Women with Disabilities: Barriers and Facilitators to Accessing ...

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WOMEN WITH DISABILITIES: BARRIERS AND FACILITATORS TO ACCESSING SERVICES DURING PREGNANCY,CHILDBIRTH AND EARLY MOTHERHOODSchool of Nursing and Midwifery, Trinity College Dublinresearch that explored women’s preferences and experience of care. While themajority of the women (n=45) in Zittel-Palamara et al’s (2008) study valuedcounselling, medication, support groups (in-person and online), spiritualassistance, psychiatric and psychology input, few received the care theydesired. Although approximately 75% of women wanted assistance from apsychologist and 78% desired care from a social worker for their postpartumdepression, less than 25% and 11% were able to access the care they required.Within Ireland, inequalities in the provision of mental health services have beenreported (D’Eath et al, 2005), and the expert group on mental health stressedthe need to move beyond the current biological and illness-focused mentalhealth services to a more ‘biopsychosocial model’ of practice. They were of theopinion that ‘the artificial separation of biological from psychological and socialfactors has been a formidable obstacle to a true understanding of mentalhealth… [and resulted in] …lost opportunities for the provision of psychologicaland social interventions for people’ (Government of Ireland, 2006:pg. 18).5.3. Barriers to accessibility of services for women with mentalhealth difficulties: Impact of symptoms on ability to take action5.3.1. Inadequate recognition or denial of pregnancyGiven the high incidence of unplanned pregnancies among women with seriousmental illness, some of these women may have difficulty in recognising oracknowledging that they are pregnant and consequently delay accessingprenatal advice. This may occur especially among women who have erraticmenstrual cycles due to the side effects of prescribed medication or substancemisuse (Hser and Niv, 2006). Although rare, women with enduring mentalhealth difficulties, such as schizophrenia, who have previously lost custody ofchildren, have been found to deny their pregnancy to avoid the grief associatedwith anticipatory custody loss (Apfel and Handel, 1993; Nicholson et al, 1998a).Such denial reduces the chances of prenatal care, and increases the risk ofpostnatal emotional problems including, in some cultures at least, neonaticide 55 Neonaticide is the killing of a baby at birth, or (an extension of the definition) within the first 4weeks of life93
WOMEN WITH DISABILITIES: BARRIERS AND FACILITATORS TO ACCESSING SERVICES DURING PREGNANCY,CHILDBIRTH AND EARLY MOTHERHOODSchool of Nursing and Midwifery, Trinity College Dublin(Green and Manohar, 1990; Lee et al, 2006), a circumstance that could beavoided if they felt confident enough to confide in health professionals. Aretrospective study of medical records in an urban academic medical centre inCleveland over a 6-year period showed that, out of 31,475 births, 61 womenhad denial of pregnancy (0.19%). For 13 of the women (21%), the babies wereremoved from their custody prior to discharge from the hospital (Friedman et al,2007).5.3.2. Women’s motivation to access servicesSeeking help for a health problem requires a level of self-confidence andmotivation. The experience of depression, with all of the resulting symptomssuch as tiredness, poor self-esteem, lack of motivation, and overwhelmingsense of worthlessness, guilt and despair can make accessing help extremelydifficult for women, especially when services are so poorly integrated anddeveloped. In Lau and Wong’s (2008) study, Chinese women with depressivesymptoms were less likely to seek help than women in the non-depressedgroup, suggesting that a reciprocal relationship exists between symptoms andhelp-seeking behaviour. In other studies, postpartum depressive symptoms,such as difficulties in motivation and self-confidence, were identified by thewomen as a barrier to seeking help (Zittel-Palamara et al, 2008). Borjesson(2005) also suggests that feelings of guilt, low self-esteem and hopelessnessaccompanying depression contribute to women’s reluctance to talk about theiremotional distress. Depression during pregnancy has also been associated withpoor attendance at prenatal care (Mowbray et al, 1995b).5.4. Barriers preventing accommodation of women with mentalhealth difficulties: Access to health information5.4.1. Women’s knowledge about antenatal mental health difficultiesAnother possible reason that pre and postpartum mental health difficulties,especially depression during pregnancy, go undetected is that women are notprepared for the possibility of it happening to them. The emphasis on postnataldepression, to the exclusion of other mental health difficulties, may exacerbate94
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