Perinatal mental health and active-duty military spouses: a scoping review

Abstract

Introduction

Mental health conditions (i.e. depression or anxiety) are the most common complication of pregnancy and childbirth in the United States (U.S.) and are associated with increased maternal and infant morbidity and mortality. Research has demonstrated a relationship between stress and mental health diagnoses in pregnancy; therefore, it is concerning that military families face unique challenges which contribute to additional stressors among spouses of active-duty (AD) military personnel during the perinatal period. The objective of this scoping review was to understand the current state of research on perinatal stress or perinatal mental health among American spouses of AD military personnel.

Methods

The Boolean phrase was created in consultation with 2 health science librarians and the following databases searched in October 2023: PubMed, Embase, Military and Government Collection, CINAHL, and PsychINFO. 2 reviewers identified 481 studies for screening once duplicates were removed. After applying inclusion and exclusion criteria, 21 studies remained for data extraction and analysis.

Results

Most of the studies were quantitative, took place in the southern U.S., and the most represented military branch was Air Force. Most of the studies included both AD military members and AD spouses; 28% focused solely on AD spouses. Samples were not racially diverse, and findings identified racial disparities in perinatal mental health conditions. There was a wide variety in outcome measures, including the following general categories: (1) stress, anxiety, and/or depression, (2) maternal-infant attachment, (3) group prenatal care, and (4) deployment focus. Our review identified the following concepts: spouses most at risk for perinatal mental health conditions, the need for perinatal mental health screening, and the need for social support.

Conclusions

Findings from the identified studies indicate a need for additional research in this area. Additionally, findings highlight circumstances unique to this population that result in an increased risk of stress and/or mental health conditions during the perinatal period. Such challenges demand improved mental health screening and additional resources for this population. Meeting the needs of this unique population also requires significant funding and policy change to allow for increased access to mental health resources and to ensure the health of the birthing person and infant.

Background

Perinatal mental health

The most common complication of pregnancy and childbirth in the United States (U.S.) is mental health conditions [1, 2]. Mental health conditions during the perinatal period include depression, bipolar disorder, anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and substance use disorder [3]. These diagnoses are associated with an increased risk of maternal and infant morbidity and mortality [3]. Perinatal distress originating from anxiety, depression, or stress has also been found to negatively influence child health [4] and development [5, 6].

In a study on socioeconomically diverse new mothers, worries about housing, income, family health, and relationships were prevalent [7]. This is worrisome since recent research has discovered that precursors to perinatal mental health conditions, such as generalized perinatal distress, also have negative health outcomes, including adverse infant socio-cognitive outcomes, such as delayed cognitive development and difficulty with emotional regulation [8]. Additionally, chronic stressors, such as perceived stress or anxiety, poverty, intimate partner violence and racism have long been associated with an increased incidence of preterm birth [9].

Thus, it is concerning that stress-related symptoms are now reported as the most common complication of pregnancy, even impacting healthy pregnancies and spanning socioeconomic statuses [8]. Left untreated, the consequences of mental health conditions are severe. Though underreported, data indicate suicide and overdose deaths are a leading cause of maternal death in the first year following childbirth in the U.S. [10, 11].

Military family challenges

Military families face many unique challenges relative to the general U.S. population that may contribute to additional stressors and mental health conditions. As of 2022, there were 2,071,451 million active-duty (AD) and reserve members of the U.S. military and 2,482,499 family members [12]. In 2021, 81% of AD military spouses surveyed had experienced a change of duty station, meaning the family was required to relocate [13]. Financial implications incur with a change in duty station. For instance, a change in duty station brings additional obstacles, including finding employment for the AD spouse (resulting in loss of income), moving costs, settling claims for damaged or missing household goods, move coordination, waiting for housing to become available, and re-establishing childcare. It is therefore not surprising that a change in duty station increases the odds of spousal unemployment and unemployment increases the odds of food insecurity [13]. In 2021, 25% of AD spouses reported food insecurity [13].

