perinatal mental health requires a significant time investment (16, 26) for adequate disclosure and consultation for both patients and clinicians (18). The absence of clearly defined pathways (19) also impacts time commitment and the treatment plan. In some health systems it remains unclear where responsibility lies, and this can be compounded by issues around communication between services (20). The overwhelming global systemic problem appears to be a lack of resources to refer patients on to (17, 19, 22, 30). GPs generally lack trust in general psychiatric services, the prioritising of care and long wait times (29). They would prefer to see local perinatal services (29) if they were readily available (30) but acknowledge that these services often have time limitations with care. Discussion Our scoping review provides an overview of what is known in the existing literature on the perception and experiences of General Practitioners when managing perinatal mental health. Most studies focused on depression in the perinatal period with limited studies existing outside of depression and anxiety. The Royal Australian and New Zealand College of Psychiatrists (31) state that perinatal mental health includes all mental health disorders, recognising that the pregnancy and postnatal period provides a time of risk for new onset or relapse of symptoms. GPs are cognisant of the breadth of mental health disorders, with a recent survey, Health of the Nation 2022 (32), stating psychological issues are one of the most common health conditions they manage. In the literature GPs appear confident in their diagnoses, but areas of stigma for both patients and health professionals occur in disclosing and navigating a diagnosis. Two aspects discussed in this review include the use of a biopsychosocial approach and the importance of consistency of care, which are considered pillars of general practice and general practice education (33, 34). The literature suggested that screening tools have their place in general practice but are possibly used more as an adjunct. It remains unclear if and how GPs are using these tools in their day-to-day practice currently, especially as consensus-based recommendations from the COPE perinatal management guidelines (2017) (35) recommend completing the first postnatal screening 6–12 weeks after birth and repeating the screening at least once in the first postnatal year. GPs in the vast majority of Australia are delivering postnatal care to women with potential barriers for screening existing including time limitations. There appears to be support for using nonpharmacological therapies first line, with variation in medication prescription and use, including some strategies not supported by the evidence such as tapering of medication (15). Delivering education is important, for both women, who were seen to cease medication abruptly on confirmation of pregnancy, consistent with studies in the literature (36), and for GPs who viewed management in pregnancy as distinct from those who are not pregnant and face uncertainty around the safety of medication. GPs disengagement with perinatal care in general is regarded as potentially leading to a deskilling in this area (27) and there are calls for a standardised GP trainee education (30) program specific to perinatal mental health. The use of clinical or best practice guidelines in this area is reported as limited. Several countries have introduced guidelines and other resources for health professionals during the time of the studies included in this scoping review, but it is not known whether GPs are aware of, find benefit from and/or are using such resources. Clinical practice guidelines aim to reduce risk by guiding clinicians based on the research literature with the latest evidence and recommendations. A review of international clinical practice guidelines for perinatal depression, and antidepressant medication published by Molenaar et.al. (3) found the need for up-to-date and specific perinatal guidelines to help clinicians and patients in the shared decision-making process. We would propose that this needs to be specific and user friendly for GPs as they report feeling overwhelmed by the amount and volume of current guidelines for the many conditions that see within their practice. The available literature suggests that GPs rely on personal experiences to guide them, with reliance on their own clinical experience and their colleagues. When considering GPs interaction with other health professionals, psychotropics are the leading medication class for which information on exposure during pregnancy and/or breastfeeding is requested from pharmacy services. This is in accordance with data published by other similar national and international medication information services, with requests increasing markedly since 2013 when the rate was 15.6% (37). The consistent demand for these services despite the increasing availability of guidelines and web-based information indicates a need for clear and accessible information for prescribers, above what is provided by product information and drug categorisation in pregnancy (38), which these studies reported GPs used. The lack of referral resources for ongoing management was a common theme in this review. A metanalysis by Ford et al. (39) in 2017 concludes that GPs remain frustrated by the lack of services and resources. It is uncertain whether the lack of resources is resulting in the undertreatment and underdiagnosis of women (17) or an increased use of prescription medication first line. Guidelines (35, 40) recommend seeking advice, preferably from a specialist in perinatal mental health particularly when initiating medication in pregnancy, but is this practical when resources are stretched? GPs are familiar with initiating pharmacological management with antidepressant and antianxiety medication (26) and would benefit from increased resources to support them in this role. Strengths and limitations The strength of this review includes its systematic approach to identifying articles related to General Practitioners (or their equivalent) experiences around perinatal mental health more broadly and to map the research area. Limitations included the different health care services and resources available, and therefore variable experiences that occurred in differing countries. Further, the quality of literature was not appraised, therefore limiting the review to a descriptive account of GPs experiences. Conclusions and implications for research and practice Overall, GPs feel confident in diagnosing mental health disorders within the perinatal period. They rely on a biopsychosocial and continuity of care model. Management of these conditions becomes more challenging with many depending on clinical experience and colleagues, with a lack of resources for consultations, referral, services, and information provision. Medication is frequently initiated by GPs with limited use of guidelines. Recommendations following this scoping review include targeted perinatal education programs specific for GPs and embedded in training programs, and the development of practice guidelines specific to general practice that recognises time, services, and funding limitations. Future research identified include the use and value of screening tools in GP, and how guidelines and resources can be developed and best delivered to optimise GP engagement to improve knowledge and enhance patient care. Declarations Ethics approval and consent to participate not applicable Consent for publication not applicable Availability of data and materials All data generated or analysed during this study are included in this published article [and its supplementary information files]. Competing interests The authors declare that they have no competing interests Funding The researchers gratefully acknowledge Therapeutics Guidelines Ltd and the RACGP Foundation for their support of this project Author’s contributions J. F., S. S., T. L., T. M., B.T. and T. N. assisted with project conception and development; S. S. and J. F. collected and analysed data, and all authors were involved in manuscript writing and editing. All authors critically reviewed and revised for content and gave approval to the final to be published version of the manuscript. Acknowledgements not applicable References Vesga-López O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008;65(7):805-15. O'Hara MW, Wisner KL. Perinatal mental illness: definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):3-12. Molenaar NM, Kamperman AM, Boyce P, Bergink V. 