Assessment of perinatal anxiety: diagnostic accuracy of five measures.

BACKGROUND: Anxiety in pregnancy and after giving birth (the perinatal period) is highly prevalent but under-recognised. Robust methods of assessing perinatal anxiety are essential for services to identify and treat women appropriately. AIMS: To determine which assessment measures are most psychometrically robust and effective at identifying women with perinatal anxiety (primary objective) and depression (secondary objective). METHOD: We conducted a prospective longitudinal cohort study of 2243 women who completed five measures of anxiety and depression (Generalized Anxiety Disorder scale (GAD) two- and seven-item versions; Whooley questions; Clinical Outcomes in Routine Evaluation (CORE-10); and Stirling Antenatal Anxiety Scale (SAAS)) during pregnancy (15 weeks, 22 weeks and 31 weeks) and after birth (6 weeks). To assess diagnostic accuracy a sample of 403 participants completed modules of the Mini-International Neuropsychiatric Interview (MINI). RESULTS: The best diagnostic accuracy for anxiety was shown by the CORE-10 and SAAS. The best diagnostic accuracy for depression was shown by the CORE-10, SAAS and Whooley questions, although the SAAS had lower specificity. The same cut-off scores for each measure were optimal for identifying anxiety or depression (SAAS ≥9; CORE-10 ≥9; Whooley ≥1). All measures were psychometrically robust, with good internal consistency, convergent validity and unidimensional factor structure. CONCLUSIONS: This study identified robust and effective methods of assessing perinatal anxiety and depression. We recommend using the CORE-10 or SAAS to assess perinatal anxiety and the CORE-10 or Whooley questions to assess depression. The GAD-2 and GAD-7 did not perform as well as other measures and optimal cut-offs were lower than currently recommended.

Exploring the psychometric properties of the professional issues in maternal mental health scale (PIMMHS) in a Chinese population.

BACKGROUND: The public health and economic implications of perinatal mental health problems are well documented. Maternity clinicians are ideally placed to effectively identify women at risk and facilitate early intervention. However, in China as globally a number of issues are implicated in a failure to recognise and treat. AIM: The present study sought to develop and evaluate the Chinese version 'professional issues in maternal mental health' scale (PIMMHS), explore its psychometric properties and potential application. METHODS: A cross-sectional design and instrument translation and evaluation approach was taken to investigate the psychometric properties of the PIMMHS in a Chinese population. A total of 598 obstetricians, obstetric nurses, and midwives participated in this study from 26 hospitals across China. FINDINGS: The Chinese PIMMHS was not a good fit to the original two factor model. The emotion/communication subscale yielded an excellent fit to the data according to all fit indices, offering compelling evidence for a single factor solution. The training (PIMMHS: Training), proved problematic throughout the analysis with divergent validity for the training subscale also being poor with a concomitant impact on the total scale performance. The performance of this subscale may be related to the nature of medical training and PMH. CONCLUSION: The Chinese PIMMHS comprises a unidimensional scale of emotion/ communication, which is simple and may provide insight into the emotional burden of providing PMH care, with the potential to mitigate that burden. Further development and investigation of the training sub-scale could be of value.

Practitioner perspectives on the use of selected fear of childbirth screening tools within a clinical context.

Fear of childbirth (FOC), or tokophobia, can influence several medical and obstetric variables, and is a significant predictor of maternal and mental health outcomes and birth experiences. Current practice in the UK does not include initial screening for tokophobia, rather, assessment and support occur under extreme circumstances e.g. maternal requests for caesarean sections or pregnancy termination requests in order to avoid childbirth. Moreover, while there are several candidate outcome measures for FOC, none have been evaluated in terms of their perceived suitability by specialist practitioners within perinatal healthcare pathways. The present study explores the perceived barriers and facilitators reported by health professionals working within the maternity and mental health services for the use of FOC candidate outcome measures. Evaluated measures included the Fear of Birth Scale, the Oxford Worries about Labour Scale, The Wijma Delivery Expectancy Scale, the Slade-Pais Expectations of Childbirth Scale the Tokophobia Severity Scale. The Tokophobia Severity Scale, followed by the Slade-Pais Expectations of Childbirth Scales were the most favourable scales selected for use according to clinicians. The identification of preferred scales and how they can be used in the local maternity system is a step towards the application of these consistently in clinical practice, to aid in the identification and assessment of FOC. The use of the correct tool at each stage of contact with the local maternity system will improve clinician confidence in the identification of FOC and facilitate the efficient implementation of treatment and support through the development of pathways of care.

