Experiences of a postpartum depression prevention programme in a circumpolar setting: insights from pregnant women and healthcare providers

Abstract

Supporting maternal mental health is a priority in circumpolar settings, where seasonality and constrained service availability can limit psychosocial support. This qualitative study explored pregnant women’s and healthcare providers’ experiences of a postpartum depression prevention programme and perspectives on integrating it into routine antenatal care in Arkhangelsk, Northwest Russia. Four focus group discussions with pregnant women (n = 17) and individual interviews with four healthcare providers were analysed using reflexive thematic analysis. Participants described the programme as providing trusting spaces for sharing, expert-led preparation for childbirth and the postpartum period, and brief individual follow-up after birth. Women reported greater confidence in identifying signs of vulnerability, articulating needs, and accessing support. Providers highlighted that these benefits depended on feasible scheduling, group formats, reusable materials, and coordinated delivery across professionals to avoid fragmentation. System-level factors (reach, retention, and cross-provider coordination) were seen as central for sustained uptake and routine integration. The findings suggest that the programme’s contribution lies in the interaction between participant experiences of support and the organisational conditions needeed to sustain them in routine antenatal care. Preventive perinatal mental health programmes in circumpolar contexts can strengthen preparedness and help-seeking when designed for relational participation and supported by coordinated service structures.

Introduction

Maternal mental health in the postpartum period is a key determinant of maternal well-being and early child development, particularly during the first 1,000 days of life [1,2]. Postpartum depression (PPD) is a common non-psychotic depressive episode occurring after childbirth and can include emotional, behavioural and physiological symptoms that persist for months [3–5]. The postpartum (maternity) blues are a transient emotional disturbance affecting up to 83% of women and usually resolve without treatment; however, unrecognised or persistent distress may progress to PPD [6–8]. Postpartum psychosis is rare but constitutes a psychiatric emergency [9].

PPD can compromise mother-infant bonding, reduce breastfeeding, and disrupt parenting practices, and it is associated with adverse child developmental outcomes [10]. It is also linked to increased risk of family conflict and reduced maternal quality of life [11]. These consequences strengthen the case for preventive and early-response strategies, especially where access to specialist mental health services is limited.

Globally, PPD affects an estimated 17.2% of women, with prevalence varying by care practices, screening thresholds and diagnostic approaches [12]. In Russia, one study reported a prevalence of 34.3% [13]. Evidence from circumpolar settings remains limited and methodologically heterogeneous: studies from Iceland, Greenland and Norway report rates of 6.5%, 8.6% and 10%, respectively [14–16]. In Arctic Russia, population-based prevalence estimates remain unavailable; however, local data from Arkhangelsk indicate that 21.2% of women screened positive for depressive symptoms in the early postpartum period using the Edinburgh Postnatal Depression Scale (EPDS) [17].

Arctic regions remain under-researched in global mental health, despite environmental and infrastructural conditions that can shape both distress and access to support [18]. Arkhangelsk is a northern urban centre with existing mental health infrastructure [19], yet psychosocial support is unevenly accessible and preventive sessions for pregnant women are not systematically offered [20]. Seasonal constraints, including long, dark winters, may further influence perinatal well-being and the feasibility of attending support in person [21–23].

Local histories may also shape expectations of care and help-seeking. The term Pomorje (“coastland”) is used in historical and ethnographic literature to describe parts of the White Sea littoral shaped by maritime livelihoods [24,25]. Such histories, alongside contemporary shifts towards greater paternal involvement, may influence what kinds of support are perceived as appropriate, timely and trustworthy [26,27].

Recognising psychosocial support during pregnancy as a key preventive strategy has gained increasing attention in the international literature. A systematic review and meta-analysis of universal antenatal psychological interventions reported a significant reduction in maternal distress compared with routine care, including depressive symptoms (Cohen’s d, standardised mean difference = 0.50, 95% CI 0.32–0.67) and stress (d = 0.52, 95% CI 0.28–0.75) [28]. A prospective study in Poland further found that higher perceived and received social support during pregnancy, including emotional, instrumental, and informational dimensions was associated with a lower risk of postpartum depression [29]. However, little is known about how preventive antenatal psychosocial programmes are experienced and quantified within routine antenatal care pathways in Arctic urban settings, where climatic, geographic, and structural conditions may shape both access to and delivery of support.

The Happy Birth programme was designed locally in response to a qualitative needs assessment in Arkhangelsk that identified low PPD awareness among pregnant women and midwives, limited time for psychological counselling in routine visits, and mismatches between women’s expectations and available support [20]. Embedded in routine antenatal care, Happy Birth combines childbirth and early parenting education with perinatal mental health literacy, facilitated emotional expression and family involvement.

