Perinatal depression is a significant public health problem occurring at a crucial point in the lives of mothers, increasing the risk of adverse consequences for their health and emotional well-being and those of their babies. Between 13% and 15% of mothers suffer from postpartum depression (Woody et al., 2017) worldwide, with a similar prevalence among Mexican women (Lara et al., 2015). The onset of depression during pregnancy is also common, with rates ranging from 9.2% to 19.2% (Lara et al., 2015; Woody et al., 2017). This prevalence is significantly higher in women in low- and middle-income countries than in high-income countries (Woody et al., 2017).

The consequences of untreated maternal depression are of particular concern. During pregnancy, it increases the risk of preterm birth, small-for-gestational-age newborns, and low birth weight, as well as maternal perinatal complications and the risk of postpartum depression (PPD) (Jahan et al., 2021). Untreated PPD is known to be a key risk factor for the quality of mother-infant interactions and child development (Slomian et al., 2019; Stein et al., 2014), even if depression symptoms are only subclinical (Tronick & Reck, 2009).

Randomized controlled trials (RCTs) of psychological interventions show that PPD can be prevented by reducing depression symptoms (Branquinho et al., 2021; Morrell et al., 2016; Muñoz et al., 2021). In Mexico, an RCT of a PPD preventive intervention implemented during pregnancy in a sample of women at risk of depression showed that the incidence of depression can be reduced (Lara et al., 2010).

Results of the effectiveness of evidence-based interventions (EBIs) are often not translated into care protocols that can easily¹ be adopted, and are therefore not disseminated or implemented in everyday practice (Battaglia & Glasgow, 2018), despite being urgently needed given the prevalence of PPD. In this respect, it has been documented that between 50% and 70% of women with perinatal depression are not identified timely, approximately 85% do not receive treatment, 91%-93% do not receive adequate treatment and 95%-97% continue to suffer symptoms without remission (Cox et al., 2016).

Implementation science emerged to address the gap between research and clinical and community contexts. Implementation involves the processes and factors associated with successfully incorporating proven interventions into a particular setting and the process and factors leading to the target population’s widespread use of these interventions (Shelton et al., 2020). The implementation of an intervention by professionals at an institution constitutes a significant step towards fine-tuning as it informs on their perspective on aspects such as barriers, compatibility with work schedules, additional training needs of professionals, and workflow (Mol et al., 2019).

A systematic review on the barriers and facilitators to implementing perinatal mental health care in health and social care settings showed that barriers to PPD screening, referral, and treatment measures included professionals’ lack of self-confidence in carrying them out and the sense that they lack sufficient training (Webb et al., 2021). Facilitators stressed the need for health-care professionals to have an open, non-critical attitude towards patients and a genuine interest in women’s needs (Webb et al., 2021). Al-abril et al. (2023) explore the experiences of a wide range of healthcare professionals, including nurses, midwives, and general practitioners, with varying years of experience in primary antenatal, peri- and postnatal care. Challenges professionals encountered with their patients included the need or desire for effective support from the health system in terms of training and providing clear protocols and guidelines for the detection and management of prenatal, peri and postnatal depression.

Health systems in certain countries, particularly higher-income countries (HICs), have incorporated perinatal mental health care into pregnancy care services (Buist et al., 2008; Milgrom & Gemmill, 2014), which is conducive to implementing evidence-based strategies. In low- and middle-income countries (LMICs), such as Mexico, though perinatal mental health has not been given enough importance, and although there are official standards in this country specifying its care, its application is not mandatory, the mechanisms for its implementation are not specified, and it fails to provide health services with the required specialized mental health personnel (Navarrete et al., 2022). The authors document the absence of systematic implementation of evidence-based interventions designed to detect, prevent, and treat perinatal depression.

As already noted, PPD has negative consequences on the emotional well-being and health of the mother, the unborn baby, and the infant, and without proper care, mothers may continue to suffer from it for months or years (Jahan et al., 2021; Slomian et al., 2019). The process of making the Postpartum Depression Intervention (PPD-PI) available to others was initiated through training courses for professionals in contact with perinatal women to provide them with the tools to identify and attend to women with PPD symptoms.

Perinatal depression, the most frequent complication of pregnancy and the postpartum period is associated with adverse obstetric, maternal, and neonatal effects (Woody et al., 2017). Nevertheless, in many countries, including Mexico, PPD is neither systematically addressed nor treated as a health priority (Navarrete et al., 2022). Furthermore, while evidence-based interventions (EBIs) are poorly implemented in the health systems and professional practice of High-Income Countries (HICs) (Battaglia & Glasgow, 2018), the challenges are significantly compounded in Low- and Middle-Income Countries (Martínez et al., 2016).

In this context, the objective of the study was to evaluate the implementation of the PPD-PI in professionals attending perinatal women in various contexts (public and private sectors, NGOs and private practice), regarding satisfaction with the course, its usefulness, barriers and adaptations to its uptake in their work environment.