Giving midwives a voice - Qualitative perspectives of an 'empowering decision-making workshop'.

AIM/OBJECTIVE: To establish midwives' perceptions of the value of workshops designed to empower their decision-making and leadership skills using validated midwifery clinical reasoning frameworks and appreciative inquiry methods. BACKGROUND: The medical lens of childbirth can disempower women and midwives. Midwives often face challenges navigating their role as autonomous practitioners and advocates for shared decision-making, particularly when there is tension between women's wishes, governance frameworks and organisational requirements. This can lead to 'Midwifery Abdication' and/or the midwifery voice being silenced. DESIGN/METHODS: Appreciative inquiry, involving qualitative analysis of 31 midwives' personal reflections during 'Empowering Midwives' Decision-Making' workshops. Standards for reporting qualitative research (SRQR criteria) guided the preparation of this manuscript. RESULTS: Decision-making tools and 'appreciative' strategies can strengthen leadership attributes, enhance feelings of empowerment and deepen understanding. Reflecting on 'Midwifery Abdication' was perceived as confronting. Workshop activities offered understanding the reasons why 'Midwifery Abdication' may or may not occur. One overarching, key theme was identified: 'Finding my midwifery voice'. This theme encompassed three sub-themes: 'I am not alone', 'Using leadership to promote collaboration to effect change' and 'An onward journey of enlightenment and empowerment'. CONCLUSION: Midwives need to find their voice and develop skills in both clinical reasoning and transformative reflection. Workshops, using Appreciative Inquiry approaches, that focused on reflection, clinical decision-making and 'Midwifery Abdication', facilitate this and may create feelings of reunification in midwives and rejuvenate inherent passion for the profession. RELEVANCE TO CLINICAL PRACTICE: Sharing feelings around providing care in the often-contested space that is advocating for women using midwifery philosophy may provide relief from moral distress and a sense of shared identity desperately sought after by midwives struggling to navigate the increasingly complex terrain of maternity care. Findings encourage the need for further discussions around strengthening midwifery leadership which may be achievable using Appreciative Inquiry frameworks and approaches.

The Tokophobia Severity Scale (TSS): measurement model, power and sample size considerations.

OBJECTIVE: To examine the measurement model of the Tokophobia Severity Scale and consider issues of statistical power and sample size from the original instrument development study. BACKGROUND: Fear of childbirth (FoC) and tokophobia represents an area of increasing concern within perinatal mental health research and clinical practice. Existing measures of the FoC have been criticised due to either measurement inconsistencies, difficulties in scoring or practical clinical application. Attempting to address these limitations, researchers developed the Tokophobia Severity Scale (TSS). A fundamental assumption underpinning the use of the TSS is unidimensionality, however this assertion may have been based on sub-optimal sample size and approach taken to factor structure determination. METHOD: Parallel analysis (PA), principal components analysis (PCA), exploratory factor analysis (EFA), power analysis and sample size calculation using a reconstruction of the original dataset from published summary data. RESULTS: Following replication of the original PCA, a three-factor model was found to offer a significantly better fit to data than a unidimensional model. Power analysis suggested the original study was underpowered. CONCLUSION: The TSS remains a promising tool but assumptions regarding its measurement model are based on an inadequate sample size. Sample sizes for a sufficiently powered study indicated.

Fear of childbirth measurement: appraisal of the content overlap of four instruments.