This study aimed to explore pregnant women’s and healthcare providers’ experiences of the Happy Birth programme and their perspectives on how it could be integrated into routine antenatal care in a circumpolar setting. In doing so, the study sought to understand both how participants experienced programme support and what organisational conditions were considered important for its delivery within routine Arctic antenatal care.

Methods

Study design

We conducted a qualitative study using individual in-depth semi-structured interviews and focus group discussions (FGDs). Topic guides used open-ended prompts to elicit participants’ own framings of the programme and its fit within routine antenatal care. Focus group procedures followed established guidance for planning and facilitation [30]. Using both methods enabled us to examine individual sense-making (interviews) and interactional meaning-making in group settings (FGDs). This combination strengthened contextual understanding of perceived benefits, challenges, and implementation conditions.

A qualitative study design was chosen to document local care pathways, staffing and access constraints, and culturally shaped expectations of support in Arctic maternity care, alongside the Happy Birth programme model, thereby facilitating assessment of the transferability of findings to maternity care settings with comparable organisational and contextual characteristics.

Setting

The Arkhangelsk Region is a geographically extensive circumpolar setting in the European Russian North. Its territory is comparable in size to France and extends from boreal forest areas to Arctic coastal and island territories [31] and officially included in the Arctic Zone of the Russian Federation [32]. The region has a population of approximately one million residents, of whom about 78% live in urban areas and 54% are women [33]. The region has historically been home to diverse ethnic groups, including Indigenous and traditional northern populations [34]. Although Indigenous peoples constitute a small proportion of the current population, they include the Nenets, Komi, Saami and other groups, with the Nenets representing the principal Indigenous Arctic population associated with the region [35]. Specialised maternity and referral services are organised within a regional three-level care system [36]: Level I is outpatient antenatal and postnatal care, including the Arkhangelsk City Polyclinic where this study was conducted, Level II is inpatient obstetric care for moderate-risk cases, and Level III is tertiary referral care represented by the Perinatal Centre at the Arkhangelsk Regional Clinical Hospital. The study was conducted at a municipal antenatal clinic (Level I) in Arkhangelsk, where participants were recruited.

Programme overview

Happy Birth is a state-funded antenatal programme integrated into routine care at the obstetrics clinic of the Arkhangelsk City Polyclinic. It has been implemented since November 2018. The programme was co-designed by an interdisciplinary clinic team (a midwife, a perinatal psychologist, a breastfeeding consultant, and a perinatal exercise specialist) to adapt established antenatal education and mind-body preparation approaches to local needs. It aims to strengthen preparedness for childbirth and early parenting by combining practical skills with perinatal mental health literacy and low-barrier opportunities for reflection and support-seeking. Participation is free under the compulsory medical insurance scheme. Women are usually referred by their midwife/obstetrician at 24–30 weeks’ gestation, with partners invited when possible. The programme is delivered in person and online to support access under seasonal and transport constraints.

The three-week curriculum comprises 14 small-group sessions (≤8 participants) and includes brief individual contacts before and after birth. Core components include: 1) facilitated mental health education and discussion that normalise emotional responses and clarify thresholds for help-seeking; 2) midwife-led sessions on labour physiology, safety, and early postnatal care; 3) structured breathing, relaxation, and safe prenatal movement; and 4) breastfeeding education with practical troubleshooting. The team delivers the programme using a shared plan with cross-cover arrangements, and missed modules can be re-attended in a later cycle.

Participants and recruitment

Study participants comprised two groups: (1) pregnant women who had attended more than one Happy Birth session and (2) healthcare providers involved in programme delivery, with expertise in midwifery, psychology, breastfeeding support, and perinatal exercise. In this paper, we use the term pregnant women because all study participants self-identified as women and maternity services in the study setting are organised around this terminology. We acknowledge that pregnancy may also be experienced by individuals with diverse gender identities. Focus group quotations are attributed using anonymised identifiers indicating the participant (PW) and the focus group discussion (FGD) (e.g. PW2, FGD3, where PW2 denotes participant 2 and FGD3 denotes focus group 3). To minimise the risk of deductive disclosure given the small healthcare provider (HP) sample, we use anonymised identifiers (HP1 - HP4) and do not report individual professional roles.

We used purposive sampling to capture variation in parity (primiparous/multiparous), age, gestational age (24–38 weeks), and programme exposure (number of sessions attended; participation format: in person, online, or hybrid; partner presence during sessions; and any re-attendance). Pregnant women were approached through programme and clinic channels (text, phone invitations). At the end of the final programme session, participants were invited to take part in a focus group discussion held immediately afterwards to discuss the programme. Participation was entirely voluntary. Healthcare providers were invited in person at their workplace. We applied no clinical exclusion criteria (pregnancy complications did not preclude participation) and did not access medical records; any health information discussed was self-reported.