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Table Table 1 Studies included in qualitative synthesis Author and year Aim of the Study Research Method Location Sample Size Key Findings and Discussion Bilszta et al 2011 Explore primary health care physician's beliefs and practices toward perinatal depression by investigating knowledge, attitudes, and practices affecting a physician’s decision to continue or discontinue antidepressant medication during pregnancy. Quantitative: Survey Australia and Canada 61 GPs; 33 Family Physicians Age, years in practice, gender, or personal experiences with depression did not lead to a significant difference in treatment choice. Prescribing is a third line choice, after counselling or partner support. Physicians appeared more likely to taper medication in pregnant women, although this is linked to a six-fold increase in risk of relapse for women, indicating an incongruency between risk concerns and potential outcomes of medication management. Brygger Venø et al 2021 To explore GP’s perceived indicators of vulnerability among pregnant women in primary care. Qualitative: Semi-structured focus groups Southern Denmark 20 GPs Patient doctor relationship is integral when deciding to ask further questions regarding mental health. GPs were aware of indicators of vulnerability to severe mental health but also referred to a gut feeling when picking up on intangible indicators. Buist et al 2005 To identify ways to improve detection of postnatal depression and access to treatment. Quantitative: Survey vignette Australia 246 GPs; 525 women A difference between GP and patient preferences may lead to a hesitancy for women to bring up difficulties if they do not want to be prescribed medication. The length of time needed for a consult period when identifying postnatal depression is a significant time investment. Routine enquiry about women’s mood and coping is needed to identify women who might otherwise go undiagnosed. Chew-Graham et al 2008 To explore the views of GPs and health visitors on the diagnosis and management of postnatal depression. Quantitative: Survey within a multicentre RCT Various locations United Kingdom 19 GPs; 14 Health Visitors GPs stress the importance of knowing the patient and using a psychosocial approach to making a diagnosis. GPs and Health Visitors agree that diagnosis of postnatal depression is important for management, but the ‘role’ of responsibility on detecting symptoms was unclear. Chew-Graham et al 2009 Exploration of views and attitudes of women and GPs following a disclosure of postnatal depression. Qualitative: In-depth interviews within a multicentre RCT Various locations United Kingdom 19 GPs; 14 Health Visitors; 28 Women Psychosocial factors need to be addressed to diagnose and treat postnatal depression. Diagnoses, or pursuing a diagnosis, are avoided when health care providers feel they have nothing to offer e.g., continuity of care, referral to services. Questioning why a diagnosis of depression is not made by the healthcare professional, and suggesting training to address this issue, is too narrow an approach. Instead, a whole system approach is necessary to improve willingness to disclose, practitioner ability to listen and intervene, and a system that will facilitate management. Edge 2010 To investigate health professionals' views about perinatal mental healthcare for Black and minority ethnic women. Qualitative: Interviews and Focus Groups United Kingdom (Northern England) 42 health professionals (5 of which were GPs) Physical health is often prioritised in the postnatal period, mental health can be overlooked. Services which limit continuity of care, health professional resistance to using psychometric tools, and lack of confidence in managing depression contribute to missed opportunities to detect and treat postnatal depression. Glasser et al 2016 To explore Israeli primary care physicians’ attitudes and practice regarding postpartum depression (PPD). Quantitative: Three question survey Israel 122 Paediatricians; 102 Family Practitioners Most of the participants reported that it was important to recognize signs of postnatal depression and to act upon them. This resulted in most respondents reporting they would refer patients onward to mental health professionals. Significantly more family practitioners would screen for postnatal depression when compared to paediatricians. Kean et al 2011 To investigate current prescribing practices among GPs of antidepressants to women presenting in the first trimester of pregnancy and during breastfeeding. Qualitative: Postal survey vignettes United Kingdom (Scotland) 32 GPs When given a list of potential medications to prescribe either in the first trimester, or during breastfeeding, GP prescribing patterns were inconsistent. Knowledge regarding classes of drugs was better than specific drugs within that class. Several GPs still had resistance to using medication for mothers with depression. There was also limited forward planning with prescribing medication that could be continued through until breastfeeding. Khan 2015 Understand the role of GPs, and women’s experiences, in disclosure, identification and support with perinatal mental health Mixed method: surveys and semi-structured interviews United Kingdom (majority) 43 GPs for the survey; 3 GPs for the interview Government action is needed to reduce the pressure on GPs and allow for longer consultations periods with women experiencing perinatal mental health problems. Higher education should work with RCGP Clinical Champion to support specific perinatal mental health training for qualified GPs. Local education and training boards should develop curriculum competencies relating to perinatal mental health through their GP training programmes. Evidence should be explored to assess the most effective way to use the six-week check to support mothers, babies, and families. McCauley & Casson 2013 To develop an in-depth understanding of GPs’ experience of using guidelines in the treatment of perinatal depression and if this enabled them to empower women to become involved in treatment decisions. Qualitative: Semi-structured interviews United Kingdom (Northern Ireland) 8 GPs The purpose of clinical guidelines is to enable GPs to empower women to make informed treatment decisions regarding pregnancy, however, the perceived usage of these guidelines is limited. GPs felt overwhelmed by too many guidelines, and conflicting safety data. GPs agree that involving women in the decision-making process is central to their empowerment, but this can be limited by the complexity of the presentation and to what level women want to be involved. Mortimer et al 2021 Investigate GPs' and psychiatrists' perceptions and experiences of caring for women with PTSD in the postnatal period. Qualitative: Fictional case vignette United Kingdom 6 GPs; 7 Psychiatrists GPs can avoid diagnosis or attribute difficulties to other changes, often taking on a watchful waiting approach. Birth often isn’t considered a traumatic event by health care professionals, which potentially contributes to the way diagnoses are approached. Most training regarding postpartum diagnoses focuses on depression and psychosis, leading to a lack of training in other postpartum disorders such as post-traumatic stress disorder (PTSD). Noonan et al 2018 To explore GPs' experiences of caring for women with perinatal mental health problems and their views on how best to prepare future GPs for a role in the provision of effective PMH care. Qualitative: In-depth semi-structured interviews Ireland 10 GPs GPs described their multifaceted role in supporting women with perinatal mental health. GPs identified stigma, cultural and linguistic barriers to disclosure and care. Specialised care when indicated for women is limited due to under resourcing and long wait times. Training in perinatal mental health is needed, with some GPs suggesting a compulsory psychiatric rotation during training programs. Other options include e-modules to help build GP confidence and knowledge. Santos Jr et al 2013 To explore experiences of Brazilian physicians and nurses caring for women with postpartum depression in primary healthcare settings. Qualitative: Open ended interviews Brazil 10 nurses; 7 family health physicians There appeared to be limited exposure to postpartum depression, which in turn created gaps in knowledge about postpartum depression, including its presentation and treatment. Limited clinical knowledge effects screening of postpartum depression and the documentation of symptoms. Gaps in GP training are highlighted as a potential causal factor for these issues. Seehusen et al 2005 To determine how frequently family physicians screen for PPD, what methods they use to screen, and what influences their screening frequency. Quantitative: 25-item questionnaire USA (Washington) 298 physicians Screening for postpartum depression is not universal. When physicians do report screening for postpartum depression, they often don’t use a validated screening measure. Recency of training and sex differences are present when comparing those who screen more frequently, with more recent residency and female physicians screening more. Ververs et al 2009 To investigate where GPs and pharmacists in the Netherlands obtain information on the safety of gestational drug use and the pharmacotherapeutic approach when managing depression and anxiety during pregnancy. Quantitative: Closed choice multiple choice questions Netherlands 130 GPs; 144 pharmacists Contraindications regarding safety of medication make it difficult and depend on differing sources of information. Differences in views on how to treat depression before, during and after pregnancy vary. GPs do consider the consequences of the mother’s illness outweighing the possible risks to the child. Concludes with the role of pharmacists being involved in developing clear policies and providing accessible information. Williams et al 2020 To explore the differences in the perception of teratogenicity risk of antidepressant and antianxiety medication commonly prescribed to pregnant women, medication counselling, prescribing practices, clinician resources and base knowledge of risk of antidepressant and antianxiety medications when used in pregnancy. Qualitative: Survey Australia 172 GPs; 373 Obstetrician/ Gynaecologists GPs perceived higher rates of patient anxiety regarding anxiolytics and antidepressants, compared to obstetricians and gynaecologists. Both groups reported continued maternal concerns with fetal malformation due to medications. There is infrequent provision of written resources due to limited patient friendly resources. GPs often allotted more time in their consults to discussing medication risks and benefits. GPs saw themselves in a primary prescriber role, comparatively, and were less likely to refer to a mental health specialist. Both healthcare providers recommended a close patient-doctor relationship and clear communication when working with perinatal mental health and discussing medications. There is a modest interest in mental health disorders in pregnancy leading to a general lack of familiarity in the area and limited knowledge of the latest evidence. Note. GPs = General Practitioners, USA = Unites States of America Additional Declarations No competing interests reported. Supplementary Files AppendixA.docx Cite Share Download PDF Status: Published Journal Publication published 02 Dec, 2023 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Major revision 13 Aug, 2023 Reviews received at journal 07 Jul, 2023 Reviewers agreed at journal 02 Jul, 2023 Reviewers invited by journal 29 Jun, 2023 Editor assigned by journal 29 Jun, 2023 Editor invited by journal 28 Mar, 2023 Submission checks completed at journal 28 Mar, 2023 First submitted to journal 13 Mar, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2685289","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":187068555,"identity":"4cb5fe2c-8087-4574-ad92-5583b54d951a","order_by":0,"name":"Jacqueline 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19:12:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36441,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flowchart for study selection process.