OBJECTIVE: To evaluate empirically the degree of content overlap between four self-report measures of fear of childbirth (FoC) identified as 'best in class' by a recent review. BACKGROUND: FoC and tokophobia is an area of increasing clinical concern and has been linked to poor maternal and neonatal outcomes. Clinical pathways have been established to improve care and interventions for FoC however, ambiguity and inconsistency remain regarding the most appropriate assessment measures. METHOD: A multi-rater and consensus content analysis was undertaken to determine the degree of overlap between four 'best in class' measures of FoC/tokophobia. RESULTS: The Slade-Pais expectations of childbirth scale (SPECS) was found to be the preferred measure in terms of symptom overlap of the tools evaluated, however, the overall level of overlap among these measures was weak. CONCLUSION: Limitations inherent to the current battery of preferred measures of FoC suggests both the desirability and urgency to develop a theoretically-grounded, psychometrically robust and accurate FoC assessment measure. Current measures of FoC are not interchangeable.

Public health nurses' perinatal mental health training needs: A cross sectional survey.

AIM: To examine public health nurses' education, training, and professional support needs in perinatal mental health. BACKGROUND: Public health nurses have a key role in supporting maternal mental health including screening, support, referral, and decreasing stigmatization. DESIGN: A cross-sectional survey. METHODS: Data were collected from a convenience sample of Irish public health nurses (N = 105) from December 2016-February 2018. The anonymous postal survey consisted of the Perinatal Mental Health Questionnaire, Mental Illness: Clinician's Attitudes scale and Perinatal Mental Health Learning Needs questionnaire. RESULTS: Public health nurses reported good levels of knowledge (77.2%) and confidence (83.8%) in recognising women experiencing stress, anxiety and depression. They indicated less confidence in caring (50.5%) for women. The average score for the Mental Illness: Clinician's Attitudes scale was 35.9 (SD 5.9), suggesting positive attitudes towards women with significant mental illness. CONCLUSION: Public health nurses require educational opportunities to explore expressions of psychological distress across cultures and their own personal attitudes to mental health, systems of clinical supervision, and support pathways. IMPACT: Generating new knowledge on the importance of incorporating an attitude component in perinatal mental health education for public health nurses.

Family physicians perceived role in perinatal mental health: an integrative review.

BACKGROUND: Responding to and caring for women who experience mental health problems during the perinatal period, from pregnancy up to one year after birth, is complex and requires a multidisciplinary response. Family physicians are ideally placed to provide an effective response as it is recognised that they are responsible for organising care and supports for women and their families. This paper reports an integrative review undertaken to examine family physicians' perceived role in perinatal mental health care and concludes with recommendations for health policy, research and practice. METHOD: A systematic search of literature in seven databases from January 2000 to March 2016 identified a total of 1125 articles. Qualitative, quantitative and mixed-method studies were eligible for inclusion if they explored family physicians' experiences of caring for women who experience perinatal mental health problems. RESULTS: Thirteen articles reporting 11 studies met the inclusion criteria for this review and quality of included studies were assessed using published criteria for the critical appraisal of qualitative and quantitative research methods. Cross-study narrative syntheses of quantitative and qualitative findings are presented under three themes: identification of perinatal mental health problems, management of perinatal mental health problems and barriers to care provision. While family physicians recognise their role in relation to perinatal mental health the collective interpretation revealed that; they receive variable levels of preparation for this role, no consistent approach to screening exists, pharmacological management of mood disorders is the main treatment modality and limited access to specialist perinatal mental health services exists which impacts on pharmacology decisions. CONCLUSION: Family physicians require timely access to local integrated care pathways that provide a wide range of services that are culturally sensitive, perinatal mental health specific, support psychological well-being and infant/family mental health. Family physicians are open to incorporating a brief validated screening tool into primary practice supported by succinct guidelines. Research that examines training needs in relation to perinatal mental health could be used to inform family physician training programmes and curriculum development around perinatal mental health.

Irish general practitioners' view of perinatal mental health in general practice: a qualitative study.