Of the 24 individuals who initially agreed to participate, three were unable to attend the scheduled session. The final sample comprised 21 participants (17 pregnant women and four healthcare providers). Participant characteristics are summarised in Table 1.

Table 1.

Characteristics of participants.

Characteristic	Healthcare providers (n = 4)	Pregnant women (n = 17)
Age range (years)	40–55	<25 (15%), 25–34 (60%), ≥35 (25%)
Gestational week	Not applicable (N/A)	24–28 (15%), 29–31 (15%), 32–35 (40%), 36–38 (30%)
Parity	N/A	Primiparous (60%), Multiparous (40%)
Number of modules attended	N/A	1 (5%), 2 (10%), ≥3 (85%)
Format	N/A	In-person (90%), Online (5%), Hybrid (5%)
Partner attendance	N/A	Yes (30%), No (70%)
Quotation label used in Results	HP1-HP4 (programme-affiliated healthcare providers)	FGD1-FGD4, PW1-PW5 (PW identifiers are unique within each focus group)

Data collection

We conducted four in-person focus group discussions with pregnant women (n = 17; 40–50 minutes each) and four individual semi-structured interviews with healthcare providers involved in programme delivery; three interviews were conducted in person and one by telephone due to scheduling constraints. Focus group size ranged from three to five participants due to availability on the scheduled days (one group of three, two groups of five, and one group of four). All sessions were conducted in Russian, audio-recorded, transcribed verbatim, and de-identified.

Two topic guides, one for focus groups and one for interviews, were developed drawing on the prior local needs assessment [20], the study aims, and relevant research on antenatal support, parenting preparation, and circumpolar service contexts [28,37]. Guides covered perceived usefulness and emotional safety; coordination across the interdisciplinary team and consistency of messaging; access and session format (including seasonal and weather-related constraints when relevant); partner roles; and suggestions for improvement. Field notes captured session logistics and group dynamics, and positionality notes and brief post-session debriefs documented reflexive considerations. Focus groups and interviews were conducted between February and September 2024.

Researcher roles and reflexivity

The first author is an independent qualitative researcher and perinatal support professional, who was not employed by the clinic or health services delivering the Happy Birth programme and had no clinical, care, or teaching relationships with participants. She contributed to the programme’s conceptual development but had no role in its funding, staffing, or delivery. The first author conducted all focus groups and interviews. Participants were informed of her independent role and that participation would not affect access to services. Her background in public health and perinatal support informed the development of topic guides and the interpretation of emotional and relational aspects of care. Reflexive memo-writing and regular team discussions were used throughout data collection and analysis to consider how researcher positioning and prior experience might shape data generation and interpretation.

Analytic approach and theoretical stance

We conducted a reflexive thematic analysis (RTA) as outlined by Braun and Clarke [38], situated within a constructivist-interpretivist epistemology [39,40], that understands meanings as co-constructed between participants and researchers and shaped by context. This approach aligned with the study aim of exploring how pregnant women and healthcare providers experienced the Happy Birth programme and understood its delivery within routine antenatal care in an Arctic setting. Coding and theme development were primarily inductive and attended to both semantic and latent meanings. Reflexive discussions and analytic memo-writing supported ongoing interpretation throughout the analytic process.

Analysis

We followed Braun and Clarke’s six phases of RTA: familiarisation with the data; coding; generating initial themes; reviewing and refining themes; defining and naming themes; and producing the report. Familiarisation involved repeated reading of transcripts and analytic note-taking. Pregnant women’s and healthcare providers’ transcripts were initially coded separately to retain differences in lived experience and programme roles. The datasets were subsequently brought together through an integrative synthesis that examined areas of convergence and divergence across accounts, particularly regarding emotional support, preparation for birth, help-seeking, and programme delivery. Throughout the process, analytic memos documented theme development and key interpretive decisions. Table 2 provides an illustrative example of the analytic pathway from data extract to initial code, sub-theme, and overarching theme across participant groups. Quotes are presented in English translation and labelled by data source (FGD1-FGD4, PW1-PW5) or (HP1-HP4).

Table 2.

Example of the coding and theme development process.

Data source and extract (translated from Russian)	Initial code	Sub-theme	Theme	Brief analytic note
“At first the picture was blurry, but now everything has been put into clear order.” (FGD4)	Gaining structure reduces uncertainty	Sense-making as reassurance	Cognitive and embodied preparation: sense-making, expectations, and embodied resources	Information is valued not as “content” but as an organising frame that reduces uncertainty and supports calmer appraisal and decision-making.
“If a woman doesn’t understand what it is for, she is unlikely to do it.” (HP1)	Meaning enables practice	From knowledge to enactment	Cognitive and embodied preparation: sense-making, expectations, and embodied resources	Professionals frame “preparedness” as contingent on coherence: practices are taken up only when linked to a personally meaningful rationale.