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2685289/v1/2bef65bdf3e9fdef9f426bf3.png"},{"id":47561226,"identity":"280f9e0b-228d-4635-b0a0-2fb8575de2d0","added_by":"auto","created_at":"2023-12-04 15:10:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":388845,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2685289/v1/3f523a29-f88c-4f4e-94ce-af4902d3bbd8.pdf"},{"id":35000890,"identity":"6d7c95fd-53a3-4b69-ac86-e3430fdf61f9","added_by":"auto","created_at":"2023-03-29 19:12:29","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15939,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-2685289/v1/91945f6d4e7b29a0a00f3368.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"General Practitioner perceptions and experiences of managing perinatal mental health: a scoping review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental health conditions are a common presentation for women of reproductive age\u0026nbsp;and occur in over a quarter of women around the time of pregnancy\u0026nbsp;(1), with perinatal mental health defined as the time period during pregnancy to one year after birth\u0026nbsp;(2). General Practitioners (GPs) manage the bulk of preconception and early pregnancy care. They also manage the majority of patients with mental health disorders, including\u0026nbsp;high prevalence disorders such as anxiety and depression, commonly with prescribed antidepressant medications\u0026nbsp;(3). More and more, GPs also manage women with severe mental illnesses who may be planning to conceive or are pregnant as part of the shared care system which exists within our community mental health care system\u0026nbsp;(4).\u003c/p\u003e\n\u003cp\u003eAlmost 1 in 12 pregnancies are associated with psychotropic prescribing and evidence suggests that this rate is increasing\u0026nbsp;(5, 6)\u0026nbsp;alongside the prevalence of mental health disorders in women of reproductive age\u0026nbsp;(7). Estimates put around 15% of women of reproductive age in the United States (US) as being prescribed antidepressant medication\u0026nbsp;(8)\u0026nbsp;and combined with high rates of unplanned pregnancy in the general population rates of exposure to psychotropic medication may be higher than suggested. This makes reproductive planning and psychotropic medication counselling difficult in most cases, but vital when considering strategies to maximise mental wellbeing\u0026nbsp;(9). Dealing with the scenarios of mental health, psychotropic prescribing and pregnancy is therefore unlikely to be an infrequent encounter within general practice and one many GPs would be familiar with.\u003c/p\u003e\n\u003cp\u003ePrescribing practices, as part of the overall comprehensive care for pregnant women with existing mental illness, can have a significant impact, not just on the women\u0026rsquo;s mental health in terms of risk of relapse\u0026nbsp;(10), but also on the risks to the pregnancy and the unborn child. It is a complex issue for women and health professionals. Available evidence from the United Kingdom suggests that many women ceased taking psychotropic medication when they learn they are pregnant, but it remains unclear what role GPs play in influencing this early decision\u0026nbsp;(11). Research in women with anxiety and depression and medication use, suggest that GPs have a strong influence on early decision-making\u0026nbsp;(12). Any discontinuation, switching, or lowering of doses of medication during planning or in the earlier stages of pregnancy needs to be carefully considered in the context of weighing up the risks and benefits of treatment, ideally as part of a shared decision-making process. This is often led by the woman\u0026rsquo;s GP, however, there is a need to explore what advice GPs give and what sources of information they use to aid this process.\u003c/p\u003e\n\u003cp\u003eClinical practice guidelines aim to reduce risk by outlining the research literature with the latest evidence and recommendations.\u0026nbsp;Over the last three decades investment into research, education and raising awareness of perinatal mental health has occurred. Countries like Australia, the United Kingdom (UK) and United States have developed resources which focus on the area of perinatal mental health to assist community members and health professionals alike including clinical practice guidelines. Further, we need to understand the use of these resources and clinical practice guidelines by general practitioners and\u0026nbsp;how GPs can best be supported in our health system to facilitate best practice prescribing to improve health outcomes for women with mental illnesses and their babies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA scoping review was deemed the most appropriate method of assessing the literature in trying to examine broadly General Practitioner experiences of managing perinatal mental health. Scoping reviews are often used to map existing research by synthesizing the evidence within a given field in terms of its nature, features, and volume and thereby identify gaps and make recommendations for future research\u0026nbsp;(13). This method is useful when the nature of the research question is complex or heterogenous.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following research question guided our review:\u003c/p\u003e\n\u003cp\u003eWhat is known from the existing literature of General practitioners\u0026rsquo; (or equivalent) perceptions and experiences when managing perinatal mental health conditions, specifically related to:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ediagnosis\u003c/li\u003e\n \u003cli\u003emedication utilisation\u003c/li\u003e\n \u003cli\u003eguideline adherence and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003emanagement of care\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Method","content":"\u003cp\u003eGuidelines set out by Arksey and O\u0026rsquo;Malley\u0026nbsp;(14)\u0026nbsp;created the methodological framework for this review. To ensure a rigorous scoping review, five stages were adhered to: \u003cem\u003eidentifying the research question, identifying relevant studies, study selection, charting the data,\u0026nbsp;\u003c/em\u003eand \u003cem\u003ecollating, summarizing, and reporting the result.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSearch Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive search strategy using nine electronic databases was undertaken between December 2021 and January 2022, with a final rerun of the search strategy completed in February 2023: GlobalHealth, PubMed, Informit Health Collection, EMBASE, MEDLINE, PsycINFO, Scopus, Best Practice, ClinicalKey; along with a search of alternative grey literature sources e.g., Google Scholar. No limits were set on date, language, or methodological design. The key words and derivatives were created by the authors and tailored for the specific requirements of each database (\u003cstrong\u003esee Appendix A\u003c/strong\u003e). Key terms were related to the perinatal period, psychotropic prescribing, best practice guidelines and mental health. The reference lists of included articles were also manually searched for any relevant research, as well as looking at articles which had cited the included articles.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCitation Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll citations were imported into a software-based reference manager EndNote. Duplicates were removed with the aid of EndNote\u0026rsquo;s software, with further duplicates removed later in the review process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll articles were screened in a two-stage process; titles and abstracts were screened for relevance, followed by a full-text review. If studies appeared to describe the management of mental health within the perinatal period, they were eligible for inclusion. Studies that were not written in English, and did not have an available translation, were excluded. Systematic reviews of perinatal mental health were excluded. Studies that appeared to assess general medication management within the perinatal period or general health within the perinatal period were excluded, along with studies that did not have a clear GP or equivalent role e.g., a family physician is the US equivalent of a GP. Studies that included other roles in addition to the GPs, such as psychiatrists, needed to provide a clear separation of findings to be included in the study, i.e., is researchers reported scores in aggregate, the article was excluded. Conference proceedings without full text articles were excluded. Articles that focused on the use of alternative or complementary medicines were also excluded. Article screening was completed by SS and reviewed by JF.