This qualitative study used the face-to-face semi-structured interview to explore how women coped with PND, the reasons for seeking or not seeking professional help, and what interventions they perceived would be helpful in the future. The interview was conducted among 33 women (from three cultural backgrounds: Malay, Chinese, and Indian) attending Maternal and Child Health (MCH) clinics in Kuala Lumpur. Healthcare services offered within MCH clinics include antenatal, postnatal, and childcare. Almost all women in Malaysia give birth in a hospital, where they will be looked after by nurse-midwives, medical doctors and/or obstetrician. Nurses working in MCH clinics provide care for postnatal women through eight home visits (1^st, 2^nd, 3^rd, 4^th, 6^th, 8^th, 10^th, and 20^th postnatal days) and one clinic visit (30^th postnatal day). Postnatal mothers are also given a scheduled appointment for the child’s health (2^nd, 3^rd, 5^th, 6^th, 9^th,12^th postnatal months) [26].

Purposive sampling was used to recruit the participants based on the following inclusion criteria: (i) women aged 18–45 years, (ii) at 6–52 weeks after the last childbirth during the screening stage, (iii) Malaysian by nationality, (iv) had been staying in Malaysia after the last childbirth and until the time of the interview, (v) scored three or more in the Patient Health Questionnaires (PHQ-2) and/or scored 12 or more in Edinburgh Postnatal Depression Scale (EPDS) and/or self-identified and/or being referred by a head nurse in charge, and (vi) sufficiently fluent in Malay or English language to participate in the interview.

In this study, both PHQ-2 and EPDS were used to screen participants with PND symptoms due to the expectation that the EPDS would capture the depressive symptoms which were not asked in the PHQ-2. The EDPS consists of ten specific questions on PND symptoms, whereas the PHQ-2 consists of two short questions on general depressive symptoms: ‘little interest or pleasure in doing things’ and ‘feeling down, depressed or hopeless’ [27-,29].

Participants who fulfilled the inclusion criteria were invited for the interview session, which was conducted either at their homes, or in a private and quiet room at the respective clinic, or at any other location that the participants preferred. The interviews were recorded and transcribed verbatim. A topic guide was used, and field notes were written and maintained immediately after each interview session to reflect the participants’ emotions and non-verbal communications. Among the questions asked within the topic guide were the participants’ family situation, cultural background, current emotional status, factors influencing help-seeking behaviour, reasons for seeking or not seeking help, and perceptions of what might improve emotional well-being.

In Malaysia, the Malay language is used as the formal or official language. There were three different cultures with different mother-tongue languages involved in the interview session. Given that Malay is the formal language in Malaysia, most Malaysian women could converse and express their experiences well using the Malay language. Also, the ability to converse in either the Malay or English language was one of this study’s inclusion criteria. Furthermore, this criterion was included to optimise communication between the researcher and participants. While there are some differences in the postnatal practices across these three main cultures in Malaysia, there are also several common postnatal practices shared by these cultures. For example, although all cultures recognised the postnatal as a “confinement” period (where both newly delivered mothers and baby are expected to remain house-bound after childbirth), this period varies from one culture to another. In Malaysia, it is common for newly delivered mothers to be taken care of by their mother or mother-in-law [27]. As a means of avoiding any health problems, the newly delivered mothers are often advised to consume certain herbs, apply heat, and massage [27].

The interview data were analysed using a framework analysis, which comprised of three stages. Firstly, six transcripts were chosen to develop a thematic framework (consisting of initial themes and initial categories). The thematic framework was then applied to all transcripts. Secondly, the connection and similarities between one theme to another were identified. Thirdly, the dataset was reviewed to analyse the degree of consistency between the phenomena and the final themes. The final themes were developed within consensus among the research team. The credibility and confirmability of the findings were verified.

All participants were informed that their participation was voluntary and that refusing to participate or withdrawing from the study would not affect their care in any way. Pseudonyms were used throughout data collection, data analysis, and dissemination of findings [32]. The permission to conduct this study was approved by the School Research Ethics Committee (SREC), University of Stirling, and the Malaysian Medical Research Ethics Committee (MREC).