The emotional impact of being a military family is also extensive. 41% of AD military spouses surveyed in 2021 reported a partner’s deployment to a combat zone and 48% reported concerns about the mental health of their spouse returning from deployment [13]. There has also been an increase in use of counselling services among AD spouses (44% in 2021 compared to 37% in 2012) [13]. Additionally, a Government Accountability Office (GAO) study determined that 36% of beneficiaries in the Department of Defense (DoD) Tricare program (the healthcare insurance of AD members and beneficiaries) received a mental health diagnosis between the years 2017 and 2019; the most common diagnoses being anxiety disorders, depressive disorders, and trauma and stressor-related disorders [14].

Furthermore, military families operate with perceived pressure to adhere to military standards, which leads to additional strain and overall dissatisfaction [15]. Military spouses report a culture “where the soldier and his career come first” and have self-proclaimed difficulties in managing their stress [16]. Military spouses have also reported higher levels of stress and depression, especially during their AD partner’s deployments [17,18,19]. Lastly, according to a GAO report to Congress on domestic abuse in the DoD, there were 8,055 incidents recorded in 2019; thereby implying significant domestic abuse among military households that possibly result from and contribute to extenuating stressors [20]. It is worth noting that this report states the incidents are likely grossly underreported [20]. Overall, there has been a general decline in spousal satisfaction in American military life since 2012 [13].

Pregnant, active-duty spouses

Pregnant spouses of AD military personnel are therefore at increased risk for perinatal mental health conditions, especially during AD spousal deployments [14, 21]. In the U.S., childbearing people are not adequately supported by national policies nor funding, leading to long term consequences for the mother and child [1]. Pregnant spouses of American AD military personnel, despite their unique circumstances, also lack support. For example, a recent news article [22] highlights deficiencies identified by a Pentagon Inspector General Report in the military healthcare system, which is directed by the Defense Health Agency (DHA). Barriers to obtaining medical care, including mental healthcare, at military treatment facilities (MTFs) both in the U.S. and abroad have been identified [23]. For example, in June 2023, pregnant Air Force dependents stationed in Okinawa, Japan were informed they would either need to deliver at a Japanese hospital or return stateside for delivery, because of staffing shortages [24]. Circumstances such as these result in additional stressors among an already marginalized population.

Rationale for scoping review

It is imperative to describe the existing literature on perinatal stress and perinatal mental health among American, AD military spouses due to their unique circumstances and needs. We narrowly defined our population of interest and focused solely on the U.S. military per the recommendation of Levac, Colquhoun, and O’Brien [25] and because military culture and support programs vary significantly on an international scale. A preliminary search of the literature identified a general lack of studies on this topic and one scoping review published in 2018 to inquire if United Kingdom (UK) military spouses were at risk for poor perinatal health [21]. The Godier-McBard et al. paper identified studies conducted in the U.S. but was completed with a focus on UK military personnel and families [26].

Our scoping review differs in our research question, our search terms, our population of interest, and is warranted since it has been 6 years since the last review was published. According to Arksey and O’Malley [27], scoping reviews are helpful in examining the extent of research activity, to see if a systematic review is feasible, to summarize findings, and identify research gaps. Given the limited amount of research on our topic of interest, we therefore proceeded with a scoping review rather than a systematic review of the literature in hopes of providing an overview of the evidence [28].

Objective

This review aims to answer the following research question: What is the current state of research on perinatal stress or perinatal mental health among American spouses of AD military personnel?

Methods

Search strategy

To ensure a quality review and rigorous methodological approach, this scoping review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and expansion [29]. The protocol was registered with OSF registries as the following: https://doi.org/10.17605/OSF.IO/TYSEZ.

To ensure a comprehensive search, we consulted with two professional librarians. The text words contained in the titles and abstracts of relevant articles, as well as the index terms describing the articles were used to develop a full search strategy for this review. The final search terms were selected after many iterations. The main concepts were perinatal mental health and the military family or spouse. We initially included the concept of stress in our search strategy but surprisingly, this did not identify any additional articles. We also initially included the concept of “overseas”, but this severely limited our results; therefore, we adjusted the concepts to exclude the concept of “overseas” in our search strategy. To demonstrate our search strategy, the database search strategy for PubMed is included as Appendix I.