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Charting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo complete a narrative review and synthesis of the articles, a data charting form was created in Excel to capture relevant information needed for analysis. Characteristics of the articles were extracted by SS and reviewed independently by JF. The information captured in the forms included the following:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eauthor(s), year and journal of publication, study location\u003c/li\u003e\n \u003cli\u003ekey words and aim of the study\u003c/li\u003e\n \u003cli\u003eresearch method type and operationalisation of this method\u003c/li\u003e\n \u003cli\u003enumber of participants\u003c/li\u003e\n \u003cli\u003ekey results and points of discussion\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFrom the information extracted, thematic process was adopted to highlight common themes within the articles included in the scoping review. These themes would then explain what the current landscape of GP experiences is when managing perinatal mental health, while also highlighting areas where there is a lack of research or limited understanding.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eOverview of the current literature\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original search was conducted over December 2021 and January 2022 and yielded a total of 1,170 potential articles. After two-stage screening, 16 articles were included in the scoping review. The flow of articles from initial identification to inclusion are represented in Of these, 44% were carried out in the UK, followed by 18% in Australia, including one Australian and Canadian joint study. The final six studies were undertaken in six separate locations worldwide. Methodological designs consisted of qualitative, quantitative survey and mixed methods and the studies are shown in \u003cstrong\u003eTable 1\u003c/strong\u003e. No quality appraisal of the literature was undertaken in this review, only the extent and range of the literature is presented. To ensure all recent research was captured, the literature search was conducted again in February 2023; the search yielded no new articles which detailed GPs perspectives on prescription of psychotropic medication in the perinatal period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll studies were required to assess the experiences and perceptions of general practitioners or equivalent. However, studies within the review also assessed the perceptions of health care visitors, obstetricians and gynaecologists, women, and psychiatrists. For the purposes of this review, the focus will remain on GP experiences and responses.\u003c/p\u003e\n\u003cp\u003eThe majority of the articles focused on perinatal depression\u0026nbsp;(15-25), depression and anxiety\u0026nbsp;(26, 27), identifying psychosocial vulnerability\u0026nbsp;(28), post-traumatic stress disorder\u0026nbsp;(29)\u0026nbsp;and overall perinatal mental health\u0026nbsp;(30).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacterisation of General Practitioner\u0026rsquo;s Experiences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDiagnosis\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe literature supports findings that GPs appear confident in the diagnosis of mental health difficulties, with particularly awareness of postnatal/perinatal depression\u0026nbsp;(16)\u0026nbsp;rather than other less common diagnoses\u0026nbsp;(29). \u0026nbsp;GPs acknowledge that perinatal mental health was an important area\u0026nbsp;(24)\u0026nbsp;though not without challenges. There was reported hesitancy for some GPs to diagnose due to perceived associations with \u0026lsquo;labelling and stigma\u0026rsquo;\u0026nbsp;(17, 18), women\u0026rsquo;s hesitancy in seeking help or disclosing issues again reported due to a perceived lack of acceptance of a problem, stigma and the interaction between the GP and patient\u0026nbsp;(16, 18, 30), and inconsistencies of how symptoms are viewed between GPs and patients. This was particularly challenging in women from Culturally and Linguistically Diverse groups\u0026nbsp;(19, 30).\u003c/p\u003e\n\u003cp\u003eA biopsychosocial approach to diagnosis was used most commonly by GPs, using perceived vulnerability and instinct, risk factors including social determinants, psychiatric and somatic conditions, supportive networks and inherent resilience\u0026nbsp;(17, 28)\u0026nbsp;with diagnosis conceptualised using this approach\u0026nbsp;(18, 30). Although GPs liked the idea of screening tools, there appeared to be a lack of use of these formal screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS), to routinely screen women\u0026nbsp;(17-19, 24). These tools were seen as being more helpful in the postpartum period\u0026nbsp;(24)\u0026nbsp;and used more as an aid to diagnosis or as part of the referral process\u0026nbsp;(30). GPs felt that consistency of care was vital in supporting diagnosis\u0026nbsp;(17-19, 26, 28-30)\u0026nbsp;but also for management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTreatment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was variability in GPs confidence in prescribing psychotropic medication. GP initiated antidepressant use in the perinatal period was high\u0026nbsp;(26). However, prescribing antidepressants as new onset in the perinatal period is viewed as second or third line in GPs, with psychological treatments and support structures taking precedence\u0026nbsp;(15, 16). This was potentially influenced by a lack of resources being available including access to care \u0026nbsp;\u0026nbsp;(16, 19, 21, 22, 30).\u003c/p\u003e\n\u003cp\u003eDecisions around treatment choice were influenced partially by patient factors\u0026nbsp;(15)\u0026nbsp;with a focus on patient centred care\u0026nbsp;(30). This was not without challenges as women were reported to stop medication abruptly on confirming a pregnancy\u0026nbsp;(22). There remained uncertainty around the safety profile of medication and low confidence in giving advice\u0026nbsp;(15, 21, 22, 25, 26, 30). Some GPs viewed treatment in pregnancy as very different compared to those who were not pregnant due to a perceived heightened vulnerability in pregnancy in general and concerns over legal liability regarding medication use in pregnancy \u0026nbsp;(15, 30). Inconsistent prescribing patterns\u0026nbsp;(21, 25)\u0026nbsp;were reported, with question concerning the undertreatment of women in the perinatal period\u0026nbsp;(22). The literature reported a strong reliance on GPs personal experience or experiences of colleagues in influencing their management\u0026nbsp;(21, 22, 30)\u0026nbsp;combined with a low use of guidelines\u0026nbsp;(21, 22)\u0026nbsp;to aid in prescribing practices.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eResources\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA limited knowledge of and access to educational opportunities, clinical exposure and appropriate resources impacted GPs in their practice\u0026nbsp;(23, 26, 30). \u0026nbsp;Training was seen to increase the use of screening tools\u0026nbsp;(24). \u0026nbsp;There was variable confidence in providing reliable information and resources to guide women in the decision making around these medications\u0026nbsp;(22)\u0026nbsp;and a lack of access of up to date safety data\u0026nbsp;(25). \u0026nbsp;Pharmacy services were commonly used by GPs, as well as routine pharmacopeia\u0026rsquo;s, the internet\u0026nbsp;(25)\u0026nbsp;with often limited written information on medication provided\u0026nbsp;(26), and then mainly sourced from MIMS and product information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe limited use of guidelines corresponded to reports of GPs feeling overwhelmed by the quantity of guidelines for various medical conditions\u0026nbsp;(22, 25), the lack of clear and specific direction\u0026nbsp;(22, 30), often being too restrictive for individual circumstance\u0026nbsp;(22), and too large in content to be useful\u0026nbsp;(30).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSystems\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSystemic limitations add difficulty. Many challenges exist for GPs around duration of consultations and how much can be covered. Perinatal mental health requires a significant time investment\u0026nbsp;(16, 26)\u0026nbsp;for adequate disclosure and consultation for both patients and clinicians\u0026nbsp;(18). The absence of clearly defined pathways\u0026nbsp;(19)\u0026nbsp;also impacts time commitment and the treatment plan. In some health systems it remains unclear where responsibility lies, and this can be compounded by issues around communication between services\u0026nbsp;(20).\u003c/p\u003e\n\u003cp\u003eThe overwhelming global systemic problem appears to be a lack of resources to refer patients on to (17, 19, 22, 30). GPs generally lack trust in general psychiatric services, the prioritising of care and long wait times (29). They would prefer to see local perinatal services (29) if they were readily available (30) but acknowledge that these services often have time limitations with care.