In describing their coping strategies, none of the participants reported that they received any help from HCPs. Instead, they mentioned that the following coping strategies helped manage their emotional distress: positive thinking, mental preparedness, talking to family members and friends, receiving physical and practical support, and practising religious rituals and diversional activities. These strategies were seen as valuable in controlling their reactions towards stressors, as stated below:

“There’s only one way: we’ve to think positively. If [we] always think negative, always crying, thinking of committing suicide, self-blaming, and all that, those negative feelings will come. We’ve to control our minds and emotion” (PT24, Malay).

“So that’s why I said this [pointing her head] should be prepared, put in all the data so you can survive. If you think you can’t, that could be an issue; your mentality couldn’t handle it, it all [depends] on yourself” (PT25, Indian).

The participants’ descriptions above indicated that they preferred to share their emotional distress with a trusted person, especially those who had some level of mothering experiences, such as friends, female family members, and neighbours. This non-professional personnel was perceived as reliable individuals to provide advice and support. However, some women reported that they sought information online, although its effectiveness was unknown:

“I went online to search [on] how to reduce stress. They said if you’re too stressed, look at [the] blue colour. It will reduce the stress” (PT15, Chinese).

Although the religious approach was also mentioned by three Chinese participants (one Buddhist and two Christians) and an Indian participant (Hindu), it was significant that all the Malay participants (all Muslims), repeatedly addressed it as an effective way to cope with their emotional distress. Prayers, reciting the Holy Book (Quran), and remembrance of God were commonly agreed as keeping them calm:

“I did dhikr [reciting Arabic verse to remember God], and it helped me to relax. That’s all I did” (PT7, Malay).

While the two Chinese Christian participants perceived reading the Bible and singing a religious song as keeping them ‘near with God’, an Indian participant stated that a special Hindu prayer could bring a positive mood in Indian mothers.

“I felt relaxed a bit. It’s because of the power” (PT21, Indian).

Although all the Malay participants described the religious approach as a helpful strategy, most Chinese participants reported that religious activities were neither applicable to them, nor effective in reducing emotional distress. There was no apparent reason for its non-effectiveness, but it seemed to be related to the deepness of their belief and consistency of their religious practice. Most participants also used diversional methods, such as playing with children, listening to music, cooking, eating, walking, exercising, reading books, browsing the internet, and watching television. It was clear from the participants’ explanations that their strategies to improve their PND experience were using self-help methods rather than seeking help from HCPs.

The analysis of participants’ descriptions indicated that their help-seeking behaviour was more likely to be influenced by their perceptions of the roles and responsibilities of HCPs and their feelings about the reaction of HCPs to their emotional distress. Most participants believed that the roles and responsibilities of HCPs were largely related to physical health and medical advice, but not emotional well-being. They also believed that their emotional distress was a personal problem and a less serious emotional condition. Below is a conversation between the interviewer and a participant:

Interviewer: How do you think they can help you in terms of reducing your stress?

PT30 (Indian): I don’t think so. They are more on the medical line; I don’t think they will help in psychology.

It was also because of the perception below that they had doubts about disclosing their emotional distress to the HCPs:

“You can share with them, but it doesn’t mean they will understand. Some will just listen to you. Some can give you advice, but not all are relevant, are they?” (PT12, Chinese).

Most participants seemed to think that their emotional distress was a personal issue that required no treatment from the HCPs. This thinking has kept them from realising that what they are experiencing was PND. This way of thinking seemed to be an important barrier to help-seeking as participants thought that emotional distress was only temporary and would get better over time. On the other hand, others thought that their PND experience had resulted from family problems. Therefore, they considered PNDas personal matters. Below are the participants’ descriptions on this matter:

“I think I can handle it. It’s just a disturbance. I think it’s just a temporary disturbance, a temporary disturbance. I don’t think it’s very severe” (PT7, Malay).

“That’s not their problem, they can’t settle it because that's my family's problem” (Jayanthi, PT27, Indian).

On the other hand, some participants appeared to believe that the HCPs had provided sufficient healthcare services, thus they should not demand more. The participants were used to following routine care, such as baby’s assessment, immunisation, antenatal education, and postnatal physical assessment. Therefore, they believed that they should not request care beyond the routine check-ups, as stated below by one of the participants:

“I think they’ve given us sufficient enough. They taught us about baby’s food matters and how to handle the baby. That was sufficient. I think everything is okay. Whatever they offer is already sufficient so far” (PT30, Indian).

