Antenatal psychosocial risk assessment project

AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

ANTENATAL PSYCHOSOCIAL RISK ASSESSMENT PROJECT Lizette WilHntck, BAppSc Antenatal Risk Assessment Project Coordinator, Wodonga Regional Health Service R o b y n Schubert, BAppSc Executive Director Patient Services, Wodonga Regional Health Service (Reprint requests to Lizette Willinck) Abstract

This article describes a six-month State Government funded project conducted at a regional Victorian hospital. The aim of the project was to develop and introduce an antenatal risk assessment p r o g r a m to identify and manage psychosocially 'at risk' women and families. The results o f the p r o j e c t indicate that the evidencebased assessment develLizette Willinck oped was acceptable to both expectant w o m e n and midwives. When compared with the trad-itional assessment it was also significantly better at identifying and referring women with risk factors. KeyWords, Antenatal, Psychosocial, Risk assessment

Note This views expressed in this article reflect those of the authors and should not be attributed to the Department of Human Services or Wodonga Regional Health Service.

Acknowledgment This project was funded by a grant from the Maternity Services Enhancement Strategy Quality Improvement Funding Rounds. ANTENATAL PSYCHOSOCIAL RISK ASSESSMENT PROJECT INTRODUCTION

Traditional antenatal care including hospital booking visits and care by medical practitioners has focused on the detection of obstetric and medical problems. In m o s t cases p s y c h o s o c i a l issues are not SEPTEMBER 2000

systematically assessed by either care provider and hence problems or potential problems are frequently not recognised. Nevertheless psychosocial issues are increasingly recognised as important health determinants for childbearing women and their families (Maternity Services Enhancement Strategy, 1999). It is of significant c o m m u n i t y c o n c e r n that antenatal depression affects some 4-16% of women (NSW Health Postnatal Depression Services Review, 1994), domestic violence during pregnancy has b e e n reported as high as 16% (Parker et al, 1993) and postnatal depression affects 15-20% of postpartum women (Brown et al, 1994). These figures are higher than the incidence of gestational diabetes, preeclampsia, placenta previa and other medical problems yet most hospitals do not routinely screen for psychosocial problems. Earlier identification and management of psychosocial risk factors has been shown to improve postpartum outcomes. Nuckolls et al (1972) demonstrated that social support can reduce significant psychosocial stressors. A more recent literature review by Oakley (1992) concluded that social support improves the health of women and babies. Awareness of previous depression episodes has permitted health care providers to provide anticipatory counselling or medication. Home visits by nurses have been found to reduce the incidence of child abuse and injuries (Olds et al, 1997). Furthermore, the World Health Organisation recommended that in order to improve perinatal health furthei; prophylactic social work among pregnant w o m e n has to be strengthened (Forde et al, 1992). Given this high incidence of perinatal psychosocial problems, the potential for early interventions to improve these problems and the national and international calls for systematic screening and m a n a g e m e n t thereof, introduction of routine antenatal assessment and intervention for

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psychosocial issues is dearly indicated. This paper describes such an initiative by Wodonga Regional Health Service (WRHS). WRHS is a 130-bed hospital in North East Victoria with 1,500 births per annum. Before commencement of this project there was no consistent approach for identifying psychosocially 'at risk' expectant w o m e n and their families. Yet data from the Victorian Perinatal Data Collection Unit suggested that significant numbers of w o m e n giving birth at the hospital presented with identified risk factors for adverse outcomes such as postnatal depression. In 1998 12% of births were to unsupported mothers and 6.3% to adolescent mothers. Despite this only 3.7% of patients attending antenatal bookings were referred to the social worker. These figures clearly suggest that during antenatal care psychosocial problems were not being consistently identified or referred. The aim of this service enhancement project was to introduce an antenatal psychosocial risk assessment to better identify and manage 'at risk' families and hence erthance postnatal outcomes such as emotional well-being. The intention was to source or develop such an assessment, introduce it during a randomised control trial and then evaluate it in terms of risk factor identification, referrals to social work and acceptability of the assessment for expectant w o m e n and midwives. T h e s e m e a s u r e s w e r e d e e m e d impoi~nt indicators of the effectiveness and clinical applicability of the assessment. METHODS After obtaining funding for the project from the Maternity Services Enhancement Strategy Quality Improvement Funding Rounds, a part time project officer was recruited and a multidisciplinm T project committee formed. The first step of the project was to source or develop an antenatal psychosocial assessment that would identify w o m e n with antenatal depression, those in situations of domestic violence and those at risk of developing postnatal depression or of abusing or neglecting their children. The assessment needed to be evidence-based, user-friendly and quick to administer. A literature search yielded a number tools used for assessing psychosocial risk in pregnancy. Orr et al (1992) had developed the Prenatal Social Environment Inventory, a self-administered questionnaire designed for use in clinical settings. PAGE 8