Analytic reflexivity was maintained through systematic returns to the transcript wording after initial coding, exploration of alternative readings, and documentation of points where EN’s professional and personal experience might shape interpretation. Ambiguous cases were discussed with co-authors to explore multiple plausible interpretations. A brief reflexive checklist supported consistent reflexive engagement during coding and theme development. Initial coding was conducted by EN. Theme development and refinement were undertaken through iterative analytic meetings across the author team (EN, JJI, ED). Across these discussions, authors brought complementary perspectives from qualitative health research, perinatal care, and circumpolar/regional health contexts, which helped interrogate assumptions and strengthen interpretive depth. Coding and memo management were supported by OpenCode (Umeå University), facilitating organisation of inductive codes, iterative refinement, and cross-group comparison.

Trustworthiness

We used multiple, epistemologically consistent strategies to support rigour and trustworthiness in line with RTA [38]. An audit trail was maintained throughout the study, including analytic memos, theme maps, and decision logs documenting code development, code merges/splits, and theme re-scoping, as well as brief minutes from analytic meetings. This enhanced dependability by making key analytic decisions transparent without implying procedural reproducibility, consistent with the foundations of RTA. Credibility was supported by grounding interpretations in the data through verbatim quotations, iterative checking of developing themes against full transcripts, and critical discussion within the team. We also attended to deviant or minority accounts to retain alternative perspectives rather than smoothing them over during theme development.

We examined convergence and divergence across (1) data sources (pregnant women and healthcare providers) and (2) researcher perspectives (EN’s primary analysis, supplemented by subset coding and team discussion), to strengthen the robustness of our interpretive claims while remaining consistent with a reflexive, non-positivist approach.

To support transferability, we provide contextual information on the Arctic healthcare setting, population, and programme model within the main text, enabling readers to assess the relevance of findings to other rural, remote, or underserved maternal health settings.

Ethical considerations

Ethical approvals were obtained from the Regional Committee for Medical and Health Research Ethics of Central Norway (REK 134185, 2019) and the Local Ethical Committee of the Northern State Medical University, Arkhangelsk (Protocol 05/11-19). Written informed consent was obtained for focus group discussions, and recorded oral consent for telephone interviews. Participation was voluntary; participants could decline to answer any question and withdraw at any time without consequences for their care or employment. All recordings and transcripts were de-identified, stored securely, and accessible only to the research team. The study was conducted in accordance with the Declaration of Helsinki and relevant publication ethics guidance.

Given the sensitivity of discussing pregnancy-related emotions and care experiences, the interviewer used a supportive, non-judgemental approach and participants could pause, skip questions, or stop the discussion at any time.

Results

Four themes describe pregnant women’s and healthcare providers’ experiences of the Happy Birth programme, and the contextual and organisational conditions shaping its perceived feasibility and value within routine antenatal care. Themes are summarised in Table 3.

Table 3.

Overview of themes and sub-themes.

Themes	Sub-themes
Participation: relational and interactional conditions	Belonging and emotional safety in the group Partner and family involvement as uneven support
Cognitive and practical preparation	Sense-making and expectation-setting Embodied coping tools for self-regulation Making it usable in everyday life
Postpartum vulnerability and navigation to support	Recognising vulnerability Turning recognition into help-seeking Navigating support after birth
System conditions for delivery and implementation	Access, reach, and format constraints Coordination across healthcare providers Routinisation under time constraints

Participation as relational and interactional work

Participation was experienced as relational rather than purely informational. Pregnant women emphasised peer belonging as a way to reduce isolation, while healthcare providers highlighted facilitation and clear boundaries as conditions for emotional safety.

Belonging and emotional safety in the group

Pregnant women described in-person sessions as a form of peer validation, particularly when maternity leave narrowed everyday social contact: “Especially when you’re already on maternity leave, it’s a reason to go out and see that, apart from your partner, there are other people” (FGD3, PW3). Healthcare providers framed emotional safety as something that needs active support through facilitation, including boundaries that prevent discussions from becoming overwhelming: “For some it feels easier, but others … can pick up other people’s fears” (HP2). Together, these accounts suggest that perceived benefit depended not only on content but on how group interactions were held and guided.

