Young mothers’ use of and experiences with mental health care services in Ontario, Canada: a qualitative descriptive study | BMC Women’s Health

Demographics

A purposeful sample of 29 young mothers (mean age = 18.83) discussed their experiences of seeking social support and health care services for their mental health disorders during pregnancy and the early years of their children’s lives. The sociodemographic characteristics of these young mothers are summarized in Table 1. The majority of the young women identified their relationship status as single (58.6%) with only 37.9% married or in a common-law relationship.

Table 1 Sociodemographic characteristics of study participants (n = 29)

Prevalence and type of mental health disorders

Within these social contexts, the majority of participants (69%) reported parenting with a current mental health disorder at the time of data collection, with 37.9% of the sample reporting a diagnosis of more than one disorder. The average number of disorders across the sample was 1.62 (SD = 1.76, minimum = 0, maximum = 7). Prevalence rates of specific mental health disorders experienced by women in this sample are summarized in Table 2.

Table 2 Prevalence rates of mental health disorders among study participants (n = 29)

Social factors influencing mental health and well-being

As these mothers completed the ecomaps, their narratives commonly included references to ACES including physical or sexual abuse, exposure to intimate partner violence or traumatic losses such as the incarceration, murder, or death of a parent. All of the women were living within conditions of economic and social disadvantage, with many describing life histories complicated by multiple family moves, disruptions in their education, precarious employment and poverty. A common stressor for participants was the responsibility of parenting alone and managing the demands of independent living. A young mother of a single infant shared,

I just moved. So those emotions are getting to me. This is my first time moving out from my mom’s or my dad’s [places]. So, it’s like, “I’m by myself, I have my baby here, but I’m by myself. I have no parents to help me. I have to pay my own rent; I have to pay my own bills. So, it scares me sometimes, and my thoughts, they just sit there. They’re like, “Hey, we’re going to make you cry today.” But ten minutes later, we’re good. [Participant 14, 20 years]

Overall, through triangulation of survey, interview, and ecomap data, it was identified that all participants had histories of trauma, were parenting while experiencing multiple social and economic stressors and managing at least one mental health disorder. Parenting within this context was perceived to negatively impact their overall well-being and increased their needs for mental health services.

Need for consistent and accessible support

The fundamental need for young mothers navigating mental health disorders while parenting was to have at least one individual in their life who was “always there” to talk to and who was trustworthy, easily accessible, and skilled in active listening. This individual could be either an informal social support (e.g., parent, friend) or a formal professional support (e.g., health care provider, counsellor). What was critical was that the source of support was available to provide help when requested and had the resources, empathy, experience, or knowledge to meet their identified needs. As one mother explained,

What do young mothers need in terms of support? Help when they need it. Especially support in getting through some of the hard times… Having someone close to you, that you can depend on in the first while [after having a baby] and who can give you a bit of a break. [Participant 15, 19 years]

Partners, friends, or family members often fulfilled the role of providing emotional and instrumental support, as well as guidance on parenting and managing stress. Mental health support networks also included engagement with heath care or social services providers. The types of informal social or formal professional supports needed and accessed varied across study participants. Overall, participants experiencing high levels of support identified connecting regularly with at least one supportive friend or family member and engaging consistently with a supportive primary health or social services provider. Having timely access to specialized mental health services to address both emergent mental health crises and long-term conditions was also important to this group.

Social support networks

Analysis of the ecomap data indicated that participants listed an average of 8 (range 3–16) social supports during their pregnancy and an average of 9 (range 4–18) in the postpartum period. Among their available supports, all participants identified having at least one closely connected and positive relationship with a friend, family member, or partner who provided them with multiple forms of social support during the prenatal and postpartum periods. Yet, most were simultaneously navigating other relationships that were difficult or tumultuous. These stressful relationships were often described as unsupportive and reflected lives with abusive partners or former partners or their own parents’ physical or emotional unavailability. The theme of loss was common across the interviews and ecomaps, with many participants discussing the loss of social networks once they became pregnant, estrangement from extended family, or parental death including by suicide.

