Referral for management of emotional health issues during the perinatal period: does mental health assessment make a difference?

BACKGROUND: There exists little evidence that routine assessment of current or past mental health in the perinatal period positively impacts on rates of referral for emotional health issues. This study aimed to evaluate the impact of this early intervention approach on reported referrals for emotional health issues during pregnancy and the first postpartum year. METHOD: A subsample of women (N = 1,804) drawn from the Australian Longitudinal Study on Women's Health participated in the study. RESULTS: Multivariate analyses showed that predictors of being given a referral for emotional health issues during pregnancy and the postnatal period, respectively, included assessment of past mental health (Adjusted Odds Ratio [AOR] = 4.40, p < 0.001, and AOR = 5.69, p < 0.001), assessment of current mental health (AOR = 2.47, p < 0.001, and AOR = 2.72, p < 0.001), and reported experience of significant emotional distress (AOR = 2.58, p < 0.001, and AOR = 2.83, p < 0.001). The odds of receiving a referral were up to 16 times greater for women who were asked about both their past and current mental health than for women who did not receive any form of mental health assessment. CONCLUSIONS: This study highlights that enquiry into risk factors such as past history (in addition to current mental health) enhances initiation of referrals. Importantly, results suggest that enquiry about current mental health is associated with appropriate rates of referral rather than a nonspecific inflation of referrals. In line with Australia's Clinical Practice Guidelines for Perinatal Mental Health, the value of a comprehensive approach to mental health assessment to aid decision making around referral for further assessment or care is particularly evident.

Disparities in reported psychosocial assessment across public and private maternity settings: a national survey of women in Australia.

BACKGROUND: Psychosocial assessment and depression screening is now recommended for all women who are pregnant or have recently given birth in Australia. Existing studies which have examined the extent of participation by women in such population-based programs have been primarily concerned with depression screening rather than a more comprehensive examination of psychosocial assessment, and have not been sufficiently inclusive of the 30% of women whose maternity care is provided in the private sector. Whether there are disparities in equity of access to perinatal psychosocial assessment is also unknown. METHODS: A sub-sample of women (N = 1804) drawn from the Australian Longitudinal Study on Women's Health participated in the study. Overall rates of assessment across five psychosocial domains (current emotional health; mental health history; current level of support; current drug or alcohol use; experience of domestic violence or abuse), as well as receipt of mental health promotion information, were examined. Log binomial regression was performed to investigate whether there were socio-demographic or health system inequalities among women who are and are not assessed across each domain. RESULTS: Two-thirds of women (66.8%) reported being asked about their current emotional health in the antenatal period, increasing to 75.6% of women in the postnatal period. Rates decreased markedly for reported assessment of mental health history (52.9% during pregnancy and 41.2% postnatally). Women were least likely to be asked about their experience of domestic violence or abuse in both the antenatal and postnatal periods (in total, 35.7% and 31.8%, respectively).In terms of equity of access to psychosocial assessment, women who gave birth in the public hospital sector were more likely to report being assessed across all domains of assessment in the antenatal period, compared with women who gave birth in the private sector, after adjusting for other significant covariates. State of residence was associated with reported rates of assessment across all domains in both the antenatal and postnatal periods. Women from non-English speaking backgrounds and women with more than one child were less likely to be assessed across various domains. CONCLUSION: This study provides an important insight into the reported overall penetration of and access to perinatal psychosocial assessment among a sample of women in Australia. Opportunities to minimise the current shortfall in assessment rates, particularly in the private sector, and for ongoing monitoring of assessment activity at a national level are discussed.

Honesty and comfort levels in mothers when screened for perinatal depression and anxiety.