Partner and family involvement as uneven support

Across datasets, partners were positioned as potentially important sources of support, although involvement was uneven. Pregnant women described wanting to share programme content at home to align expectations and prepare partners: “Right after the session I wanted to go and tell my husband about it, so I could prepare him in advance” (FGD1, PW5). Healthcare providers similarly noted that participation could increase partners’ confidence in offering support, while also describing limited uptake: “On my sessions, not many partners come … out of 10 women, about two or three partners” (HP4). In programme terms, these findings indicate that relational benefits may be strengthened by clearer, low-effort ways to involve partners (e.g. short take-home summaries), while maintaining group boundaries that protect emotional safety.

This theme sets the stage for the next: preparedness depended on whether information and techniques became workable resources beyond the session.

Cognitive and practical preparation

Participation supported preparedness by combining facilitated explanation and expectation-setting with practical techniques that women could realistically remember and use in daily life.

Sense-making and expectation-setting

Healthcare providers described explaining bodily changes and what to expect during pregnancy and birth: “My role was to explain the woman’s body … what processes take place during pregnancy and during birth” (HP1). Pregnant women linked this to reduced uncertainty and less reliance on online searching: “It’s easier when you understand what to expect … you can choose ways to deal with it - without having to search online” (FGD1, PW4). These accounts suggest that perceived preparedness was partly produced through structured sense-making, not only through “information provision”.

Embodied coping tools for self-regulation

Pregnant women described breathing and movement techniques as immediately usable for calming: “I felt calmer after the breathing sessions for labour” (FGD1, PW1) and “I remember the belly-breathing technique … I start calming down, and … my pulse normalised” (FGD3, PW3). Healthcare providers framed these techniques as feasible in brief periods after birth: “These breathing techniques can be a recovery resource after birth … if she has two free minutes while feeding the baby, she can use them” (HP3). Taken together, these accounts indicate that “practicality” meant time-efficient tools that could be used in short windows under postnatal constraints.

Making it usable in everyday life

Across datasets, preparedness was evaluated in terms of transfer to real-life conditions. Healthcare providers emphasised that uptake depended on understanding the rationale: “If a woman does not understand why she is doing it, she is unlikely to do it” (HP1). Some pregnant women were uncertain about using techniques across settings: “I can’t imagine how I will use these techniques in the postnatal ward” (FGD1, PW5). Others in the same focus group echoed this uncertainty, while another participant emphasised the value of low-threshold options that reduced travel burden: “It’s easier to call than to travel specifically and book an appointment” (FGD1, PW3). For programme delivery, this points to the value of short explanations of why the techniques may work alongside practice opportunities, and of formats that remain workable when mobility and time are limited. Preparedness became most salient in the next theme, when women described recognising postnatal difficulties and navigating pathways to support.

Postnatal vulnerability and navigation to support

The early postnatal period was described as a high-demand transition. Programme value was framed less as “prevention” and more as supporting recognition of postnatal vulnerability and making support pathways feel more accessible in practice.

Recognising vulnerability

Pregnant women noted that postnatal content could feel distant during pregnancy, even when questions remained: “That topic - I didn’t really remember it … I still have questions about the postpartum state … You don’t really think it could affect you” (FGD2, PW1). At the same time, recognition work was described as normalising: “It was important to know it’s normal … so if I feel it, it’s not that something is wrong with me” (FGD3, PW1). Healthcare providers similarly described postnatal vulnerability as increased demands and reduced control: “When you’re in contact with a newborn … the idea that I can control everything shows its failure … after birth I have very little control” (HP2). These accounts suggest the programme’s role may lie in shifting thresholds for recognising when support is warranted, rather than promising to avert distress.

Turning recognition into help-seeking

Across datasets, thresholds and next steps were described as particularly useful when fatigue and uncertainty make decisions harder. Pregnant women highlighted a timeframe as a cue for action: “I learned there are timeframes—for example, if baby blues doesn’t pass within two weeks, then you need to seek help” (FGD1, PW5). Healthcare providers situated this within routine pathways while noting constraints: “Women know they can ask for a referral at the five-week visit, even if the gynaecologist is busy … only 10 minutes for the check-up” (HP3). In programme terms, this indicates the value of concrete, easy-to-remember “decision cues” and clearly signposted pathways that fit within short postnatal contacts.

Navigating support after birth

Feasibility of accessing support was repeatedly emphasised. Pregnant women preferred routes that reduced travel and logistical burden: “It’s easier to call than to travel specifically and book an appointment” (FGD1, PW3). In FGD3, women built on this point by proposing continuity formats better aligned with postnatal routines: “It might be more convenient to organise a webinar after birth, so everyone can listen at home” (FGD3, PW2), and another participant added “to keep a shared chat where we can ask questions even after birth” (FGD3, PW1). Healthcare providers echoed the gap between formal availability and practical accessibility: “Women can sign up at reception … the psychologist’s door is always open … [but] if she has the baby in her arms, it becomes more difficult” (HP2). Together, these accounts suggest pathways to support were seen as workable only when they were low-threshold and designed around the realities of early postnatal life.

