Bakgrund: Under graviditet genomgår kvinnan fysiologiska, psykologiska och hormonella förändringar. Att drabbas av psykisk ohälsa i samband med graviditet och tiden efter barnets födelse är inte annorlunda än att drabbas av psykisk ohälsa under andra perioder i livet men psykisk ohälsa under den perinatala perioden kan påverka bindningen till barnet och barnets anknytning till sin mamma. Psykisk ohälsa kan leda till att kvinnor ifrågasätter sin modersroll och barn till mödrar med psykisk ohälsa kan påverkas negativt genom emotionella-, kognitiva- och beteendemässiga svårigheter som kan bli långvariga. Barnmorskan har i uppgift att upptäcka och identifiera kvinnor med risk för psykisk ohälsa, tidiga insatser är av vikt. Barnmorskan kan remittera kvinnan till adekvat vård inom och utanför professionen. Det är av vikt att barnmorskan skapar förtroendefulla relationer, vården ska ges med värdighet och vara personcentrerad samt möjliggöra kontinuitet. Dock visar forskning att kvinnor upplevt att bemötande och vård inte tillgodoses vilket leder till att den psykiska ohälsan inte uppmärksammas. Syfte: Att, utifrån barnmorskors erfarenheter och upplevelser, belysa vad som påverkar bemötandet och vården gentemot kvinnor i relation till psykisk ohälsa i samband med graviditet och tiden närmast efter barnets födelse, så kallad perinatal psykisk ohälsa. Metod: Litteraturöversikt med kvalitativa och kvantitativa artiklar som analyserades med integrativ metod. Resultat: Barnmorskor ansåg att relationsskapandet var viktigt i avseendet att främja den psykiska hälsan och för att identifiera psykisk ohälsa. Barnmorskorna upplevde inte att stödet alltid räckte till, varken för att skapa förtroendefull relation eller för att erbjuda lämplig vård till kvinnor som drabbats av psykisk ohälsa. Helhetsperspektivet var bristande, en del barnmorskor ansåg att perinatal psykisk ohälsa var deras ansvar, medan ansvarsrollen upplevdes som otydlig av andra barnmorskor. Barnmorskor tillfrågade inte kvinnor om den psykisk hälsan under graviditeten och de kände sig mer bekväma att prata om fysiska besvär och frågor specifikt riktade mot graviditeten och dess fortskridande. Det framkom också negativa attityder och stigma kopplade till psykisk ohälsa, och att vården och bemötandet påverkades av tidsbrist. Barnmorskor upplevde kompetensbrist och otydlighet gällande remittering, vilket bidrog till osäkerhet och oro. Det visade sig att flertalet barnmorskor hade kunskapsbrister angående perinatal psykisk ohälsa. Slutsats: Bemötande och vård påverkas av förtroendefulla relationer, kontinuitet och kunskapsbrist. Genom att synliggöra betydelsen av förtroendefulla relationer skulle det möjliggöra att barnmorskor skulle kunna förebygga perinatal psykisk ohälsa och därmed kunna skydda, kanske den viktigaste relationen i livet, mammans bindning till sitt barn och barnets anknytning till sin mamma. / Background: During pregnancy, the woman undergoes physiological, psychological, and hormonal changes. Suffering from mental illness in context to pregnancy; before, during and the time after child’s birth, is no different than suffering from mental illness during other periods in life. But mental illness during the perinatal period can have a negative impact on the attachment to the child and the child´s attachment to the mother. Mental illness can lead to women´s questioning their role as mothers and children of mothers with mental illness can be negatively affected by emotional, cognitive, and behavioral difficulties that can be long-lasting. The midwife has the task of discovering and identifying women at risk of mental illness and early intervention is important. The midwife can refer the woman to adequate care within and outside the profession. It is important that the midwife creates trusting relationships, enable continuity and the care must be given with dignity and be person-centered. However, research shows that women have experienced that treatment and care are not provided, which leads to perinatal mental illness not being noticed.  Purpose: To, based on midwife’s view´s and experience, shed light on what affect the treatment and care towards women in relation to mental illness in connection with pregnancy and the time immediately after the child´s birth, so-called perinatal mental illness. Method: Literature review with qualitative and quantitative articles that were analyzed with an integrative method. Results: Midwives considered that building a relationship was important in promoting mental health and in identifying mental illness. The midwives did not feel that their support was always sufficient, neither to create a trusting relationship nor to offer appropriate care to women who have suffered from mental illness. The holistic perspective was lacking, some midwives considered that perinatal mental illness was their responsibility, while the role of responsibility was perceived as unclear by other midwives. Midwives did not ask women about their mental health during pregnancy, and midwives felt more comfortable talking about physical ailment and issues specifically related to pregnancy and its progression. There were also negative attitudes and stigmas associated with perinatal mental illness, and that care and treatment were affected negatively by lack of time. Midwives experienced a lack of skills and uncertainty regarding referral, which contributed to doubt and concern. It turned out that most midwives had a lack of knowledge regarding perinatal mental illness. Conclusion: Treatment and care are affected by trusting relationships, continuity, and lack of knowledge. By highlighting the importance of trusting relationships, it would enable midwives to prevent perinatal mental illness and thus protect, perhaps the most important relationship in life, the mother´s attachment to her child and the child´s attachment to the mother.