Curry et al (1994) had designed the Prenatal Psychosocial Profile to detect psychosocial factors associated with adverse pregnancy outcomes and Norwood (1996) used the Social Support Apgar to screen for perceptions of adequacy of social support in pregnancy. However most of these tools had limitations such as tack of supporting evidence, excessive length or limited focus on only a few risk factors. The best evidence-based existing p s y c h o s o c i a l a s s e s s m e n t w a s the A n t e n a t a l Psychosocial Health Assessment (ALPHA) developed in Canada b y Reid et al (1998). The ALPHA systematically screened for 15 risk factors associated with adverse outcomes. With some modifications it was considered the most appropriate tool available. Changes made included amendments to domestic violence questions, inclusion of additional risk factors identified by recent research (Jackson et al, 1999), a risk scoring system and referral guidelines. This modified version of the ALPHA was piloted with 60 w o m e n attending their antenatal booking at the hospital. The tool was then refined on a number of occasions in response to women's and midwives feedback. The tool consisted of a three-step process. The first s t e p w a s c o m p l e t i o n of a single p a g e selfadministered questionnaire by all expectant w o m e n before their antenatal booking. The second step comprised a fifteen-minute interview Conducted by the midwife during the antenatal booking. This resulted in assignment of patients' risk scores using a checklist of 20 evidence-based risk factors (see Appendix). Patients attaining a score of two or greater p r o g r e s s e d to the third step w h i c h i n v o l v e d assessment, management and community referrals by the social worker. A randomised control trial was introduced following the pilot study. A control group of 50 patients and five midwives conducted antenatal bookings using the traditional assessment while an experimental group of 50 patients and seven midwives conducted antenatal b o o k i n g s using the Antenatal Risk Assessment Tool. The midwife sample size was relatively small due to resource constraints. The midwives and patients in both groups were randomly assigned based on staff rosters and consecutive antenatal bookings in July-August 1999. Midwives in the experimental group attended a one-hour t r a i n i n g s e s s i o n that i n c l u d e d a s s e s s m e n t

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administration instructions and strategies for eliciting and responding to sensitive information. Midwives in the control group were informed they w e r e participating in the trial and instructed to conduct antenatal bookings according to standard protocols using the traditional antenatal assessment.

using t tests and chi square analysis (see Table 1). The results demonstrated that the experimental group had a higher percentage of primiparous subjects (p=0.05). Overall the groups w e r e similar and therefore it was appropriate to compare them.

The randomised control trial hypotheses were:

Table 1: Socio-demographic and Social Work Referral Data

1. That e x p e c t a n t w o m e n in the control and experimental groups have similar demographic profiles 2. That expectant w o m e n in the experimental group have higher referrals to social work (as a function of better risk identification) than those in the control group 3. That expectant w o m e n in the experimental group have similar satisfaction levels or be slightly more satisfied with the antenatal assessment than those in the control group 4. That midwives in the experimental group be more satisfied with the antenatal assessment than those in the control group Expectant women's satisfaction with the assessment process was assessed via a phone satisfaction survey conducted by the Antenatal Project Officer. The survey contained six questions with a four-point response scale. The questions were designed to obtain patients' perceptions about opportunity to discuss medical and personal issues, adequacy of information on support services, level of comfort with the assessment, satisfaction with the length of the booking and whether the booking met their needs. Women had been informed that a telephone survey would occur. The Project Officer surveyed the first 18 consenting and contactable w o m e n from each group. This sample size was selected as being a logistically viable number of w o m e n to contact. Midwife satisfaction was determined from a written satisfaction survey. The survey c o n t a i n e d six questions with a five-point response scale. Questions were designed to obtain midwives' perceptions about ease a n d c o m f o r t of administration, c o m p r e h e n s i v e n e s s , ability to identify m e d i c a l a n d psychosocial issues and ability to meet patients' needs. All 12 m i d w i v e s p a r t i c i p a t i n g in the randomised control trial completed the survey. RESULTS