These requirements were developed further in the next theme through system capacity and implementation arrangements.

System conditions for delivery and implementation

Programme feasibility depended on system capacity (time, staffing, routinisation) and delivery arrangements that made participation and follow-up workable within routine care.

Access, reach, and format constraints

Access was shaped by how women learned about the programme and by whether delivery formats were workable under local constraints. Women described digital barriers alongside reliance on remote options: “I had difficulties installing the app … then I couldn’t find the recording - but I really need these sessions because I couldn’t attend in person” (FGD1, PW5). Others highlighted distance-related feasibility: “Online was comfortable … we live far away, so I didn’t have to spend time and money travelling” (FGD2, PW1). Healthcare providers pointed to overloaded routine consultations as a constraint on reach: “Information about courses often doesn’t reach women … it may be the overload of routine appointments” (HP2). These accounts indicate that reach depended on both communication pathways inside routine care and the usability of digital/remote formats.

Coordination across healthcare providers

Healthcare providers described delivery as parallel rather than integrated, limiting shared monitoring and consistent messaging: “I feel quite isolated from other specialists in this programme” (HP2) and “Each specialist is in their own field” (HP4). Pregnant women’s accounts suggested coordination mattered most at transition points when practical guidance was needed: “It was helpful that the midwife explained … how to go to the maternity hospital, what to take” (FGD3, PW3). In implementation terms, perceived value was linked to coordination that makes the programme feel like a coherent pathway rather than a set of disconnected sessions.

Routinisation under time constraints

Accounts highlighted tensions between routinisation and responsive tailoring under persistent time constraints. Recruitment and routinisation were described as uneven: “Doctors at the antenatal clinic do not often recommend the programme … there is no time for the district gynaecologist. More often women see the timetable on the door” (HP1) and “Recommendations don’t come from all districts - only from certain doctors; it’s not yet in the system” (HP3). Time pressure was explicit: “There are 12 minutes per patient” (HP2). Postnatal follow-up was also described as compressed: “At the five-week (after birth) visit … only 10 minutes for the check-up” (HP3). Overall, pregnant women emphasised feasibility as lived constraints (distance, digital access, and willingness to speak depending on format), whereas healthcare providers emphasised structural limits (short appointments, uneven routinisation, and weak coordination).

Together, the four themes suggest that relational participation and preparedness carry over into the postnatal period only when pathways to support are low-threshold and implementation is operationally supported.

Discussion

This study explored how pregnant women and healthcare providers experienced the Happy Birth programme and what organisational conditions they considered important for its integration into routine antenatal care in an Arctic setting. The findings suggest that the programme’s contribution lies in the ways participants experienced support through emotional safety, structured sense-making, and clearer pathways for recognising vulnerability and seeking help, while also highlighting the conditions required for these experiences to be sustained within routine care. Although the programme is framed as preventive, participants did not primarily describe it as preventing distress. Instead, they experienced it as a relational and pathway-oriented intervention that supports (a) emotional safety and engagement, (b) structured sense-making with usable coping tools, and (c) earlier recognition of vulnerability with easier transitions into support. Across accounts, the programme’s contribution was therefore less about avoiding difficulty and more about strengthening recognition, meaning-making, and navigability under service and geographical constraints.

Participants’ descriptions suggested a coherent mechanism pathway: relational safety fostered engagement and willingness to address sensitive topics; engagement enabled sense-making and uptake of embodied or practical tools; these in turn sharpened recognition cues and shifted perceived thresholds for action; and clearer thresholds made pathways more navigable when time, distance, and capacity were limited. Our data thus specify an experience-based chain linking relational conditions to help-seeking readiness within constrained care.

The programme’s perceived value was closely tied to relational participation. Pregnant women emphasised peer belonging and reduced isolation, whereas healthcare providers emphasised facilitation and boundaries as conditions for emotional safety. This indicates that programme effects were not limited to information transfer. Rather, the group format appeared to support emotional safety and peer validation, shaping whether participants could engage with sensitive topics and use the sessions as a meaningful resource. This is consistent with wider qualitative evidence that relational conditions - trust, non-judgement, and perceived safety are central to engagement with perinatal psychosocial support and to whether women view help-seeking as acceptable and feasible [41,42]. Our findings specify, in an Arctic context, how facilitation practices and boundary-setting were understood as the practical conditions that made emotional safety possible within the group format.