We searched the following databases in October 2023: PubMed, Embase, Military and Government Collection, CINAHL, and PsychINFO. No limits were placed during this initial search. The search strategy, including all identified keywords and index terms, was adapted for each database.

Study selection process

Following the initial search, the citations were uploaded into Covidence [30], a web-based software platform that streamlines the production of literature reviews. Once duplicates were removed, 481 articles remained to review. Following a pilot test, titles and abstracts were screened by two independent reviewers for assessment against the inclusion and exclusion criteria. An additional 2 articles were identified through backward search. After application of inclusion and exclusion criteria, 21 articles were included in this scoping review for full review. The results of the search and the study inclusion process are presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) flow diagram (see Fig. 1).

Fig. 1

PRISMA-ScR flow diagram

Inclusion and exclusion criteria

We included qualitative and quantitative research studies written in English, conducted either in the U.S. or abroad, with a study population that included American, AD spouses, focused on perinatal mental health or stress, and published in a peer-review journal. We included both experimental and quasi-experimental study designs, including randomized controlled trials (RCT), non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies were considered for inclusion. This review also considered descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion. Qualitative studies were also included.

We excluded commentaries, case studies, literature reviews, letters to the editor, books, dissertations, and monographs. We also excluded systematic reviews so that the extracted studies would not demonstrate redundancy. To remain current, we only included studies published since the year 2000. An ancestry search was done to identify other additional studies. Disagreements that arose between the reviewers at any stage of the selection process were resolved via discussion.

Data extraction

Data was extracted by two independent reviewers using a data extraction tool developed by the reviewers (see Appendix II). This extraction tool was created to address the objective and research question and therefore includes specific details about: methods, setting, population, perinatal period, details of intervention or program, findings or perinatal outcomes, and implications of the study. This extraction tool was not modified in the extraction process. However, after trends were noted, we opted to present the body of literature in additional tables to demonstrate trends. Any disagreements about the data in the extraction table were resolved via discussion. The charted data was then discussed among the team members to further identify trends and derive concepts. A critical appraisal of the selected studies was not completed for this scoping review.

Results

Study design

The majority (21/22; 95%) of the identified articles were quantitative, with 1 article reporting mixed methods [31] and 1 article utilizing qualitative methods [32]. Of the quantitative articles, 24% (5/21) were intervention studies with a RCT design [31, 33,34,35,36]. Two of the RCT studies involved implementing group prenatal care [31, 34]. The remaining methods were as follows (in order of most frequent): 6 retrospective studies [37,38,39,40,41,42,43], 4 cross-sectional surveys [44,45,46] including a comparative descriptive study [47], and 3 prospective or longitudinal studies [48,49,50].

Study setting

Table 1 and Appendix II describe details of the setting and the region in which the studies occurred. The majority of studies (42%) took place in the southern U.S. [36, 38, 44,45,46,47,48, 50], followed by 23% in the Western U.S. [31, 34, 41,42,43], 9% in the U.S. - not specified [32, 49], and 4% in the Midwestern U.S. [33]. 19% of the selected studies utilized national health data information that represented the entire military personnel population and was not regionally specific [37, 39, 40, 51]. Other than the studies that utilized national health data information [37, 39, 40, 51], studies primarily obtained data from subjects seeking healthcare at MTFs located on base (see Table 1).

Study population and perinatal time period

The number of participants among all included studies totals 340,666 (one study did not provide sample size, thus, this data was not included [51]). The range of samples for studies varied significantly with the largest samples representing studies utilizing national health data information and the smallest utilizing qualitative methods. For example, 161,454 pregnancies were included to assess for odds of postpartum depression (PPD) relative to spousal deployment [39] versus 10 women interviewed to understand the lived experience of widowhood during pregnancy [32]. The majority (61%) of the studies included persons that were both AD and spouses of AD [31, 34,35,36,37, 39, 40, 44,45,46, 48, 50, 51]. However, many (28%) studies did focus solely on AD spouses [33, 41,42,43, 47, 49]. One study included AD, AD spouses, AD daughters, and Veteran Affairs patients [38] and one study specified that both civilians and AD spouses were included [32].