BACKGROUND: Identification of perinatal mental health problems and effective care for women who experience them are important considering the potentially serious impact that they may have on the wellbeing of the woman, her baby, family and wider society. General practitioners (GPs) play a central role in identifying and supporting women and this study aimed to explore GPs' experiences of caring for women with perinatal mental health problems in primary care. The results of this study may provide guidance to inform policy, practice, research and development of curriculum and continuous professional development resources. METHOD: In-depth semi-structured interviews were undertaken between March and June 2017 with GPs (n = 10) affiliated with a University training programme for general practice in Ireland. Thematic data analysis was guided by Braun and Clarkes (2013) framework. RESULTS: Data were categorised into three themes with related subthemes: identification of perinatal mental health problems, decision making around perinatal mental health and preparation for a role in perinatal mental health. GPs described the multifaceted nature of their role in supporting women experiencing perinatal mental health issues and responding to complex psychological needs. Inbuilt tools on existing software programmes prompted GPs to ask questions relating to perinatal mental health. Limited access to referral options impacts on assessment and care of women. GPs desire further continuous professional development opportunities delivered in an online format and through monthly meetings and conference sessions. CONCLUSIONS: GPs require access to culturally sensitive; community based perinatal mental health services, translation services and evidence based perinatal psychological interventions. A standardised curriculum on perinatal mental health for trainee GPs needs to be established to ensure consistency across primary care and GP education should incorporate rotations in community and psychiatry placements.

A mixed methods review to develop and confirm a framework for assessing midwifery practice in perinatal mental health.

AIM: To ascertain whether a new framework examining midwifery practice in perinatal mental health (PMH) is supported by the research literature. BACKGROUND: The identification and care of women with PMH problems is increasingly considered part of midwifery practice. Research suggests that many midwives lack knowledge, skills and confidence. It would be useful to be able to determine barriers and facilitators to effective clinical practice. The authors propose a framework comprising five potentially measurable domains which have an impact on midwives' ability to identify, assess and care for women with PMH problems. DESIGN: This mixed-methods review uses an innovative qualitative convergent design based on framework synthesis. DATA SOURCES: Relevant electronic databases were searched for the period from January 2007-December 2016; 33 studies from nine countries met the inclusion criteria. REVIEW METHODS: Study quality was assessed using critical appraisal tools. Study findings were mapped onto the five domains of the framework: knowledge, confidence, attitudes, illness perception and infrastructure. Findings were then synthesized for each domain. RESULTS: All five domains are substantially represented in the literature, thus supporting the proposed framework. Several sub-domains and relationships between domains were identified. Varying levels of knowledge, confidence, attitudes and illness perceptions were found; evidence suggests that midwives benefit from further training within these domains. Features of organizational infrastructure act as barriers or facilitators to effective care; these need to be addressed at organizational level. CONCLUSION: The proposed framework was confirmed and can be used to inform practice, policy and research.

A qualitative meta-synthesis: public health nurses role in the identification and management of perinatal mental health problems.

AIM: To report findings of a systematic review and meta-synthesis of qualitative studies exploring public health nurses' perceptions and experiences of identifying and managing women with perinatal mental health (PMH) problems. BACKGROUND: Public health nurses play a key role in supporting women who experience PMH problems and several qualitative studies have explored their role. DESIGN: Systematic review and meta-synthesis DATA SOURCES: A comprehensive search was developed and multiple databases were searched from 2000-2015. REVIEW METHODS: Studies that employed qualitative methods to explore experiences of public health nurses in identifying and managing women with PMH problems were included. Two reviewers independently assessed the methodological quality of studies. Themes, concepts and interpretations were extracted and synthesized using the process of thematic analysis. RESULTS: Fifteen papers including 14 unique qualitative studies were included. Two overarching themes were identified: 'conceptualization and detection of PMH problems' and 'barriers and facilitators to management'. The former of these comprised several subthemes including the use of formal screening tools vs. clinical intuition and challenges encountered in detection. The latter theme, barriers to management included availability of referral pathways and time. In terms of facilitators, training, public health nursing interventions, support groups and referral pathways were identified as factors that optimize management. CONCLUSIONS: Public health nurses use a variety of methods to identify women with PMH problems. However, several support structures are needed to optimize management including access to appropriate referral pathways, support groups and relationship continuity.

Understanding asexual identity as a means to facilitate culturally competent care: A systematic literature review.