Formal professional supports

The young mothers in this study were well connected to a range of professionals or community service agencies. Almost all participants (97%) engaged with at least one health care provider (e.g., obstetrician, family physician, midwife, or public health nurse) to receive prenatal health care. A majority of participants (72%) also lived in or accessed services from a community-based maternity home that provided residential, health, and education services to young pregnant or parenting girls. Analysis of the ecomap and interview data revealed that most mothers identified using multiple services, with 59% of participants reporting accessing three or more professional supports during pregnancy and 83% accessing professional supports in the postpartum period (Table 3).

Table 3 Number of professional supports accessed by study participants during pregnancy or postpartum period as disclosed in ecomaps and qualitative interviews

From the survey data, participants reported completing an average of 16.38 (SD = 19.91; minimum = 0, maximum = 74) professional visits specifically for addressing mental health disorders over the last 12 months. On average 2.14 (SD = 1.53, minimum = 0, maximum = 4) professionals were seen to address participants’ mental health disorders and the types of providers this sub-sample of participants saw or talked to on the phone about emotional or mental health problems or the use of alcohol or drugs in the last 12 months are summarized in Table 4. The most common providers accessed were social workers, counsellors or psychotherapists (58.6%), family doctors/general practitioners (48.3%) and nurses (44.8%).

Table 4 Types of health care or social service providers accessed for mental health problems

Young mothers’ decisions to seek mental health care

In reflecting on their mental health disorders and support needs, the mothers shared insights as to why they decided to manage their mental health disorders either independently, with the support of family or friends or through seeking professional health or social care services. Participants who chose to manage their mental health independently often saw themselves as needing to be self-reliant. As a 21-year-old mother of one child explained, “I always feel like I can deal with things myself. It would be a good idea if I did (seek professional support), but I probably won’t, just because I’m more of a strong-headed, stubborn person” [Participant 20]. Their reasons for not seeking support however were underpinned with language that signaled feelings of vulnerability, fear, or worry about discussing their mental health with a professional. For some, their words alluded to concerns that if they could not help themselves, no one could. As one mother shared,

If you can’t handle [your mental health issues] by yourself, how do you expect someone else, who doesn’t even know you, to do it? Like, if I can’t handle my anger, I can only imagine how I’m going to freak out when someone else is trying to tell me how to control it right? I don’t like being told what to do. [Participant 18, 18 years]

An understanding of their health history, accessibility, and a sense of trust and connection were rationale provided for connecting with families or close friends for help in managing mental health disorders. One mother, who had a very positive relationship with her parents and siblings, expressed that:

I feel like I can relate more to my family and they can relate to me more; so, they can help me with an issue. So, if I’m feeling upset, my mom or my sisters tell me, “That’s normal. That’s not normal. You’re fine. It’ll pass. Or whatever.” I don’t know if that’s different or not, but a professional who would be helping me from an agency would be doing the same thing. So, I just feel more comfort knowing that my family is there. And comfort is the biggest thing. [Participant 20, 21 years]

Among those deciding to seek professional help, many of their narratives were underpinned however with a hesitancy to access mental health care. This hesitancy to seek help was often related to a fear of being judged by others and an acknowledgement of the stigma attached to experiencing mental illness and being a young mother. There were also fears about perceived negative outcomes they associated with accessing mental health care, such as being medicated or being reported to child protective services. For many participants, their hesitancy to seek care was also grounded in past negative care experiences. For other participants, there was an acute awareness that the symptoms associated with their mental health disorder significantly influenced their behaviours and motivation to be able to locate, access, and then participate in mental health services or treatments.

For those who ultimately sought professional care, many referenced an increased openness and willingness to seek and accept professional support during their pregnancy. The transition to motherhood was also commonly identified as a primary motivating factor to seek mental health care. One mother [Participant 26, 21 years], with two young children stated, “it’s not just me anymore. It (seeking mental health care) was for the baby.” Another mother shared that making this decision also required the confidence to dismiss worries about stigma and others’ perceptions of her decision to seek professional help:

It’s not about them. It’s about you and you do what you have to do for you and your child. So, don’t do what’s better for everyone else. I didn’t care what everybody else thought because I was doing it for me, I wasn’t doing it for them. Whatever I did was just to help me out and to make things easier on me. [Participant 15, 19 years]

Past experiences with health care professionals also influenced their decisions to seek mental health care in pregnancy or the postpartum period. Young mothers who shared examples of positive health care experiences during the prenatal period were more confident in their decision to accept a referral for mental health care. These positive past experiences were illustrated with examples of health care professionals who provided reassurances, identified and acknowledged the young mothers’ strengths, explained procedures, offered help, and outlined options for care, thus allowing the young mother to have control over her decisions.