Background: Antenatal Psychosocial Assessment (APA) has recently been introduced into routine antenatal care, but the ways in which maternity service providers assess and respond to maternal stress are subject of debate. There is a lack of consensus on the instrument(s) of choice and lack of evidence regarding appropriate interventions. Further, national guidelines have not kept apace with the conceptual shift from ‘postnatal depression’ to ‘perinatal anxiety and depression’. Adopting the Medical Research Council Complex Interventions Framework, the ARMS research aimed to inform the development of interventions that support women who are experiencing, or at risk of, mild-moderate mental health disorder in pregnancy. Methods: A mixed methods approach was adopted. In the quantitative element (Study Part 1) participants (n=191) completed a questionnaire when attending for their first formal antenatal appointment, using a procedure and materials that had been previously tested in a pilot study. Details including mental health assessment and referrals were obtained from their health records, following delivery. In the qualitative element (Study Part 2) a sub-sample of women (n=22) experiencing high levels of maternal stress took part in up to three serial in-depth interviews during pregnancy and the early postnatal period.Findings: Maternal stress was found to be common. Using the Edinburgh Postnatal Depression Scale (EPDS) threshold of ≥10, approximately 1 in 4 women were classed as high depression (halving to 1 in 8 at the more conservative threshold of ≥13). Almost 1 in 3 women were classed as high anxiety, using the state scale of the State-Trait Anxiety Inventory (STAI-S, threshold ≥41), compared with 1 in 5 using the two-item GAD (threshold ≥3). Fewer than half of the women identified as high anxiety were identified by both measures. Factor analyses of the symptom measures were consistent with wider literature suggesting a three-item anxiety component of the EPDS; however, concurrent validation using regression analyses did not indicate that the EPDS could be used as an anxiety case finding instrument. Women reported that maternal stress had significant impact on their lives that may not be captured with existing clinical approaches. Women commonly found it difficult to self-assess severity of maternal stress and the assessment process could itself act as an intervention. The research provided the first validation of the depression case finding questions in UK clinical practice. The Whooley items completed in clinical practice identified only half of the possible cases identified by the EPDS, at both commonly adopted EPDS thresholds. Inclusion of the Arroll 'help' question as a criterion improved specificity of the assessment completed in clinical practice but substantially compromised sensitivity, missing 9 in 10 possible cases. Women’s mental health history and treatment history were similarly under-reported, particularly concerning anxiety. APA was introduced into routine clinical practice without attention to topics of relevance to women, context of disclosure or to provision of adequate resources for consistently responding to identified need. Women experiencing, or at risk of, mild-moderate disorder were thus usually ineligible for further support. Implications: Care pathways are needed that encompass both assessing and responding to maternal stress, where communication with health professionals, subsequent referral and management are addressed. The development, implementation and evaluation of low-cost resources embedded in such pathways are a priority and the research presented in the thesis offers a foundation on which to build.