AIMS AND OBJECTIVES: To provide a contemporary overview of asexuality and the implications this has for healthcare practice. BACKGROUND: Individuals belonging to sexual minority groups face many barriers in accessing appropriate health care. The term "sexual minority group" is usually used to refer to lesbian women, gay, bisexual and transgender individuals. Anecdotal and research evidence suggests that those who identify as asexual have similar poor experiences. DESIGN: Systematic review and qualitative analysis. METHODS: This work uses a systematic review and qualitative analysis of the existing interview data from self-identified asexuals, to construct features of the asexual identity. The findings will help practitioners and health professionals develop an understanding of this poorly understood construct. Ultimately this work is aimed at facilitating culturally competent care in the context of asexuality. RESULTS: Qualitative analysis produced three themes, which can be used, not only to frame asexuality in a positive and normalising way, but also to provide greater understanding of asexuality, "romantic differences coupled with sexual indifference," "validation through engagement with asexual communities" and "a diversity of subasexual identities." CONCLUSIONS: Having some understanding of what it means to identify as asexual, and respecting the choices made by asexuals can markedly improve the experiences of those who embrace an asexual identity when engaging with health care. RELEVANCE TO CLINICAL PRACTICE: Anecdotal evidence, taken from one of the largest asexual online forums, suggests that a number of self-identified asexuals choose not to disclose their identity to healthcare professionals through fear of their asexual status being pathologised, problematised or judged. Given that asexuality is a poorly understood concept, this may be due to lack of understanding on behalf of healthcare providers. The review provides health professionals and practitioners working in clinical settings with some insights of the features of an asexual identity to facilitate culturally competent care.

Determining the psychometric properties of the Enhancing Decision-making Assessment in Midwifery (EDAM) measure in a cross cultural context.

BACKGROUND: The ability to act on and justify clinical decisions as autonomous accountable midwifery practitioners, is encompassed within many international regulatory frameworks, yet decision-making within midwifery is poorly defined. Decision-making theories from medicine and nursing may have something to offer, but fail to take into consideration midwifery context and philosophy and the decisional autonomy of women. Using an underpinning qualitative methodology, a decision-making framework was developed, which identified Good Clinical Reasoning and Good Midwifery Practice as two conditions necessary to facilitate optimal midwifery decision-making during 2nd stage labour. This study aims to confirm the robustness of the framework and describe the development of Enhancing Decision-making Assessment in Midwifery (EDAM) as a measurement tool through testing of its factor structure, validity and reliability. METHOD: A cross-sectional design for instrument development and a 2 (country; Australia/UK) x 2 (Decision-making; optimal/sub-optimal) between-subjects design for instrument evaluation using exploratory and confirmatory factor analysis, internal consistency and known-groups validity. Two 'expert' maternity panels, based in Australia and the UK, comprising of 42 participants assessed 16 midwifery real care episode vignettes using the empirically derived 26 item framework. Each item was answered on a 5 point likert scale based on the level of agreement to which the participant felt each item was present in each of the vignettes. Participants were then asked to rate the overall decision-making (optimal/sub-optimal). FINDINGS: Post factor analysis the framework was reduced to a 19 item EDAM measure, and confirmed as two distinct scales of 'Clinical Reasoning' (CR) and 'Midwifery Practice' (MP). The CR scale comprised of two subscales; 'the clinical reasoning process' and 'integration and intervention'. The MP scale also comprised two subscales; women's relationship with the midwife' and 'general midwifery practice'. CONCLUSION: EDAM would generally appear to be a robust, valid and reliable psychometric instrument for measuring midwifery decision-making, which performs consistently across differing international contexts. The 'women's relationship with midwife' subscale marginally failed to meet the threshold for determining good instrument reliability, which may be due to its brevity. Further research using larger samples and in a wider international context to confirm the veracity of the instrument's measurement properties and its wider global utility, would be advantageous.

A Home-Start peer support scheme for women with low mood following childbirth.

Perinatal mental health problems vary in impact and severity, and can have long-lasting effects on maternal health and child psychological health and development. The evidence to support the effectiveness of postnatal peer and volunteer support schemes to improve the long-term health of women is mixed, with some studies highlighting positive effects in terms of reducing symptoms of depression. Using data from a peer support scheme designed to support women with low mood following childbirth, this paper provides insight into the initial support needs of women, alongside the challenges of using volunteer and peer support services. This paper provides health visitors and others working in community settings with an understanding of how volunteer befriending services may, or may not work in community settings. The data suggests that Home-Start does have a positive impact on the lives of some women, however more work is required in order to understand which aspects of the Home-Start intervention women find effective and why.