Apart from that, some participants associated unreadiness to seek help with their past experiences in the healthcare settings and perceptions of HCPs’ behaviours. The HCPs were perceived as giving a brief, simple, and unsatisfying advice when they were approached. Some participants’ experiences indicated their lack of confidence in the HCPs due to various incidences, such as the nurse’s inability to explain the purpose of Hepatitis B vaccination, irrelevant description of the baby’s position during vaccination, unprofessional attitudes when questioned about family planning, derogatory expressions, and less focus in their care. Almost all participants thought that no particular attention had been given to maternal emotional well-being. Rather, HCPs were seen to focus only on family planning, breastfeeding, and child development. Below are the participants’ descriptions on this matter:

“They didn’t ask about me, not at all. They only asked about my baby” (PT34, Indian).

“The nurses didn’t ask like: “[Do] you have any problem?” They just ask about my baby’s health, and then they asked about family planning, that’s all, nothing on emotional things” (PT20, Indian).

Other participants described that the help-seeking process was difficult, particularly when one responded to their call for help. During the routine postnatal clinic and home visits, almost all participants felt that the HCPS did not pay particular attention to maternal mental health. Instead, the HCPS were seen to emphasise issues related to family planning, breastfeeding, and baby’s health and growth. Below are the participants’ descriptions on this matter:

“The nurses didn’t ask like, do you have any problem? They just ask about my baby’s health, and then they asked about family planning, that’s all, nothing on emotional things” (PT20, Indian).

“I don’t think they asked me before, never! I don’t remember” (PT26, Indian)

The participants also mentioned that the settings and infrastructure in most of the clinics were not suitable to talk about their problems. Generally, a consultation room is shared by two nurses. However, in the two selected clinics, the consultations were conducted in an open space, where at least two nurses performed consultations with mothers and children. At the same time, many of the participants appeared to express their frustrations about the mistreatment of their emotional distress, a few participants felt that the HCP's roles were limited by a large number of patients in the clinics. For instance, a participant stated that the HCPs were rushing to finish the consultation session because there were too many mothers attending the clinic, making it difficult to ask about their emotional health:

“They were less talking because of too many patients. It’s not easy to ask about that” (PT18, Chinese).

Existing literature suggested that there is less emphasis on the emotional aspects in the process of disease recognition and understanding PND within Malaysian primary healthcare setting [24]. There is also less attention to primary prevention such as training of HCPs working within MCH clinics that could enable them to screen for PND, to deal with cases, and to provide public education, awareness programmes and screening activities [24].Without such specific training, antenatal or postnatal women with any mental health issues (including PND) are commonly referred from MCH clinic to the psychiatric unit in the hospital. When it is required, they are then treated within the same psychiatric setting as patients with general depression and other psychiatric problems.

Consistently, participants in this present study believed that the accessibility of professional support would help improve their emotional well-being in the future. As stated below, participants repeatedly spoke of counselling and telephone-based support as alternative ways to share their feelings:

“For the counselling part, I guess they can give us support, motivation, can’t they?” (PT13, Malay).

“Maybe by advising, maybe sometimes, you know, maybe giving a call or asking the mother: [How] you’re doing, [is] the baby right? That would make the mother share their problems” (PT26, Indian).

There was also a suggestion for an extended health education session and a support group intervention led by a nurse. This group serves as a platform for the HCPs to share their vast experience of dealing with postnatal mothers. Below is a comment from a participant regarding this matter:

“I hope the nurses or doctors can give more information regarding becoming a first-time mother. This is our first baby, we know nothing, do we? It’s because sometimes when they advise us, it seems that they expect us to know everything. Of course, we wish we could be given more information. If they could conduct any seminar for the first-time mother, that would be great! Or they can give advice when we visit the clinic for check-ups. We need more and more advice. I wish they can do that” (PT7, Malay).

A participant also proposed the need for a more thorough assessment from HCPs:

“I guess their advice is okay, but maybe should be more details. I mean a longer time with the patients, right? No rushing” (PT23, Malay).