Psychosocial Assessment and Depression Screening in Private Obstetric Care

Abstract

The perinatal period offers a unique opportunity to identify women at risk of, or currently experiencing mental health disorders, to offer support to enhance resilience, and implement appropriate referral and treatment. There is international intent to standardise and make routine the psychosocial assessment and depression screening of all pregnant women as early intervention has been shown to promote better health for women, their infants, partners and the whole family. In Australia, national clinical guidelines for perinatal depression and anxiety recommend perinatal mental health assessment as best-practice for clinical care. However, despite approximately 30-40% of pregnant women choosing to birth in the private sector in Australia, little is known about such initiatives within this sector. The aims of this study were to establish what is known about psychosocial assessment and depression screening for women who choose private obstetric/maternity and postnatal care, with a particular emphasis on the availability and appropriateness of referral pathways and barriers to the implementation of screening within non-metropolitan settings. Barriers were explored from the perspective of the pregnant woman, midwives, obstetricians and other health care professionals working in private obstetric services in both regional and metropolitan settings. Using a sequential mixed methods approach, the study piloted a program of psychosocial assessment and depression screening as part of women’s obstetric ‘booking-in’ process at a regional private hospital in the state of New South Wales (NSW), Australia. A sequential mixed methods design permitted the selection of research methods appropriate to research questions posed for each of a series of study phases. In Phase 1, a retrospective audit of women’s medical records was undertaken to understand the profile and background prevalence of antenatal psychosocial issues/risk factors in women choosing to birth in a small, non-metropolitan private hospital. An integrative literature review was undertaken in Phase 2 to determine the extent and quality of international research in relation to the implementation of psychosocial assessment and depression screening in private hospital/obstetric settings. Specifically, the aim of the integrative review was to discover new knowledge and identify barriers for the development and implementation (in Phase 3) of a Perinatal Psychosocial Care Guideline and the sourcing of appropriate referral services for women identified at risk. Phase 4 used qualitative interview methods to further explore barriers to antenatal psychosocial assessment and depression screening with both health professionals at the study site, and with midwives at three other sites across NSW offering private midwifery care. The literature review confirmed that little is known about screening in private obstetric care but that evidence of positive outcomes exist. The profile and background prevalence of antenatal psychosocial issues/risk factors in women choosing to birth in a small, non-metropolitan private hospital was highlighted. The audit showed that Australian women seeking private obstetric care were older and mainly primiparas. The implementation determined that a lack of resources, perinatal mental health training, confidence and time and overall attitude to screening were the main barriers and qualitative interviews revealed that many midwives themselves expressed that they were either unsure or not necessarily committed to undertaking screening within private hospital settings. These results show that data for women at the study and local hospital sites were similar, indicating that the demographic profile of women was comparable. However, there were substantial differences in birth type with more interventions in the private sector and a lower prevalence of completed EPDS. This study not only successfully implemented psychosocial screening and assessment in one small private hospital in NSW but also explored health professionals and women’s views of perinatal screening and assessment. This is the first study to specifically represent and explore the views of private hospital midwives about psychosocial and depression screening in the Australian private obstetric context. During the follow-up telephone interview, the 209 women agreeing to continue with the study had the opportunity to expand upon their EPDS responses. Women were also recommended additional supports if a psychosocial need or risk was identified during this conversation. Nine women offered further comments during the telephone conversation and of these, seven had total EPDS scores greater than 10 (3.3%). At the study site, five midwives, two obstetricians and one social worker participated in interviews. A further 11 midwives from the three other private hospitals also participated in interviews Therefore, a total of 16 midwives, two obstetricians and one social worker form the sample of 19 interview participants in Phase 4. The themes derived from the thematic content analysis describe how participants perceived the advantages and disadvantages of psychosocial and depression screening. The three main themes were; The need to know, Awareness- knowing what, Preparation, knowing how. These added to the specific reasons that midwives and other health professionals identified for not engaging in screening. Obstetricians at the study site were generally supportive of psychosocial and depression screening but noted that they did not feel any more informed about the psychosocial health or referral of their patients to other services from the midwives than previously. New knowledge was gained and barriers were identified to the development and implementation of psychosocial screening in the private sector. The study concludes that it is crucial to understand and eliminate barriers to implementing psychosocial screening in the private sector in order for this to be successfully implemented as recommended by the 2017 Australian Commonwealth Government review and update of the Australian Perinatal Mental Health Guidelines by the national Centre of Perinatal Excellence (COPE). Once barriers are addressed implementation of psychosocial screening and assessment can be achieved in the private sector.