In comparison, the mothers who shared their stories of negative and traumatic experiences with health care professionals, including during the prenatal and intrapartum periods, were much more fearful and hesitant to re-engage with the health care system to address their mental health disorders. In particular, their narratives included exemplars of not being listened to nor having their experiences validated, their requests for information or help being ignored, and the use of power by health care professionals to override their decisions or requests for services.

Factors influencing young mothers’ use of mental health care services

Participants discussed multiple factors (Table 5) that served as either facilitators or barriers in their decision-making to use mental health care services.

Table 5 Factors influencing young mothers’ use of mental health care services

Barriers to using mental health care services

There was consensus that managing logistics around getting to community-based agencies that provide mental health services was a primary barrier. Participants confirmed that most, if not all, agencies provided bus tickets or taxi coupons to help the mother attend her appointment. While this small financial support was perceived to be necessary and important, it was evident that getting to the appointment was actually a much more complex, and physically and emotionally demanding process for young mothers with infants. They described complex lives where they are responsible for the health, safety, and well-being of themselves and their infants. Within this context, they manage, juggle, and coordinate appointments with multiple programs, services and professionals and do so in the absence of private transportation and financial resources. The participants emphasized that this work of care coordination was time-consuming and exhausting. At times, it even meant not being able to attend an appointment or program, as one participant explained:

I didn’t really have time to do the program because I was pretty much a single mom, doing it all on my own. So, it was hard, like, it wasn’t too hard to get to the programs, it was just to find time to do them and trying to catch up on sleep and get everything else done.” [Participant 1, 20 years]

For other mothers, the complexity and challenges were found within the action of getting to the program or appointment. Arriving on-time to an appointment often required planning around the infant’s schedule, for example,

After you have the baby, it’s difficult to get to an appointment. It’s more difficult because you have to worry about, “Oh is my child going to be hungry during this time? What do I need to pack? What if the bus runs late? Am I going to miss my appointment?” [Participant 3, 21 years]

The young mothers revealed that navigating small physical spaces, including on public transportation, and accessing buildings with a stroller, often in inclement weather without anyone else to help, and exposed to the judgments and “rude comments” of strangers was exhausting.

For young mothers with anxiety disorders, navigating the logistics of finding an agency for the first time and not knowing “what to expect” at the appointment were highlighted as additional stressors. Returning home, again often on public transportation, was difficult for some mothers who spoke about not having a private space to reflect on what happened within the client-clinician encounter or to express post-appointment emotions.

Organizational policies that reduced flexibility or limited communication to book or re-schedule appointments were barriers to consistent engagement with services. A hesitancy to return to service organizations also occurred when participants experienced a lack of privacy or a threat to their emotional safety through multiple requests to repeat their medical histories.

Facilitators to accessing mental health care services

Based on their varied experiences of engaging in a wide range of mental health-focused services, participants were able to describe specific attributes of organizations that facilitated their engagement with mental health services. There was a clear preference for working with organizations where health and social services were co-located. Access to a consistent or primary care provider, and the option to receive services through home visits were also highly valued attributes. One mother, with two young children, explained,

Having a public health nurse come to your house is a huge advantage. There are tons of emotional advantages, tons of intellectual advantages. It was a huge thing for me and it’s easier with a newborn to have the nurse come to me and to work around my schedule. [Participant 26, 21 years]

An organization’s flexibility and responsiveness in scheduling an appointment at a time convenient for the mother, or “fitting her in,” so that an imminent mental health concern could be addressed in a timely fashion was highly appreciated. As one mother explained,

My doctor’s office is very flexible. If you are like, “Oh, look, like this is important, I really need to get in,” they put you in the earliest time they can which is great. They always answer their phones. [Participant 3, 21 years]

The use of cell phones was a constant in these mothers’ lives, and they identified that being able to text the organization or provider to book, cancel, or re-schedule an appointment facilitated better communication. Finally, some participants indicated a higher degree of engagement with voluntary programs, in comparison to a program that they were mandated to attend.