Table 1 Region and detailed branch representation among identified articles

Samples were predominantly White [33,34,35,36,37, 44, 49, 50], representing a younger population (median age of 27 [37], means of 26 years [41, 50], means of 28 years [34, 35] range between 18 and 28 years [33]), and educated [32, 35, 36, 49, 50]. While the samples represented all branches of the military, the Air Force was most represented [33, 35, 36, 47, 49, 50], followed by the Marine Corps [43,44,45,46], the Army [39, 42, 48], and the Navy [31] (see Table 2).

Table 2 Branch representation in articles, in order of most frequent

Pregnant and postpartum women were included in the identified studies. The specific perinatal time in which women were studied include the following (in order of prevalence): pregnancy and postpartum [31,32,33,34, 38, 41,42,43, 45, 48, 49], pregnancy only [35, 36, 44, 46, 50] pregnancy and up to 1 year postpartum [37, 39], postpartum up to 1 year [40, 51], and postpartum only [47]. Additionally, one study focused on widowed spouses [32].

Perinatal outcomes

The studies assessed for a variety of outcomes, such as: incidence and prevalence of mental health conditions, predictors or risk factors for mental health conditions, compliance of PPD screening, predictors of maternal-infant attachment, outcomes of various interventions, and effects of deployment on maternal acceptance of pregnancy and PPD. The various outcomes fall into the following general categories: (1) stress, anxiety, and/or depression, (2) maternal-infant attachment, (3) group prenatal care, and (4) deployment-focused. The details will be briefly discussed below, and the specific tools utilized by the studies are depicted in Table 3.

Stress, anxiety, and depression

Some retrospective cohort studies utilized national health data to identify incidence and prevalence of specific mental health conditions. For example, one study analyzed national health data to identify incidences of psychiatric disorders, including PPD, and predictors of such diagnoses [37]. Findings identified significant differences in outcomes based on race/ethnicity: incidence of psychiatric disorders during pregnancy was significantly lower among White women compared with Asian or African American women and higher among single women [37].

Rates of antidepressant use was assessed in one study, where it was determined that the rate of usage was higher among: younger women, women of lower socioeconomic status, and women with a history of military service [40]. Haas et al. [44,45,46] conducted 3 separate cross-sectional surveys to assess for self-reported or self-perceived stress during pregnancy and found the following were associated with higher stress: women with 2 or more children at home before delivery [44,45,46], not having a support person, and having a deployed partner [44, 46], especially to a combat zone during pregnancy [44].

Table 3 Standardized tools in identified articles

A descriptive study examined protective and risk factors of PPD and identified elevated depressive symptoms in more than 50% of the women (consistent with at risk populations) and identified that family change or strain, lower self-reliance, and lower social support were predictors of PPD among military wives [47]. Another study assessed for influencers of Edinburgh Postnatal Depression Scale (EPDS) scores and found higher EPDS scores were associated with isolation, a personal history of depression, and having a husband/partner deploy during pregnancy [41].

Regarding screening, a retrospective study assessed for screening of depression in a large MTF OB (obstetrics) department and identified excellent screening rates during the first trimester and room for improvement at the 28-week and postpartum visits [38].

Maternal-infant attachment

Many studies included maternal-infant attachment in their approach. One longitudinal study aimed to identify predictors of postpartum maternal-infant attachment, including the impact of spousal deployments and found that spousal deployment in the 1st trimester, having a history of depression, and a higher EPDS score impacted satisfaction with motherhood and infant care [49]. An RCT compared an intervention versus routine care in facilitating maternal role adaptation and assessed for prenatal adaption, postpartum adaption, external resources, social support, and internal resources [33]. This intervention, “Baby Boot Camp” may have enhanced external and internal resources to facilitate prenatal and postpartum maternal role adaptation, however not all differences were statistically significant [33].