Developing specialist perinatal mental health services.

Perinatal mental illness (PMI) represents a significant public health concern affecting considerable numbers of pregnant women and mothers of infants. Depression and anxiety are key issues; however accurate identification of PMI, suitable intervention and provision of adequate services are salient contemporary challenges. Coherence in the commissioning of PMI services, appropriate and contextually sensitive to the needs of the locality, remains a critical factor in the provision of high quality, integrated and seamless care. However, such coherence has had difficulty in finding traction, largely as a consequence of complex service and organisational structures and commissioning pathways. This paper discusses many of the issues that must be considered in the provision of high quality PMI services that are sensitive and appropriate for the needs of women and their families in the community. An exemplar of the development of a local service is discussed in detail.

Ethnic minority women's experience of maternity services in England.

OBJECTIVES: Provision for ethnic minority groups has been acknowledged as integral to good maternity care in England and ethnicity has been highlighted as an indicator of both poorer clinical outcomes and poorer experiences. Improving outcomes and services is dependent on understanding women's interaction with both service delivery and provision. The aim of this study was to explore Black and minority ethnic (BME) women's experiences of contemporary maternity care in England. DESIGN: A UK-wide survey which investigated core aspects of maternity care sought the views of BME women about their experiences. A random sample of women were selected by the Office for National Statistics from birth registration in England and invited to complete a questionnaire three months after the birth. In a secondary analysis, text responses to open-ended questions about their maternity care were analysed using thematic analysis. RESULTS: Sixty per cent of the 368 women who self-identified as BME responded with open text. Themes that emerged related to 'feeling cared for,' with subthemes of 'expectations of care' and 'policies, rules and organisational pressures'; 'staff attitudes and communication' with sub-themes of 'please believe me,' 'hospital as a safe place,' 'choices denied' and 'being sensitive and supportive would help,' and 'ethnicity and culture' with sub-themes of 'stereotyping' and 'improving the quality of care.' CONCLUSION: The findings highlight issues affecting the quality of maternity care that BME women in England receive. Many issues are not unique to BME women; however, the findings reflect some seemingly enduring issues and coherence with other wider international findings, particularly in relation to post-natal care and staff attitudes. Actually being cared for and supported across their child-bearing experience are needs that women themselves identified as critical for care providers to recognise and respond to. The failures of care provision described should inform the development of services.

Sexual health information seeking: a survey of adolescent practices.

AIMS AND OBJECTIVES: To identify sources of information and support preferred by young people to understand adolescent practices as adolescents develop a sexual health knowledge base. BACKGROUND: Statistics suggest that adolescents are not always making safe sexual health decisions. It is essential to develop an understanding of preferred sources of information and support to structure health and education services so that adolescents develop skills and knowledge to make safer choices. DESIGN: A cross-sectional survey design. METHODS: A wide-ranging questionnaire was developed using validated questions, drawn from similar adolescent lifestyle surveys and adapted with guidance from an advisory group; 2036 13-16-year-olds responded. Two questions, reporting information sources adolescents find useful and sources of approachable support, are considered here. RESULTS: Adolescents find informal sources more useful and experience higher levels of comfort accessing informal support especially from their best friends and mothers. Of formal provision, school-based sources are preferred; however, sexual health information seeking is gendered and changes across year groups. The range of sexual health information sources adolescents access increases with age, and how they access these information sources changes as sexual activity increases and the information becomes more relevant. CONCLUSIONS: The findings support the targeting of sexual health provision in relation to age and gender and suggest a youth-focused approach to formal provision, including outreach working and a collaborative relationship with adolescents and parents. RELEVANCE TO CLINICAL PRACTICE: The findings contribute to an understanding of sources of information and support preferred by adolescents. In particular, they need to reconsider how services external to the school may be developed so they are youth-focused and approachable. Nurses need to consider how best to work in partnership with adolescents and their families to disseminate accurate information and develop relevant services.