Provider attributes that influence engagement with mental health care services

Reflecting on their experiences with multiple providers, participants provided a consistent list of provider attributes that were highly valued. The mothers were most likely to engage and consistently work with providers with excellent communication skills, the ability to develop a therapeutic relationship characterized by trust, and who prioritized exploring and understanding the client’s goals of care.

The opportunity to access care or support at the time they were experiencing a high number of stressors or mental health issues was of primary importance. In parallel, because of unpredictable or changing events in their lives, participants also appreciated working with providers who had the flexibility to re-schedule an appointment at short notice and who demonstrated understanding about the mother’s need to change or cancel an appointment. Being able to communicate via text also facilitated last minute changes. One young mother, in speaking about her nurse home visitor explained,

And she [the public health nurse] texts if we have an appointment. Like it’s perfect. And then if I have to say, ‘Oh, there’s an emergency, can I see you sooner?’ Then she’s like, ‘Yeah, of course. These are the days I have free…. And when are you available?’ And then she comes to me. [Participant 3, 21 years]

To be able to discuss their mental health concerns it was paramount to the young mothers that they feel “connected” to their provider. With respect to the therapeutic relationship, the mothers sought out genuine connections and appreciated when their need to seek support was valued and not perceived as a burden. As one mother summarized,

I connected with her [the addiction counsellor] so good because I felt that she was so down to earth, and I could open up to her. So, I opened up and I told her everything. I guess she then switched to work at another site and so a new counsellor came in. I was actually able to open up to her too, because she also worked shifts at [the maternity home]. So, I was like, “Okay, you know, I’ve met her before. She’s cool. I’ve talked to her.” And now I can open up to her with anything. [Participant 12, 19 years]

Within the care encounter, participants expressed a preference to work with providers who were respectful and non-judgmental and who created a safe space where they could speak privately and in confidence. There was an appreciation for providers who, regardless of the mother’s early resistance to engage, recognized that the process of building trust takes time and stayed committed to the process. One mother explained,

I didn’t get along with [my counsellor] at first. When I started going there, I was a rebel, I didn’t like them, and I use to tell them off. But they were there for me. So, I just started liking them more. Eventually, I was just like, “Okay, you guys are actually here to help me. Like, not everybody is out to get me.” So, I don’t know…I just built a bond with them and I still have it now. [Participant 4, 21 years]

Repeatedly, mothers expressed appreciation for professionals who were skilled active listeners. Equally important was to work with a professional who prioritized identifying the mother’s most immediate needs, and then instead of focusing on the professional’s “agenda,” explored strategies to address priority concerns. When a referral to another clinician or agency was needed, participants valued when their primary mental health care clinician would explain the different options for the referral, outline in detail what services would be offered, and then actively assist in connecting the participant to the next agency.

In contrast, participants identified the negative attributes of client-provider relationships that limited their use mental health services. When participants experienced what they perceived to be a lack of physical privacy or confidentiality, then they were hesitant to discuss their mental health. For several participants, they found it particularly upsetting to be asked about sensitive and personal experiences when other family members were present. The participants did not value working with providers who controlled the agenda, did not listen to their description of their immediate needs, or who made assumptions about their needs and told them what to do without exploring the acceptability of those options to them. When participants perceived that the service provider was judging their behaviour or parenting, they were reticent to continue to seek services. Several participants identified that providers’ questions and words were experienced as intrusive and made them feel guilty or overwhelmed. One mother [Participant 12, 19 years] explained, “Having to manage and navigate a thousand and one questions like ‘Why didn’t you come sooner, blah, blah, blah…it’s too much.” To avoid these experiences and feelings, it was easier to no longer continue with the provider.

Young mothers’ recommendations to mental health care professionals

Within the interviews, the participants were asked to reflect on their experiences and share recommendations on how mental health care professionals could better engage and support young mothers. The key recommendations are summarized, staying close to the participants’ own words, in Table 6. It was important to participants that professionals providing specialized mental health care recognize and address the social and economic stressors impacting the mothers’ mental health in addition to treating their mental health disorders. The remaining recommendations reflect the young mothers’ needs to be able to engage in a therapeutic alliance where they listened to, respected, and actively engaged in decision-making.

Table 6 Young mothers’ recommendations for mental health care professionals

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