Group prenatal care

The RCTs primarily involved comparing group prenatal care versus routine care [31, 34]. For example, Kennedy et al. (2011) assessed the impact of group prenatal care on mental health, stress, depressive symptoms during pregnancy, and PPD [31] while Tubay et al. (2019) assessed for the impact of group prenatal care on anxiety, depression, and infant birthweight [34]. Both RCTs identified no significant differences in outcome measurements; however, group prenatal care participants were less likely to report feelings of guilt or shame in one study [31] and the group prenatal care was found to be more accessible and convenient in the other study [34].

Another RCT compared a prenatal support program (“Mentors Offering Maternal Support”) versus routine care and assessed for prenatal maternal adaptation, maternal/fetal attachment, community support, and self-esteem [36], finding no significant differences between the groups. However, higher levels of contact with deployed husbands did result in higher scores of self-esteem and lower anxiety [36]. This same program was later tested again, and the assessed outcomes were prenatal adaption, self-esteem, resilience, and depression [35]. When repeated, the intervention did reduce prenatal anxiety and identified single participants and those with deployed husbands as being at greater risk of anxiety [35].

Deployment-focused

Most of the articles (57%) conducted studies that included information relating to deployments [35, 39, 41,42,43,44,45,46, 48,49,50]. Retrospective studies assessed for the effects of deployment on depression screening scores during (1) pregnancy [42], and (2) pregnancy and postpartum [43]. Findings included that deployment status significantly affected the prevalence of depression in pregnant women [42, 43] and postpartum [43].

Another study assessed the effects of deployment on pregnancy outcomes, finding that deployment of a spouse to a combat zone during the pregnancy resulted in a 3-fold increased risk of PPD [48]. Another longitudinal study evaluated the effect of deployment on maternal acceptance of pregnancy and included measures on social support [50]. This study found that women with deployed husbands had a significant increase in conflict associated with acceptance of pregnancy, that conflict with acceptance of pregnancy decreased with social support, and that social support located on base (versus off base) resulted in greater acceptance of pregnancy [50].

Lastly, another study analyzed national health data to determine the odds of PPD relative to spousal deployment [39] and found the odds of PPD were higher among: those of younger maternal age, experiencing spousal deployment during pregnancy, with a diagnosis of depression or anxiety prior to pregnancy, alcohol/drug/tobacco use while pregnant, being married to a White (non-Hispanic) spouse, being affiliated with the Army, and complications with their infant upon delivery. Additionally, the highest levels of PPD were noted among women with husbands deployed during delivery [39].

Concepts identified

Spouses most at risk

In reviewing the articles, the profile of the American, AD military spouse most at risk for perinatal stress and/or depression is the following: identifying as Asian or African American [37], being of younger maternal age [39, 40], being married to a White (non-Hispanic) spouse [39], being affiliated with the Army [39], being of lower socio-economic status [40], having children at home before delivery [44,45,46], having a deployed partner [35, 39, 41,42,43,44, 46, 49, 50], not having a social support or reporting isolation [41, 44, 47, 50], having an antepartum diagnosis of depression or anxiety [39, 41, 49], alcohol/drug/tobacco use in pregnancy [39], having pregnancy complications [37], and experiencing neonatal complications [39].

Need for perinatal mental health screening

Many of the identified articles addressed screenings for PPD and/or anxiety either in their study design or when discussing implications. Screening military personnel and dependents during the postpartum period is recommended [51], especially during deployments [39]. Additionally, it is suggested that there be focused screening for suicidal behavior among persons already diagnosed with PPD [51]. One study found compliance of depression screening in military settings was excellent at initial visit but required an improved commitment for maintenance throughout the entire pregnancy [38].