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur scoping review provides an overview of what is known in the existing literature on the perception and experiences of General Practitioners when managing perinatal mental health. Most studies focused on depression in the perinatal period with limited studies existing outside of depression and anxiety. \u0026nbsp;The Royal Australian and New Zealand College of Psychiatrists\u0026nbsp;(31)\u0026nbsp;state that perinatal mental health includes all mental health disorders, recognising that the pregnancy and postnatal period provides a time of risk for new onset or relapse of symptoms. GPs are cognisant of the breadth of mental health disorders, with a recent survey, Health of the Nation 2022\u0026nbsp;(32), stating psychological issues are one of the most common health conditions they manage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the literature GPs appear confident in their diagnoses, but areas of stigma for both patients and health professionals occur in disclosing and navigating a diagnosis. Two aspects discussed in this review include the use of a biopsychosocial approach and the importance of consistency of care, which are considered pillars of general practice and general practice education\u0026nbsp;(33, 34). The literature suggested that screening tools have their place in general practice but are possibly used more as an adjunct. It remains unclear if and how GPs are using these tools in their day-to-day practice currently, especially as consensus-based recommendations from the COPE perinatal management guidelines (2017)\u0026nbsp;(35)\u0026nbsp;recommend completing the first postnatal screening 6\u0026ndash;12 weeks after birth and repeating the screening at least once in the first postnatal year. GPs in the vast majority of Australia are delivering postnatal care to women with potential barriers for screening existing including time limitations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere appears to be support for using nonpharmacological therapies first line, with\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003evariation in medication prescription and use, including some strategies not supported by the evidence such as tapering of medication\u0026nbsp;(15). Delivering education is important, for both women, who were seen to cease medication abruptly on confirmation of pregnancy, consistent with studies in the literature\u0026nbsp;(36), and for GPs who viewed management in pregnancy as distinct from those who are not pregnant and face uncertainty around the safety of medication. GPs disengagement with perinatal care in general is regarded as potentially leading to a deskilling in this area\u0026nbsp;(27)\u0026nbsp;and there are calls for a standardised GP trainee education\u0026nbsp;(30)\u0026nbsp;program specific to perinatal mental health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe use of clinical or best practice guidelines in this area is reported as limited. Several countries have introduced guidelines and other resources for health professionals during the time of the studies included in this scoping review, but it is not known whether GPs are aware of, find benefit from and/or are using such resources. Clinical practice guidelines aim to reduce risk by guiding clinicians based on the research literature with the latest evidence and recommendations.\u003cem\u003e\u0026nbsp;\u003c/em\u003eA review of international clinical practice guidelines for perinatal depression, and antidepressant medication published by Molenaar et.al.\u0026nbsp;(3)\u0026nbsp;found the need for up-to-date and specific perinatal guidelines to help clinicians and patients in the shared decision-making process. We would propose that this needs to be specific and user friendly for GPs as they report feeling overwhelmed by the amount and volume of current guidelines for the many conditions that see within their practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe available literature suggests that GPs rely on personal experiences to guide them, with reliance on their own clinical experience and their colleagues. When considering GPs interaction with other health professionals, psychotropics are the leading medication class for which information on exposure during pregnancy and/or breastfeeding is requested from pharmacy services. This is in accordance with data published by other similar national and international medication information services, with requests increasing markedly since 2013 when the rate was 15.6%\u0026nbsp;(37). The consistent demand for these services despite the increasing availability of guidelines and web-based information indicates a need for clear and accessible information for prescribers, above what is provided by product information and drug categorisation in pregnancy\u0026nbsp;(38), which these studies reported GPs used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe lack of referral resources for ongoing management was a common theme in this review. A metanalysis by Ford et al.\u0026nbsp;(39)\u0026nbsp;in 2017 concludes that GPs remain frustrated by the lack of services and resources. It is uncertain whether the lack of resources is resulting in the undertreatment and underdiagnosis of women\u0026nbsp;(17)\u0026nbsp;or an increased use of prescription medication first line.\u0026nbsp;Guidelines\u0026nbsp;(35, 40)\u0026nbsp;recommend seeking advice, preferably from a specialist in perinatal mental health particularly when initiating medication in pregnancy, but is this practical when resources are stretched? GPs are familiar with initiating pharmacological management with antidepressant and antianxiety medication\u0026nbsp;(26)\u0026nbsp;and would benefit from increased resources to support them in this role.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe strength of this review includes its systematic approach to identifying articles related to General Practitioners (or their equivalent) experiences around perinatal mental health more broadly and to map the research area. Limitations included the different health care services and resources available, and therefore variable experiences that occurred in differing countries. Further, the quality of literature was not appraised, therefore limiting the review to a descriptive account of GPs experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions and implications for research and practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, GPs feel confident in diagnosing mental health disorders within the perinatal period. They rely on a biopsychosocial and continuity of care model. Management of these conditions becomes more challenging with many depending on clinical experience and colleagues, with a lack of resources for consultations, referral, services, and information provision. Medication is frequently initiated by GPs with limited use of guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRecommendations following this scoping review include targeted perinatal education programs specific for GPs and embedded in training programs, and the development of practice guidelines specific to general practice that recognises time, services, and funding limitations. Future research identified include the use and value of screening tools in GP, and how guidelines and resources can be developed and best delivered to optimise GP engagement to improve knowledge and enhance patient care.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eThe researchers gratefully acknowledge Therapeutics Guidelines Ltd and the RACGP Foundation for their support of this project\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u0026nbsp;\u003c/strong\u003eJ. F., S. S., T. L., T. M., B.T. and T. N. assisted with project conception and development; S. S. and J. F. collected and analysed data, and all authors were involved in manuscript writing and editing. All authors critically reviewed and revised for content and gave approval to the final to be published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVesga-L\u0026oacute;pez O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008;65(7):805-15.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Hara MW, Wisner KL. Perinatal mental illness: definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):3-12.\u003c/li\u003e\n\u003cli\u003eMolenaar NM, Kamperman AM, Boyce P, Bergink V. Guidelines on treatment of perinatal depression with antidepressants: An international review. Aust N Z J Psychiatry. 2018;52(4):320-7.\u003c/li\u003e\n\u003cli\u003eHauck Y, Nguyen T, Frayne J, Garefalakis M, Rock D. Sexual and reproductive health trends among women with enduring mental illness: a survey of Western Australian community mental health services. Health Care Women Int. 2015;36(4):499-510.\u003c/li\u003e\n\u003cli\u003eAndrade SE, Reichman ME, Mott K, Pitts M, Kieswetter C, Dinatale M, et al. Use of selective serotonin reuptake inhibitors (SSRIs) in women delivering liveborn infants and other women of child-bearing age within the U.S. Food and Drug Administration\u0026apos;s Mini-Sentinel program. Arch Womens Ment Health. 2016;19(6):969-77.\u003c/li\u003e\n\u003cli\u003eEpstein RA, Bobo WV, Shelton RC, Arbogast PG, Morrow JA, Wang W, et al. Increasing use of atypical antipsychotics and anticonvulsants during pregnancy. Pharmacoepidemiol Drug Saf. 2013;22(7):794-801.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Donnell M, Anderson D, Morgan VA, Nassar N, Leonard HM, Stanley FJ. Trends in pre-existing mental health disorders among parents of infants born in Western Australia from 1990 to 2005. Med J Aust. 2013;198(9):485-8.\u003c/li\u003e\n\u003cli\u003eDawson AL, Ailes EC, Gilboa SM, Simeone RM, Lind JN, Farr SL, et al. Antidepressant Prescription Claims Among Reproductive-Aged Women With Private Employer-Sponsored Insurance - United States 2008-2013. MMWR Morb Mortal Wkly Rep. 2016;65(3):41-6.\u003c/li\u003e\n\u003cli\u003eYonkers KA. Treatment of Psychiatric Conditions in Pregnancy Starts With Planning. Am J Psychiatry. 