What is the Health Professional’s Role in Perinatal Psychosocial Screening Assessment and Referral in the Private Sector?

1. Background

Publications in Australian and international literature, as well as Australian Government initiatives [1], leading to the National Perinatal Depression Initiative) provide evidence for the importance of ensuring the mental health of women who are pregnant or caring for young children [2]. Attention to psychological and social aspects of obstetric/maternity and postnatal care including depression screening, is inconsistent across the public sector and virtually non-existent in the private sector [3]. Various studies have investigated psychosocial assessment and [4, 5] depressive symptoms in early pregnancy [5]. Psychosocial assessment is integral in good antenatal care [6]. A national psychosocial approach to mental health is needed in Australia [7]. Various initiatives, e.g. Beyondblue; the national depression initiative, with its National Action Plan [1] NHMRC-approved Clinical Guidelines and Workforce Training and Development Working Party (2010-2011) have attempted to identify best practice and procedural difficulties and address these. Nevertheless, issues of inconsistency in screening, resources and approach are evident in the public health situation and no programs have been definitively established to date in the private system, where some 30% of births occur [3].

There is a need for further education and training of healthcare professionals to increase their awareness and treatment of perinatal depression [6]. What is in fact the role of the midwife in regards to psychosocial screening in the private sector? Does the fact that the women are not under the direct care of the midwife, influence their decision/involvement/ choice to discuss with women their psychosocial concerns/ screen women for risk factors? Early detection of maternal depression may facilitate treatment and offer support for women who are vulnerable to recurrent depressive episodes [8]. Screening is dependent upon the setting, the population, the health resources available, system changes that enhance the impact of screening efforts and the quality of the programme’s aims, design and implementation [9].

2. Introduction

Antenatal depression is prevalent and has potentially far-reaching adverse consequences. Reported prevalence rates of depression in the antenatal period are similar to postpartum levels and range from 12% to 20% [10-14]. Depression in pregnancy may compromise a woman’s physical and mental health and the health of her unborn baby through diminishing her capacity for selfcare, including inadequate nutrition, increased drug or alcohol abuse and poor antenatal clinic attendance [7]. Antenatally depressed mothers have been found to experience increased episodes of pre-eclampsia [15], preterm delivery and placental abruption [16, 17] as well as adverse obstetric outcomes [18]. Antenatal depression is also recognised as a powerful predictor of postnatal depression [19, 12]. Thus, some women may not only spend time in pregnancy depressed, but might also enter parenthood in a depressed state, which in turn has been associated with cognitive and behavioral developmental difficulties in infants [20]. Successful treatment for depression is available [21-23] but early detection and management seems imperative to achieve this outcome.

There is acceptance of the value of routine perinatal psychosocial assessment of some form as long as adequate pathways to care and training are available. Great variation is identified between the antenatal and postnatal settings, and across jurisdictions, with pathways to care not always adequate or well-integrated Research evidence and clinical experience indicate it is critical that psychosocial assessment begin in the antenatal setting to optimise early detection for mental health and wellbeing [24]. All women screened in one study (100%) reported that the screening experience was acceptable and not upsetting [9, 10]. Almost 50% reported that the screening process raised their awareness of perinatal depression. No woman reported feeling stigmatised, labelled or distressed by the screening process. Women reported that gaining immediate feedback from midwives was reassuring.

3. Private Sector Workforce

The Australian Institute of Health and Welfare (AIHW) reports that 31% of women who give birth in hospitals choose to do so in private hospitals, ranging from 19.2% in the Northern Territory to 41.1% in Western Australia [25]. It should be noted that in addition to private hospitals, private sector providers include Medical Practitioners (General Practitioners, Psychiatrists, Obstetricians, Paediatricians), Midwives, Mental Health Nurses, Psychologists, Social Workers, and Occupational Therapists. Like the public sector, as private sector providers work to meet the emerging challenges of addressing perinatal mental health issues there is a significant impact on the capacity of these workforces to undertake universal, routine assessment, access quality training programs, identify relevant pathways to care, and ensure organisational and professional policies exist to support these activities. These activities along with the development and endorsement of national standards for perinatal mental health will need to be incorporated into private sector evaluation and continual improvement processes in fulfilling accreditation requirements.

4. Strategies for Change

Health professionals providing maternity care need the skills to identify and manage challenging psychosocial problems such as depression, domestic violence, child and substance abuse, homelessness, intellectual disability, social isolation, lack of capacity to care for a baby, lack of social and interpersonal support, mental illness. Yet traditional midwifery and medical training has not equipped them well for this role. A common response to this is the development of a psychosocial risk assessment checklist and the implementation of antenatal screening (26). Maternity units involved in antenatal screening need training for referral and support systems. A policy or guideline is also important for the management of women with depression, including referral pathways.

5. Information

It is recognised that many families choosing the private sector for birthing and other services will, at times, also require the resources of the public sector to support their care. To achieve this, the formation and maintenance of collaborative partnerships between public, private and Non-Government Organisation service providers will be necessary to assist the delivery of appropriate care and support to ensure that privately insured women or those who birth in the private sector receive equally high quality mental health care and can move easily between services and sectors.

Infrastructure and programs within AGPN that can support quality routine perinatal mental health care in the primary health care sector include: delivery of perinatal mental health education and training; clinical support and enhancement of perinatal mental health knowledge and skills for General Practitioners, Psychologists, Allied Health professionals and nurse practice staff; health promotion through the Pregnancy Lifescripts tool kit [27] support for uptake of related MBS Mental Health items and numbers; development and promotion of linkages; and systematic referral pathways.

Declarations

Authors Contributions

The main author conducted the study and analysed and interpreted the data. The main author wrote the article with suggestions from the co-author. All authors read and approved the final manuscript.

Ethical approval and consent to participate

The University of Sydney ethics committee has approved the study as part of the authors PhD. Informed consent was not applicable as there were no human participants.

Consent for publication

The article is the author(s) original work. The article has not received prior publication and is not under consideration for publication elsewhere. All authors have seen and approved the manuscript being submitted. The author(s) abide by the copyright terms and conditions of Elsevier.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Competing Interests

The authors declare that there are no competing interests.

Funding

No funding was provided or available for the research.

Acknowledgements

There are no Grants, financial support and technical or other assistance.

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