Need for social support

A prevalent concept that emerged among the articles was the need for social support among pregnant or postpartum military spouses. The need for social support has been explicitly requested by military spouses [36] and is especially needed when dealing with unanticipated external stressors that can occur in military life [32]. Social support was found to positively influence maternal acceptance of pregnancy, which facilitates maternal-fetal and infant attachment [50]. Not having a support person during pregnancy correlated with higher stress [44] and feeling isolated significantly influenced the risk for a diagnosis of PPD [41]. Lower social support also predicted PPD [47]. This is concerning given the geographic challenges of military life; one study found that 1/5 pregnant persons did not have a support person beyond their partner [45].

Discussion

Key findings and associated limitations of the evidence base

Overall, the identified research demonstrates that research is lacking regarding perinatal mental health among AD military spouses. This lack of research may be related to barriers that limit research among military personnel and their dependents [52]. For example, obtaining access to military personnel and data is typically restricted to those affiliated with the DoD or to those affiliated with select universities. Additionally, military leaders often prioritize medical readiness over other medical, indirect outcomes that may be the focus of research studies [52]. This restriction on conducting research is reflected in the limited amount of literature to review, the limited variety of journals, and the predominance of publication of studies in Military Medicine, by government employees (see Table 4). It is worth noting that many of the authors of the identified articles are nurses, demonstrating nursing’s interest in this area of research.

Table 4 Journal distribution, deployment, and interventions of identified articles

Study design, setting, population, and outcomes

Since many of the articles were quantitative, further investigation into the perspective of the AD pregnant, military spouse is warranted and qualitative research might be helpful to ensure specialized needs are met. Additionally, while 5 RCTs were identified, continued intervention studies are needed given that many of the tested interventions were questionable in their efficacy.

Additionally, the Southern U.S. was over-represented in the sample and therefore other regions, and associated military bases, might have been overlooked. Furthermore, despite the large number of military dependents stationed overseas (approximately 170,000 dependents in 2021 [12]), none of the identified articles focused on AD spouses stationed overseas. In reviewing pertinent research, we identified two articles related to being stationed overseas. One was a systematic review of the impact of foreign postings among military spouses (both American and British). The review identified studies published primarily in the 1980s and early 1990s and findings included spousal satisfaction being linked to spousal employment status [53]. The other study, completed in 2001, compared prenatal care needs in the U.S. and abroad, yet this comparison did not include any mental health factors [54]. However, this study did find that those stationed overseas reported challenges to obtaining care within a different culture and barriers to prenatal care were identified [54]. Thus, future research should include all regions of the U.S. as well as American spouses stationed abroad. Conducting research with the overseas population is critical, since this population may face additional stressors that impact perinatal mental health outcomes.

Furthermore, while 28% of the identified studies focused on AD spouses only, the majority included both AD and spouses of AD. While AD personnel do require support and warrant research, the AD spousal population has unique needs and should be studied separately. Since many of the samples were predominantly White, there is also concern that underrepresented populations were not adequately sampled. However, the identified articles did represent both the pregnant and postpartum population and it was reassuring to see some extend to 1 year postpartum given the national emphasis to care for the mother during this extended period [55]. Future research should aim to include more racially diverse samples of AD spouses and extend outcome measurements to at least 1 year postpartum.

Despite the differences among military branches, there was not equal representation in the studies since the Air Force was predominantly represented (see Table 2). This warrants further investigation given the varying stressors that impact the branches differently. For example, military personnel in the Army, Navy, and Marines are more likely to be deployed than the Air Force, and experience higher levels of PTSD and anxiety [56].

The outcome measures of the identified articles fell into the following general categories: (1) perinatal stress, anxiety, and/or depression, (2) maternal-infant attachment, (3) group prenatal care interventions, and (4) deployment-focused. Our identified outcome categories were similar to themes identified in the 2018 scoping review on perinatal mental health: deployment increases prenatal stress and depression, protective or risk factors from perinatal mental health problems, and support interventions for this population [26]. Since some of these outcomes are now well understood, such as the negative impact of deployment and the insignificant difference of many of the interventions, future research should aim to evaluate the effect of new and innovative support programs on perinatal mental health outcomes. Additionally, since precursors to perinatal mental health conditions are known to have negative health outcomes [8, 9], studying acute or chronic stress within this population is warranted.