Participants described preparation as a practical outcome of the programme’s explanatory and skills-based components. Healthcare providers emphasised explaining bodily changes and what to expect during pregnancy and birth, and pregnant women linked this to reduced uncertainty and less reliance on online searching. Women also described breathing and movement techniques as usable for calming, while providers noted that these techniques could be applied in brief periods after birth. This is consistent with literature suggesting that feasibility and integration into everyday routines are central to how antenatal psychosocial programmes are taken up and experienced by participants [43,44]. Our data indicate that participants defined usefulness not as mastering programme content, but as having a concise, readily applicable set of tools and explanations that could be drawn on under fatigue and time pressure.

Participants most often framed the programme’s preventive contribution in terms of supporting recognition of postnatal vulnerability and enabling navigation to appropriate support, rather than in terms of avoiding emotional difficulty. Women noted that postnatal topics could feel distant during pregnancy, yet valued concrete cues and timeframes for deciding when to seek help. Healthcare providers highlighted that formal availability of referral pathways did not ensure practical access, particularly under short appointments and postnatal constraints. This suggests that prevention, as experienced by participants, was linked to earlier recognition of vulnerability, clearer thresholds for action, and reduced friction in moving from recognition to help-seeking. This reframing is consistent with synthesis evidence showing that women’s help-seeking for postpartum mental health concerns is shaped by appraisal of symptoms, stigma, uncertainty about what is “normal”, and the perceived difficulty of accessing appropriate care [41,42]. This study provides a programme-specific description of recognition cues and next-step clarity as the practical bridge between awareness and action.

Accounts also indicated that organisational conditions shaped feasibility within routine care. Women described distance-related barriers and mixed experiences with digital formats, while healthcare providers described limited time, uneven routinisation of invitations, and cross-disciplinary gaps in delivery. These feasibility constraints - distance, digital barriers, and limited time are widely described as barriers to perinatal mental health care and help-seeking [41,45,46]. Our data add detail on how these constraints were experienced as specific points where progression along the care pathway stalled, and why simple design features clear cues and routinised signposting mattered in Arctic routine antenatal care.

Evidence on psychosocial and psychological approaches to postpartum depression prevention has been mixed and heterogeneous, with earlier reviews noting limited overall preventive effects across diverse interventions and suggesting that intensity and timing may matter [47]. More recent reviews and syntheses indicate increasing diversity of preventive approaches, including programmes targeting women without baseline depressive symptoms and digital and app-based formats, while emphasising variability in outcomes and the need to clarify mechanisms and implementation conditions [43,48]. The present findings contribute by specifying participant-perceived mechanisms that are plausibly relevant even when an intervention is not experienced as preventing distress: normalisation, reduced uncertainty, feasible self-regulation tools, and navigable pathways to support.

The findings also align with research on perinatal mental health literacy and help-seeking thresholds. Women in this study valued cues that distinguished transient distress from indications to seek support, and valued clear next steps under fatigue and uncertainty. This parallels evidence that limited knowledge about perinatal mental health, stigma, and uncertainty about service pathways delay help-seeking, and that women’s decisions are shaped by perceived legitimacy of symptoms and expectations of healthcare responses [41,42].

In circumpolar and other remote settings, the gap between nominal service availability and practical access is often widened by transportation, weather, distance, and constrained local capacity [49,50]. Our findings resonate with this literature by showing that participants prioritised low-threshold support pathways that reduce travel burden and fit postnatal routines, and that providers emphasised short appointments and uneven routinisation as persistent constraints. The study therefore adds context-specific detail on how women assess feasibility and how healthcare providers describe operational limits within Arctic antenatal care.

Taken together, the findings indicate that experiences of programme support and implementation conditions were closely interconnected. Women and healthcare providers described the programme as valuable because it fostered emotional safety, practical preparation, and clearer help-seeking pathways, but they also emphasised that these benefits depended on routinised delivery, coordination across professionals, and feasible access arrangements. The study therefore contributes both an account of how support was experienced and an understanding of the organisational conditions required for those experiences to be translated into routine Arctic antenatal care.

Four implications follow for routine antenatal care implementation in constrained settings.

• 1)Routinised signposting at 24–30 weeks.

A minimum-viable adaptation is to embed a brief, standardised signposting step within a routine antenatal contact at 24–30 weeks’ gestation. This timing is feasible because routine antenatal contacts are commonly scheduled in this period, including contacts at 26 and 30 weeks in the WHO model [51]. In practice, this would take 30–90 seconds at the end of the appointment and be delivered consistently for all women using a short script or checklist. The signposting content should cover three core elements: when to make contact (a small number of clear indicators or situations that warrant reaching out), when to act (a simple timeframe or escalation guide), and what to do next (one explicit next step, specifying who to contact and how). This adaptation is intended to promote consistent delivery across professionals and appointments and to enable timely help-seeking by making the first step clear and actionable.