2021;178(3):213-4.\u003c/li\u003e\n\u003cli\u003eBayrampour H, Kapoor A, Bunka M, Ryan D. The Risk of Relapse of Depression During Pregnancy After Discontinuation of Antidepressants: A Systematic Review and Meta-Analysis. J Clin Psychiatry. 2020;81(4).\u003c/li\u003e\n\u003cli\u003ePetersen I, McCrea RL, Sammon CJ, Osborn DP, Evans SJ, Cowen PJ, et al. Risks and benefits of psychotropic medication in pregnancy: cohort studies based on UK electronic primary care health records. Health Technol Assess. 2016;20(23):1-176.\u003c/li\u003e\n\u003cli\u003eKothari A, de Laat J, Dulhunty JM, Bruxner G. Perceptions of pregnant women regarding antidepressant and anxiolytic medication use during pregnancy. Australas Psychiatry. 2019;27(2):117-20.\u003c/li\u003e\n\u003cli\u003ePeters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141-6.\u003c/li\u003e\n\u003cli\u003eArksey H, O\u0026apos;Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19-32.\u003c/li\u003e\n\u003cli\u003eBilszta JL, Tsuchiya S, Han K, Buist AE, Einarson A. Primary care physician\u0026apos;s attitudes and practices regarding antidepressant use during pregnancy: a survey of two countries. Arch Womens Ment Health. 2011;14(1):71-5.\u003c/li\u003e\n\u003cli\u003eBuist A, Bilszta J, Barnett B, Milgrom J, Ericksen J, Condon J, et al. Recognition and management of perinatal depression in general practice--a survey of GPs and postnatal women. Aust Fam Physician. 2005;34(9):787-90.\u003c/li\u003e\n\u003cli\u003eChew-Graham C, Chamberlain E, Turner K, Folkes L, Caulfield L, Sharp D. GPs\u0026apos; and health visitors\u0026apos; views on the diagnosis and management of postnatal depression: a qualitative study. Br J Gen Pract. 2008;58(548):169-76.\u003c/li\u003e\n\u003cli\u003eChew-Graham CA, Sharp D, Chamberlain E, Folkes L, Turner KM. Disclosure of symptoms of postnatal depression, the perspectives of health professionals and women: a qualitative study. BMC Fam Pract. 2009;10:7.\u003c/li\u003e\n\u003cli\u003eEdge D. Falling through the net - black and minority ethnic women and perinatal mental healthcare: health professionals\u0026apos; views. Gen Hosp Psychiatry. 2010;32(1):17-25.\u003c/li\u003e\n\u003cli\u003eGlasser S, Levinson D, Bina R, Munitz H, Horev Z, Kaplan G. Primary Care Physicians\u0026apos; Attitudes Toward Postpartum Depression: Is It Part of Their Job? J Prim Care Community Health. 2016;7(1):24-9.\u003c/li\u003e\n\u003cli\u003eKean LJ, Hamilton J, Shah P. Antidepressants for mothers: what are we prescribing? Scott Med J. 2011;56(2):94-7.\u003c/li\u003e\n\u003cli\u003eMcCauley C-O, Casson K. A qualitative study into how guidelines facilitate general practitioners to empower women to make decisions regarding antidepressant use in pregnancy. International Journal of Mental Health Promotion. 2013;15(1):3-28.\u003c/li\u003e\n\u003cli\u003eSantos Junior HP, Rosa Gualda DM, de Fatima Araujo Silveira M, Hall WA. Postpartum depression: the (in) experience of Brazilian primary healthcare professionals. J Adv Nurs. 2013;69(6):1248-58.\u003c/li\u003e\n\u003cli\u003eSeehusen DA, Baldwin LM, Runkle GP, Clark G. Are family physicians appropriately screening for postpartum depression? J Am Board Fam Pract. 2005;18(2):104-12.\u003c/li\u003e\n\u003cli\u003eVervers T, van Dijk L, Yousofi S, Schobben F, Visser GH. Depression during pregnancy: views on antidepressant use and information sources of general practitioners and pharmacists. BMC Health Serv Res. 2009;9:119.\u003c/li\u003e\n\u003cli\u003eWilliams S, Bruxner G, Ballard E, Kothari A. Prescribing antidepressants and anxiolytic medications to pregnant women: comparing perception of risk of foetal teratogenicity between Australian Obstetricians and Gynaecologists, Speciality Trainees and upskilled General Practitioners. BMC Pregnancy Childbirth. 2020;20(1):618.\u003c/li\u003e\n\u003cli\u003eKhan L. Falling through the gaps: perinatal mental health and general practice. Centre for Mental Health, Royal College of General Practitioners; 2015.\u003c/li\u003e\n\u003cli\u003eBrygger Veno L, Jarbol DE, Pedersen LB, Sondergaard J, Ertmann RK. General practitioners\u0026apos; perceived indicators of vulnerability in pregnancy- A qualitative interview study. BMC Fam Pract. 2021;22(1):135.\u003c/li\u003e\n\u003cli\u003eMortimer H, Habash-Bailey H, Cooper M, Ayers S, Cooke J, Shakespeare J, et al. An exploratory qualitative study exploring GPs\u0026apos; and psychiatrists\u0026apos; perceptions of post-traumatic stress disorder in postnatal women using a fictional case vignette. Stress Health. 2022;38(3):544-55.\u003c/li\u003e\n\u003cli\u003eNoonan M, Doody O, O\u0026apos;Regan A, Jomeen J, Galvin R. Irish general practitioners\u0026apos; view of perinatal mental health in general practice: a qualitative study. BMC Fam Pract. 2018;19(1):196.\u003c/li\u003e\n\u003cli\u003eRANZCP. Perinatal mental health services: The Royal Australian and New Zealand College of Psychiatrists; 2021 [updated October 2021. Available from: https://www.ranzcp.org/news-policy/policy-and-advocacy/position-statements/perinatal-mental-health-services.\u003c/li\u003e\n\u003cli\u003eRACGP. General Practice Health of the Nation. 2022.\u003c/li\u003e\n\u003cli\u003eThomas H, Best M, Mitchell G. Whole-person care in general practice: The nature of whole-person care. Australian Journal for General Practitioners. 2020;49:54-60.\u003c/li\u003e\n\u003cli\u003eWright M. Continuity of care. Australian Journal for General Practitioners. 2018;47:661-.\u003c/li\u003e\n\u003cli\u003eAustin MP, Highet N, Group atEW. Mental Health care in the Perinatal Period Australian Clinical Practice Guideline: Centre of Perinatal Excellence; 2017 [Available from: https://www.cope.org.au/wp-content/uploads/2018/05/COPE-Perinatal-MH-Guideline_Final-2018.pdf.\u003c/li\u003e\n\u003cli\u003ePetersen I, Gilbert RE, Evans SJ, Man SL, Nazareth I. Pregnancy as a major determinant for discontinuation of antidepressants: an analysis of data from The Health Improvement Network. J Clin Psychiatry. 2011;72(7):979-85.\u003c/li\u003e\n\u003cli\u003eKennedy D, Eamus M, Hill M, Oei JL. Review of calls to an Australian teratogen information service regarding psychotropic medications over a 12-year period. Aust N Z J Obstet Gynaecol. 2013;53(6):544-52.\u003c/li\u003e\n\u003cli\u003eMorton AP. A to X: the problem of categorisation of drugs in pregnancy - an Australian perspective. Comment. Med J Aust. 2012;196(3):172; author reply -3.\u003c/li\u003e\n\u003cli\u003eFord E, Lee S, Shakespeare J, Ayers S. Diagnosis and management of perinatal depression and anxiety in general practice: a meta-synthesis of qualitative studies. Br J Gen Pract. 2017;67(661):e538-e46.\u003c/li\u003e\n\u003cli\u003eNICE. Antenatal and postnatal mental health: clinical managemnt and service guidance UK: National Institute for Health and Care Excellence; 2014 (updated 2020) [Available from: https://www.nice.org.uk/guidance/cg192.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStudies included in qualitative synthesis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor and year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAim of the Study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e\u003cstrong\u003eResearch Method\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey Findings and Discussion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eBilszta et al 2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eExplore primary health care physician\u0026apos;s beliefs and practices toward perinatal depression by investigating knowledge, attitudes, and practices affecting a physician\u0026rsquo;s decision to continue or discontinue antidepressant medication during pregnancy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQuantitative: Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eAustralia and Canada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e61 GPs;\u003cbr\u003e\u0026nbsp;33 Family Physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eAge, years in practice, gender, or personal experiences with depression did not lead to a significant difference in treatment choice.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePrescribing is a third line choice, after counselling or partner support.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePhysicians appeared more likely to taper medication in pregnant women, although this is linked to a six-fold increase in risk of relapse for women, indicating an incongruency between risk concerns and potential outcomes of medication management.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eBrygger Ven\u0026oslash; et al 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo explore GP\u0026rsquo;s perceived indicators of vulnerability among pregnant women in primary care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQualitative: Semi-structured focus groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eSouthern Denmark\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e20 GPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003ePatient doctor relationship is integral when deciding to ask further questions regarding mental health. GPs were aware of indicators of vulnerability to severe mental health but also referred to a \u003cem\u003egut feeling\u003c/em\u003e when picking up on intangible indicators.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eBuist et al 2005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo identify ways to improve detection of postnatal depression and access to treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQuantitative: Survey vignette\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e246 GPs;\u0026nbsp;\u003cbr\u003e\u0026nbsp;525 women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eA difference between GP and patient preferences may lead to a hesitancy for women to bring up difficulties if they do not want to be prescribed medication.