Identified concepts

Our review identified the following concepts: spouses most at risk for perinatal mental health conditions, a need for perinatal mental health screening, and the need for social support among perinatal American AD-spouses. From the articles reviewed, the profile of the pregnant, AD-spouse most at risk has also been identified: Asian or African American, younger maternal age, married to a White (non-Hispanic) spouse, an affiliation with the Army, lower socio-economic status, having children at home before delivery, having a deployed partner, not having social support or reporting isolation, having an antepartum diagnosis of depression or anxiety, using alcohol/drug/tobacco in pregnancy, and experiencing pregnancy or neonatal complications. Additionally, our review identified continued racial disparities in perinatal mental health outcomes. These findings are supported by an integrative review that also found racial disparities among perinatal outcomes among beneficiaries of the military health system [57].

Our review also found evidence highlighting the need for continued perinatal mental health screening among perinatal American AD military spouses. This in line with the current recommendation that mental health screening occur among all Tricare beneficiaries in the prenatal and postpartum time periods [14]. Furthermore, programs need to be in place to ensure continued adherence to mental health screening among perinatal persons. Accessibility to appropriate support programs is also critical for this population.

The need for adequate social support and mental health resources for perinatal American AD military spouses was also highlighted in our review. The need for social support among this specific population is previously known and there are existing programs within the military network [58], such as the “New Parent Support Program”, which was established to help military families “navigate through pregnancy, transition successfully into parenthood and provide a nurturing environment” [59]. However, our review suggests that such programs need to be bolstered and potentially adjusted to meet the specific needs of the AD perinatal military spouse. Additionally, future research and screening or support programs should target the most at risk persons to address disparities.

Limitations

This study is not without limitations. As per the guidelines for conducting a scoping review, we did not complete a risk of bias or a thorough assessment regarding the quality of the included studies. Thus, our results and implications are limited in their impact. Despite our best effort to construct a thorough search and maintain methodological rigor throughout the entire review process, it is possible we missed relevant studies. Additionally, application of our inclusion and exclusion criteria, such as only including studies published since 2000, may have excluded sentinel papers on this topic. Despite these limitations, this scoping review makes an important contribution to the current body of knowledge by highlighting a critical gap in the literature about perinatal mental health among American spouses of AD military personnel. This review only identified 21 studies; thus, there is a need for additional research in this area. Furthermore, this review emphasizes the unique circumstances facing this specific population and identifies areas of directed improvement.

Conclusions

Perinatal mental health is of vital importance; ensuring appropriate screening and support for the pregnant, AD spouse is necessary to prevent the increasing burden of maternal and infant morbidity and mortality in the U.S. Findings from this scoping review have identified key areas relative to practice and future research. For example, persons most at risk for perinatal mental health conditions within this population have clearly been identified and additional resources should be made available to this specific population. This need for tailored support is supported by prior research, given that their needs differ from the typical perinatal person [26]. Additionally, many (57%) of the articles included in this review addressed deployment; however, the need for support of AD military spouses despite a spousal’s deployment status is warranted. Given the additional challenges that come with being stationed abroad, the minimal research on the impact of living abroad among military families is concerning. Thus, more research on the pregnant AD military spouse stationed abroad is warranted.

There is also room for improvement in both screening and providing much needed services for those most at risk. Meeting the needs of this unique population requires significant funding and policy change to allow for increased access to mental health resources and to ensure the health of the mother and infant. Barriers to obtaining medical care, including mental healthcare services, have been documented at MTFs both in the U.S. and abroad [23]. Efforts should be made by the DHA to address these barriers and provide crucial resources, which is in line with the GAO’s suggestions [14].

In conclusion, military families face unique challenges, which contribute to additional stressors among spouses of U.S. military AD personnel during the perinatal period. Meeting the needs of this unique population requires significant funding and policy change from the highest level, additional and specific research, improvements in screening, and additional support interventions. Only then can we adequately identify those who need assistance, increase access to mental health resources, and ensure the health of the mother and infant.