• 2)One-page referral cue sheet.

A further minimum-viable adaptation is a one-page pathway and referral cue sheet for women and staff, summarising recognition cues, thresholds for action, contact routes, and what to expect after making contact. Such a low-resource tool may reduce uncertainty, support consistent messaging across professionals, and fit within short routine appointments.

• 3)One named coordinator function.

A practical implementation step is to assign one named coordinator function, without necessarily creating a new post, to support routinised delivery within routine care. This is supported by our findings and wider implementation evidence indicating that barriers often relate less to the nominal availability of support than to inconsistent messaging and discontinuities between service components [52]. The coordinator role could focus on maintaining recruitment routines, keeping programme materials up to date, and supporting cross-professional consistency in how the programme and referral pathways are presented.

• 4)One or two brief postnatal touchpoints.

One or two brief postnatal touchpoints may help sustain the programme’s pathway functions after birth, when women described limited capacity to act on antenatal information. These could be delivered as a moderated webinar/chat or a brief check-in; where digital access is variable, a short telephone contact plus a written summary can provide recognition cues, thresholds for action, and a single clear next step. These touchpoints would not constitute treatment, but would reinforce how to recognise concerns and initiate contact, consistent with help-seeking syntheses and implementation evidence [42,44,52,53].

Strengths and limitations

This study is strengthened by including both pregnant women and healthcare providers, enabling comparison of service-user and delivery perspectives, and an explicit audit trail supporting analytic transparency (memos, documented decisions, and iterative theme development). The study also provides context-rich insight into how organisational conditions in Arctic routine antenatal care shape programme feasibility and perceived value.

The first author’s dual position - contributing to the programme’s conceptual development while leading data collection and initial analysis, was reflexively managed through positionality notes and analytic memos, regular debriefings with co-authors not involved in programme development, independent coding, and collaborative theme refinement, supporting critical scrutiny of interpretations. Limitations include the single-region setting, a small healthcare provider sample, potential selection bias towards pregnant women already engaged with services, and self-selection into the FGD due to its voluntary nature; focus group dynamics may also have shaped disclosure of sensitive experiences. The contextual detail provided enables readers to assess the relevance of the findings to other rural, remote, or circumpolar maternity systems.

Future research

Future research could examine whether the mechanisms identified here operate similarly across maternity systems characterised by seasonal disruption, travel burden, short routine appointments and coordination constraints, including circumpolar settings. Studies extending into the postnatal period could explore participants’ postpartum experiences and the perceived feasibility and acceptability of brief postnatal follow-up integrated into routine contacts. Further work on hybrid delivery could refine low-friction digital options and specify facilitation needed to maintain emotional safety and meaningful participation, alongside equity-focused examination of differential access across formats. Building on the importance of consistent messaging and routinised signposting, future research could assess the feasibility of a brief midwife-led capacity-building package aligned with existing workflows.

Conclusions

Based on the perspectives presented in this study, the Happy Birth programme appeared to support women through a combination of relational participation, structured sense-making, and clearer pathways for recognising vulnerability and seeking support. The study contributes by showing not only how participants experienced support within the programme, but also which organisational conditions they considered important for sustaining these experiences within routine antenatal care in an Arctic setting. The programme supported peer belonging and structured sense-making, and it was valued for helping women recognise vulnerability and navigate support, but feasibility was shaped by distance, digital access, short routine contacts, and coordination constraints. These findings suggest that the benefits of preventive psychosocial programmes in circumpolar settings are closely linked to the conditions through which they are delivered. Next steps from this study are first to examine postnatal experiences among programme participants and how programme content is used under postnatal time constraints, and second to identify locally feasible ways to strengthen routinised signposting, coordination, and low-threshold continuity after birth.

Funding Statement

The initial phase of this project was supported by funding secured by Professor Jon Øyvind Odland through the Norwegian University of Science and Technology.

Disclosure statement

The first author contributed to the conceptual development of the Happy Birth programme but has no financial, employment, supervisory, or commercial interests related to its delivery. She is not employed by the clinic providing the programme and had no role in participants’ access to services. All other authors declare no competing interests.

Data availability statement

De-identified quotation extracts supporting the findings are available from the corresponding author on reasonable request, subject to ethical approval and confidentiality safeguards.

Ethics approval and consent to participate

Ethical approvals were obtained from the Regional Committee for Medical and Health Research Ethics of Central Norway (REK 134185, 2019) and the Local Ethical Committee of the Northern State Medical University, Arkhangelsk (Protocol 05/11-19), and all participants provided informed consent.