\u003c/p\u003e\n \u003cp\u003eThe length of time needed for a consult period when identifying postnatal depression is a significant time investment.\u003c/p\u003e\n \u003cp\u003eRoutine enquiry about women\u0026rsquo;s mood and coping is needed to identify women who might otherwise go undiagnosed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eChew-Graham et al 2008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo explore the views of GPs and health visitors on the diagnosis and management of postnatal depression.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQuantitative: Survey within a multicentre RCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eVarious locations United Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e19 GPs;\u0026nbsp;\u003cbr\u003e\u0026nbsp;14 Health Visitors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eGPs stress the importance of knowing the patient and using a psychosocial approach to making a diagnosis. GPs and Health Visitors agree that diagnosis of postnatal depression is important for management, but the \u0026lsquo;role\u0026rsquo; of responsibility on detecting symptoms was unclear.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eChew-Graham et al 2009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eExploration of views and attitudes of women and GPs following a disclosure of postnatal depression.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQualitative: In-depth interviews within a multicentre RCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eVarious locations United Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e19 GPs;\u0026nbsp;\u003cbr\u003e\u0026nbsp;14 Health Visitors;\u0026nbsp;\u003cbr\u003e\u0026nbsp;28 Women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003ePsychosocial factors need to be addressed to diagnose and treat postnatal depression.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDiagnoses, or pursuing a diagnosis, are avoided when health care providers feel they have nothing to offer e.g., continuity of care, referral to services. Questioning why a diagnosis of depression is not made by the healthcare professional, and suggesting training to address this issue, is too narrow an approach. Instead, a whole system approach is necessary to improve willingness to disclose, practitioner ability to listen and intervene, and a system that will facilitate management.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eEdge 2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo investigate health professionals\u0026apos; views about perinatal mental healthcare for Black and minority ethnic women.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQualitative: Interviews and Focus Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eUnited Kingdom (Northern England)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e42 health professionals (5 of which were GPs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003ePhysical health is often prioritised in the postnatal period, mental health can be overlooked.\u003c/p\u003e\n \u003cp\u003eServices which limit continuity of care, health professional resistance to using psychometric tools, and lack of confidence in managing depression contribute to missed opportunities to detect and treat postnatal depression.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eGlasser et al 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo explore Israeli primary care physicians\u0026rsquo; attitudes and practice regarding postpartum depression (PPD).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQuantitative: Three question survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eIsrael\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e122 Paediatricians;\u003cbr\u003e\u0026nbsp;102 Family Practitioners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eMost of the participants reported that it was important to recognize signs of postnatal depression and to act upon them. This resulted in most respondents reporting they would refer patients onward to mental health professionals.\u003c/p\u003e\n \u003cp\u003eSignificantly more family practitioners would screen for postnatal depression when compared to paediatricians.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eKean et al 2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo investigate current prescribing practices among GPs of antidepressants to women presenting in the first trimester of pregnancy and during breastfeeding.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQualitative: Postal survey vignettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eUnited Kingdom (Scotland)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e32 GPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eWhen given a list of potential medications to prescribe either in the first trimester, or during breastfeeding, GP prescribing patterns were inconsistent. Knowledge regarding classes of drugs was better than specific drugs within that class. Several GPs still had resistance to using medication for mothers with depression.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThere was also limited forward planning with prescribing medication that could be continued through until breastfeeding.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eKhan 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eUnderstand the role of GPs, and women\u0026rsquo;s experiences, in disclosure, identification and support with perinatal mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eMixed method: surveys and semi-structured interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eUnited Kingdom (majority)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e43 GPs for the survey;\u0026nbsp;\u003cbr\u003e\u0026nbsp;3 GPs for the interview\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eGovernment action is needed to reduce the pressure on GPs and allow for longer consultations periods with women experiencing perinatal mental health problems.\u003c/p\u003e\n \u003cp\u003eHigher education should work with RCGP Clinical Champion to support specific perinatal mental health training for qualified GPs.\u003c/p\u003e\n \u003cp\u003eLocal education and training boards should develop curriculum competencies relating to perinatal mental health through their GP training programmes.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEvidence should be explored to assess the most effective way to use the six-week check to support mothers, babies, and families.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eMcCauley \u0026amp; Casson 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo develop an in-depth understanding of GPs\u0026rsquo; experience of using guidelines in the treatment of perinatal depression and if this enabled them to empower women to become involved in treatment decisions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQualitative: Semi-structured interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eUnited Kingdom (Northern Ireland)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e8 GPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eThe purpose of clinical guidelines is to enable GPs to empower women to make informed treatment decisions regarding pregnancy, however, the perceived usage of these guidelines is limited.\u003c/p\u003e\n \u003cp\u003eGPs felt overwhelmed by too many guidelines, and conflicting safety data.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGPs agree that involving women in the decision-making process is central to their empowerment, but this can be limited by the complexity of the presentation and to what level women want to be involved.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eMortimer et al 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eInvestigate GPs\u0026apos; and psychiatrists\u0026apos; perceptions and experiences of caring for women with PTSD in the postnatal period.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQualitative: Fictional case vignette\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eUnited Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e6 GPs;\u003cbr\u003e\u0026nbsp;7 Psychiatrists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eGPs can avoid diagnosis or attribute difficulties to other changes, often taking on a \u003cem\u003ewatchful waiting\u003c/em\u003e approach.\u003c/p\u003e\n \u003cp\u003eBirth often isn\u0026rsquo;t considered a traumatic event by health care professionals, which potentially contributes to the way diagnoses are approached.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMost training regarding postpartum diagnoses focuses on depression and psychosis, leading to a lack of training in other postpartum disorders such as post-traumatic stress disorder (PTSD).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eNoonan et al 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo explore GPs\u0026apos; experiences of caring\u003cbr\u003e\u0026nbsp;for women with perinatal mental health problems and their views on how best\u003cbr\u003e\u0026nbsp;to prepare future GPs for a role in the provision of effective\u003cbr\u003e\u0026nbsp;PMH care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQualitative: In-depth semi-structured interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eIreland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e10 GPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eGPs described their multifaceted role in supporting women with perinatal mental health. GPs identified stigma, cultural and linguistic barriers to disclosure and care. Specialised care when indicated for women is limited due to under resourcing and long wait times.