The professionals who received the training expressed satisfaction with the course in achieving objectives, acquiring knowledge, developing skills, and group activities, with no significant differences between work environments. Overall, training provided healthcare professionals with the tools to support women during pregnancy and postpartum and to address their mental health, while the training course and the accompanying educational materials constituted a useful strategy for disseminating PPD-PI among the target population. Developing educational materials and conducting educational sessions is a common implementation strategy to support women during the perinatal period (Taple et al., 2022). The professionals who received the training consider that improving the knowledge and skills required to identify perinatal depression in obstetric service providers is a fundamental part of any intervention to ensure that perinatal women receive better care (Byatt et al., 2021).

Half (56.7%) of the professionals reported having implemented the intervention. In the literature, implementation refers to an organization or community’s decision to commit to or begin adopting an evidence-based intervention (EBI) (Rabin et al., 2008). In this case, the professionals decided to implement it in addition to their professional and institutional responsibilities. These data indicate a clear need for tools to support the perinatal women they serve. However, the uptake of the PPD-PI was evaluated very generally without requesting specific information on the situations in which it was implemented, or the characteristics of the population to which it was provided. Despite this shortcoming, what is important about these data is that at least some elements of the course proved useful for the professional’s attending women whom they thought had symptoms of depression or other emotional problems in a range of contexts.

Having been trained in the PPD-PI was useful in their everyday work for the majority (87.5%-100%) of those who were employed. The first reason it was useful for them has to do with the first barriers to perinatal mental health care: lack of knowledge (Tabb et al., 2015). In this respect, the trained professionals thought it was useful because they acquired the knowledge and tools to support the women they attended during this period. The second reason was that they developed greater empathy towards the women they attended. This result is a pivotal finding given the lack of empathy, disinterest, and prejudice perinatal women perceive regarding their mental health in prenatal care (Lara et al., 2014; Navarrete et al., 2022).

Most participants (90.5%) adapted certain aspects of the PPD-PI to implement it effectively within their work context. The main changes involved the sequence of topics, the number of sessions, and the choice of activities suited to their specific situation. Bina et al. (2018) noted that the rigidity often associated with EBIs hinders their implementation in primary care services. This is especially apparent in the number of sessions needed and the topics to be covered. The latter indicates that it is essential to tailor EBIs to the specific needs of the context for effective implementation in everyday practice. This adaptation allows researchers to advance to the next stage, which involves disseminating the intervention, implementing it, and continuing its development (Wampold & Imel, 2015). The next step in the implementation process is to evaluate the modified interventions to reduce the risk of postpartum depression and compare them with the original design (Lara et al., 2010).

The need for adaptations raises essential questions about fidelity and the effectiveness of interventions aimed at preventing depression. This issue is significant not only for the beneficiaries but also for the professionals responsible for making adaptations. These individuals must determine which changes to implement while adhering to the original intervention (von Thiele Schwarz et al., 2020). The authors highlight the challenge of balancing fidelity and adaptation when applying EBIs to ensure they are suitable for specific contexts while achieving results comparable to the original version. In the case of PPD-PI, the initiative was initiated by professionals working with perinatal women rather than by the institutions they are affiliated with. To have the support of their institution to implement the program, health professionals must adjust the intervention to meet their pre-established daily activities.

Barriers to implementation are widely recognized, as much evidence-based interventions (EBIs) have not been designed for a single perinatal context (Overbeck et al., 2016). The practitioners in our study identified a lack of time, resources, and institutional support as the most significant limitations. Other studies have also noted an excessive institutional workload as a barrier to the implementation of health programs (Al-Abri et al., 2023). Implementing the intervention is not only an institutional decision, which creates barriers for professionals who wish to provide it. This highlights the need to advocate for decision-makers to acknowledge the importance of this type of intervention. Additionally, there is a need for a regulatory framework that supports its adoption and implementation.

The professionals observed improvements in the women who received the intervention, although this assessment is subjective and not based on the evaluation of depressive symptoms, health professionals observe that PPD-IP benefits the expression of positive emotions in perinatal women. The professionals perceive the women as feeling more empowered, experiencing improved moods, having more positive feelings towards their roles as mothers, and engaging in more self-care behaviors. These findings are consistent with the subjective evaluations reported by the women who participated in the controlled study in which the PPD-IP was evaluated (Lara et al., 2010).

The health-care professionals found the content to be useful, as it equipped them with the knowledge and strategies necessary for working with perinatal women who may be experiencing depression. Most of these professionals needed to make changes to adapt the intervention to their specific work environments and to overcome barriers, mainly due to a lack of institutional support. They noted improvements in the women they served, aligning with the program’s objectives.

These findings constitute an initial approach to implementing EBIs in Mexico, but they have several limitations. The most significant limitation is the general nature of the questions in the questionnaire, which need to address how PPD-PI was applied. Additionally, the study did not measure the participants’ levels of depression or any potential changes in those levels.

On an international scale, there is growing concern regarding the need for rigorous qualitative evaluations of the implementation of EBIs (Toews et al., 2016). This paper makes a modest contribution to the limited research on the and implementation of EBIs, particularly concerning the phenomenon of PPD and its detection, prevention, and treatment within health systems. The aim is to show what is achievable and use these findings as a foundation for improving strategies to address this issue.