After the screen: A social work-led stepped referral pathway for perinatal mood and anxiety disorders and psychosocial risk in Ugandan antenatal clinics

Antenatal services increasingly screen for perinatal mood and anxiety disorders (PMADs) and other psychosocial and contextual risks, yet many women do not reach care when referral pathways are fragmented, costly, or unsafe. This qualitative process evaluation, informed by implementation science and realist inquiry, examined a social work-led stepped referral pathway embedded in two public-sector antenatal clinics in Uganda. Data comprised clinic observations and interviews with pregnant and postpartum women and with the clinical, social work, community, and referral personnel involved in linkage and follow-up. Analysis examined implementation context, mechanisms, pathway breakdowns, and participant-reported early-postpartum engagement. Linkage depended on workflow fit, private space, role clarity, referral documentation, transport feasibility, and follow-up negotiated around phone access, mobility, and partner control. Same-day social work case formulation changed referral from passive direction-giving to a safety-sensitive and practically feasible plan. Consent-based village health team assistance supported navigation for some women but required strict confidentiality safeguards. Reported postpartum changes concerned functioning, perceived safety, and service use rather than standardized clinical outcomes. Integrating social work into antenatal teams, protecting privacy, and routinely tracking referrals may strengthen post-screening care in resource-constrained maternal health systems.