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTraining in perinatal mental health is needed, with some GPs suggesting a compulsory psychiatric rotation during training programs. Other options include e-modules to help build GP confidence and knowledge.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eSantos Jr et al 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo explore experiences of Brazilian physicians and nurses caring for women with postpartum depression in primary healthcare settings.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQualitative: Open ended interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eBrazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e10 nurses;\u0026nbsp;\u003cbr\u003e\u0026nbsp;7 family health physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eThere appeared to be limited exposure to postpartum depression, which in turn created gaps in knowledge about postpartum depression, including its presentation and treatment. Limited clinical knowledge effects screening of postpartum depression and the documentation of symptoms.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGaps in GP training are highlighted as a potential causal factor for these issues.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eSeehusen et al 2005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo determine how frequently family physicians screen for PPD, what methods they use to screen, and what influences their screening frequency.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQuantitative: 25-item questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eUSA (Washington)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e298 physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eScreening for postpartum depression is not universal. When physicians do report screening for postpartum depression, they often don\u0026rsquo;t use a validated screening measure.\u003c/p\u003e\n \u003cp\u003eRecency of training and sex differences are present when comparing those who screen more frequently, with more recent residency and female physicians screening more.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eVervers et al 2009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo investigate where GPs and pharmacists in the Netherlands obtain information on the safety of gestational drug use and the pharmacotherapeutic approach when managing depression and anxiety during pregnancy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQuantitative: Closed choice multiple choice questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eNetherlands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e130 GPs;\u0026nbsp;\u003cbr\u003e\u0026nbsp;144 pharmacists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eContraindications regarding safety of medication make it difficult and depend on differing sources of information.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDifferences in views on how to treat depression before, during and after pregnancy vary. GPs do consider the consequences of the mother\u0026rsquo;s illness outweighing the possible risks to the child. Concludes with the role of pharmacists being involved in developing clear policies and providing accessible information.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eWilliams et al 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.61855670103093%\"\u003e\n \u003cp\u003eTo explore the differences in the perception of teratogenicity risk of antidepressant and antianxiety medication commonly prescribed to pregnant women, medication counselling, prescribing practices, clinician resources and base knowledge of risk of antidepressant and antianxiety medications when used in pregnancy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003eQualitative: Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e172 GPs;\u003cbr\u003e\u0026nbsp; 373 Obstetrician/\u003cbr\u003e\u0026nbsp;Gynaecologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.95876288659794%\"\u003e\n \u003cp\u003eGPs perceived higher rates of patient anxiety regarding anxiolytics and antidepressants, compared to obstetricians and gynaecologists. Both groups reported continued maternal concerns with fetal malformation due to medications. There is infrequent provision of written resources due to limited patient friendly resources. GPs often allotted more time in their consults to discussing medication risks and benefits.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGPs saw themselves in a primary prescriber role, comparatively, and were less likely to refer to a mental health specialist.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBoth healthcare providers recommended a close patient-doctor relationship and clear communication when working with perinatal mental health and discussing medications.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThere is a modest interest in mental health disorders in pregnancy leading to a general lack of familiarity in the area and limited knowledge of the latest evidence.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cem\u003eNote.\u0026nbsp;\u003c/em\u003eGPs = General Practitioners, USA = Unites States of America\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"general practice, perinatal mental health, scoping review, psychotropic medication","lastPublishedDoi":"10.21203/rs.3.rs-2685289/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2685289/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeneral Practitioners (GPs) manage the majority of preconception, early pregnancy, and postnatal care. Overall, mental health remains a significant contributor to disease burden affecting 1 in 4 pregnant women. Psychotropic medication prescribing occurs in almost 1 in 12 pregnancies, and appears to be increasing, along with the prevalence of mental health disorders in women of reproductive age. Perinatal mental health management is therefore not an unlikely scenario within their clinical practice. This scoping review aims to map current research related to GPs perceptions and experiences managing perinatal mental health, particularly exploring their experiences of diagnosis, medication use, guideline adherence and management of care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive search strategy using nine electronic databases, and grey literature was undertaken between December 2021 and February 2023. Relevant studies were sourced from peer review databases using key terms related to perinatal mental health and general practitioners. Search results were screened on title, abstract and full text to assess those meeting inclusion criteria and relevance to the research question.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter screening, 16 articles were included in the scoping review. The majority of articles focused on perinatal depression. Findings support that\u003cstrong\u003e \u003c/strong\u003eGPs are largely confident with diagnosing perinatal depression. However, over the last two decades, prescribing confidence in perinatal mental health remains variable with concerns for the safety profile of medication, low level of confidence in providing information and a strong reliance on personal experience. Despite the establishment of perinatal guidelines by countries, the utilisation of these and other existing resources by GPs appears to be infrequent. Many challenges exist for GPs around time pressures, a lack of information and resources, and difficulty accessing referral to services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecommendations following this scoping review include targeted perinatal education programs specific for GPs and embedded in training programs. The development of practice guidelines and resources specific to general practice that recognises time, services, and funding limitations. Future research is needed on how guidelines and resources can be developed and best delivered to optimise GP engagement to improve knowledge and enhance patient care.\u003c/p\u003e","manuscriptTitle":"General Practitioner perceptions and experiences of managing perinatal mental health: a scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-29 19:12:24","doi":"10.21203/rs.3.rs-2685289/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-08-13T15:05:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-07-07T13:45:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"992829f6-f7c2-4b65-ac12-516f199e15b1","date":"2023-07-03T00:05:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-06-29T22:38:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-06-29T16:46:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-03-28T07:36:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-03-28T07:24:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2023-03-13T04:03:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6202815-07bd-4829-90d3-ac42f0dafaca","owner":[],"postedDate":"March 29th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-12-04T15:05:24+00:00","versionOfRecord":{"articleIdentity":"rs-2685289","link":"https://doi.org/10.1186/s12884-023-06156-6","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2023-12-02 15:01:50","publishedOnDateReadable":"December 2nd, 2023"},"versionCreatedAt":"2023-03-29 19:12:24","video":"","vorDoi":"10.1186/s12884-023-06156-6","vorDoiUrl":"https://doi.org/10.1186/s12884-023-06156-6","workflowStages":[]},"version":"v1","identity":"rs-2685289","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2685289","identity":"rs-2685289","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}