PURPOSE: To evaluate the degree of honesty and level of comfort reported by women when questioned about their emotional wellbeing during the perinatal period; to investigate if honesty and comfort are associated with perinatal depression or perinatal anxiety; and to examine the reasons why women may not always respond honestly. METHODS: Qualitative and quantitative data from 1597 women from the cross-sectional perinatal mental health substudy (part of the Australian Longitudinal Study on Women's Health) were analysed using a mixed methods approach. RESULTS: When questioned by their health practitioner about their emotional wellbeing in the perinatal period, 20.7% of women indicated they had not always responded honestly. Reasons for not being honest reflected four main themes: normalizing of symptoms/coping; negative perceptions (self-and others); fear of adverse repercussions; and fear of involvement of health services (trust and confidentiality). The 38.9% of women who did not feel comfortable when questioned by their health practitioner about their emotional wellbeing were four times more likely to report perinatal depression (odds ratio = 4.09; 95% confidence interval = 2.55, 6.57) and nearly twice as likely to report perinatal anxiety (odds ratio = 1.90; 95% confidence interval = 1.24, 2.94) than other women. CONCLUSIONS: Women who are most likely to need mental health care during the perinatal period are also those least likely to be honest about their mental health. A non-judgemental, open and reassuring approach by clinicians may help to reduce the stigma and fears contributing to lack of honest responses, and improve early diagnosis and treatment of mental health problems.

History of pregnancy loss increases the risk of mental health problems in subsequent pregnancies but not in the postpartum.

While grief, emotional distress and other mental health conditions have been associated with pregnancy loss, less is known about the mental health impact of these events during subsequent pregnancies and births. This paper examined the impact of any type of pregnancy loss on mental health in a subsequent pregnancy and postpartum. Data were obtained from a sub-sample (N = 584) of the 1973-78 cohort of the Australian Longitudinal Study on Women's Health, a prospective cohort study that has been collecting data since 1996. Pregnancy loss was defined as miscarriage, termination due to medical reasons, ectopic pregnancy and stillbirth. Mental health outcomes included depression, anxiety, stress or distress, sadness or low mood, excessive worry, lack of enjoyment, and feelings of guilt. Demographic factors and mental health history were controlled for in the analysis. Women with a previous pregnancy loss were more likely to experience sadness or low mood (AOR = 1.75, 95% CI: 1.11 to 2.76, p = 0.0162), and excessive worry (AOR = 2.01, 95% CI: 1.24 to 3.24, p = 0.0043) during a subsequent pregnancy, but not during the postpartum phase following a subsequent birth. These results indicate that while women who have experienced a pregnancy loss are a more vulnerable population during a subsequent pregnancy, these deficits are not evident in the postpartum.

The impact of routine assessment of past or current mental health on help-seeking in the perinatal period.

BACKGROUND: Clinical practice guidelines now recommend that women be asked about their past or current mental health as a routine component of maternity care. However, the value of this line of enquiry in increasing engagement with support services, as required, remains controversial. AIM: The current study aimed to examine whether assessment of past or current mental health, received with or without referral for additional support, is associated with help-seeking during pregnancy and the postpartum. METHODS: A subsample of women drawn from the Australian Longitudinal Study on Women's Health (young cohort) who reported experiencing significant emotional distress during pregnancy (N=398) or in the 12 months following birth (N=380) participated in the study. RESULTS: Multivariate analysis showed that women who were not asked about their emotional health were less likely to seek any formal help during both pregnancy (adjOR=0.09, 95%CI: 0.04-0.24) and the postpartum (adjOR=0.07, 95%CI: 0.02-0.13), as were women who were asked about these issues but who were not referred for additional support (antenatal: adjOR=0.26, 95%CI: 0.15-0.45; postnatal: adjOR=0.14, 95%CI: 0.07-0.27). However, considerable levels of consultation with general practitioners, midwives and child health nurses, even in the absence of referral, were evident. CONCLUSION: This study demonstrates that enquiry by a health professional about women's past or current mental health is associated with help-seeking throughout the perinatal period. The clinical and resource implications of these findings for the primary health care sector should be considered prior to the implementation of future routine perinatal depression screening or psychosocial assessment programmes.