Depression has quite high prevalence among women, especially during child-bearing years with prevalence rates ranging from 10% to 20% [1–3]. Hormonal, psychological, and social factors in the pre-natal and post-natal periods, as well as in early child-rearing years, have been strongly linked to the onset of depression . Maternal depression is related to the child's physical, mental, and social health. It may interfere with mother-infant interaction [5–10], and it may impede child neurophysiological [11–13] cognitive, and socio-emotional development [14–17]. The mothers' depression has also been linked to anxiety, depression [18, 19], attention deficit/hyperactivity disorder, and externalizing problems among their offspring .
Previous studies pointed out that women facing depression in the perinatal period are at increased risk for pre-term delivery and low birth weight of offspring compared to non-depressed mothers . Maternal depression is also associated with breastfeeding cessation, less healthful feeding and sleeping practices in infants [14, 22], and also failure to thrive . There is evidence that maternal depression results in poor physical child health outcomes by affecting parenting behaviors and skills . Underuse of child health preventive practices and overuse of pediatric emergency services have also been reported in studies of depressed mothers [21, 25–28].
Pediatricians are the health care providers with the most frequent contacts with women of child-bearing age and therefore could play a key role in detecting maternal depression during the well-child visits [29–32]. Despite this, pediatricians do not seem to sufficiently address the issue . Delays in detection of depression set the mother and the child in enormous risk and deprive the opportunity for the mother to receive appropriate care from health care services or participate in a mental health promotion intervention. The early recognition and management of maternal depression are implied by the European policy framework that includes ‘support parenting and the early years of life’ as a major action area .
Barriers exist both at organizational and individual levels. The most common organizational barriers for maternal depression screening and management include (1) work overload and time restrictions, (2) absence of interdisciplinary team work, (3) lack of relevant health insurance coverage, (4) poor cooperation and collaboration between general and mental health sectors, and (5) inadequate community mental health services [30, 35–37]. Facilitating factors include the establishment of supportive policies for family-oriented health care and the integration of general health and mental health services [33, 38]. The most frequently reported barriers at the pediatrician level include (1) reduced awareness and limited skills regarding basic aspects of maternal depression (clinical manifestation, impact, screening, and management practices), (2) perceived roles and responsibilities, (3) poor perceived self-efficacy, (4) fear of stigmatizing mothers, and (5) previous negative experiences in communicating with mental health professionals [39, 40]. The importance of addressing the above individual level's obstacles is of high a priority since they are common barriers at both public and private pediatric settings and they can be more easily modified compared to the organizational ones [1, 37, 41, 42]. Educational interventions and training in the use of screening tools, semi-structured clinical interviews, and counseling skills seem to be beneficial and can increase the health professionals' self-efficacy and early recognition and management of maternal depression [43, 44]. The European Forum for Primary Care  suggests that a strategy indicating positive results in recognition and management of depression is the training for primary health care professionals in depression screening tools.
It should be stressed that theory is a crucial aspect of all health promotion learning interventions. Theory provides a framework to reason how and why people alter their behavior . It also aids the evaluation of the program's effectiveness . The absence of theory cannot ensure that all the variables which influence the problem are targeted .
The present study aimed to examine the impact of a theory-based educational intervention to pediatricians, in order to improve early identification and management of maternal depression. It was hypothesized that the intervention would manage to (1) increase the pediatricians' knowledge about maternal depression and its effect on children health, mental health, and well-being, (2) change the pediatricians' beliefs about the severity and impact of maternal depression, (3) change the pediatricians' attitudes toward their responsibility for the identification and follow-up of mothers with depression, and (4) increase the pediatricians' perceived self-efficacy toward the identification and referral of mothers with depression.