Socio-demographic profiles of the patients in the control and experimental group were compared SEPTEMBER2000

VARIABLE Samplesize Age Parity Gravida Primip Married/defacto Employed Australian born Smoke Socialwork referral

CONTROL

EXPERIMENTAL P-VALUE

(sal err)

(std err)

50 29.5 (0.8) 1.36 (0.20) 2.84 (0.22) 24% 84% 34% 92% 40% 6%

50 28 (0.9) 1.12 (0.17) 2.71 (0.28) 42% 88% 48% 96% 32% 30%

0.21 0.37 0.72 0.05 0.10 0.36 0.40 0.41 0.002

Referrals to social work were conducted for 30% of patients in the experimental group and only 6% of patients in the control group (see Table 1). After using a logistic regression model to adjust for the d e m o g r a p h i c differences b e t w e e n the g r o u p s referrals to social work remained significantly higher in the experimental group (.13=0.002). It was assumed the similar socio-demographic profiles of the control and experimental groups indicated similar f r e q u e n c i e s and t y p e s of risk factors ie that approximately 30% of patients in the control group were at risk and should have been referred to the social worker. However it is not possible to make a definitive statement of this nature and a separate study measuring risk factors in both groups needs to be conducted. Table 2: Expectant Women's Satisfaction VARIABLE

CONTROL (std err) Samplesize 18 Total score (out of possible 24) 21.9 (0.38) Q10pporllmitytodiscussmedicalissues 3.8 (0.9) Q2OpportunitytodLscttsspet~nalissues 3.4 (0.18) Q3 Informationon support services 3.1 (0.23) Q4 Comfortwith booking 3.9 (0.06) Q5 Satisfactionwithlengthof booking 4.0 (0) Q6 Bookingmet needs 3.8 (0.1)

EXPERIMENTALP-VALUE (std err) 18 22.8 (0.26) 0.06 3.8 (0.9) 0.99 3.7 (0.11) 0.2 3.6 (0.12) 0.06 3.9 (0.08) 0.56 3.8 (0.01) 0.04 3.8 (.0.09) 0.68

Expectant women's satisfaction with the assessment was high in both groups but as hypothesised it was slightly greater in the experimental than the control

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group (see Table 2). However a t test demonstrated this trend was not a statistically significant result (p=0.06). Table 3: Midwife Satisfaction VARIABLE

Sample size Total score (out of possible 30) Q1 User-friendly

CONTROL EXPERIMENTAL P-VALUE (std err) (std err)

5 20.4 (2.6) 3.8 (0.45) Q2Thorou# 3.0 (0) Q3 Identifies relevaut medical issues 3.6 (0.55) Q4Identifiesrelevantpsychosodalissues 2.8 (1.3) Q5 Comfort with booldng 4.4 (0.55) Q6 Booking met patient needs 2.8 (1.6)

7 22.9 (3.7) 3.9 (0.69) 4.4 (0.53) 3.7 (0.95) 3.4 (1.6) 3.6 (0.98) 3.9 (0.38)

0.23 0.88 0.0002 0.82 0.49 0.12 0.23

Midwife satisfaction with the assessment was slightly greater in the experimental group than the control group (see Table 3). Again a t test demonstrated this trend was not statistically significant (p=0.23) but the small sample size limited the p o w e r of the statistical test. Analysis of individual questions within the survey demonstrated several noteworthy findings. Firstly, a question about the comprehensiveness of the assessment indicated the risk assessment was perceived as significantly more thorough than the traditional assessment (p=0.0002). Secondly, a separate question asked only of the experimental midwives about their preference for the risk versus the traditional assessment demonstrated that more than half (57%) preferred the risk assessment. A further 29% were undecided and only one midwife (14%) preferred the traditional assessment. Due to the small sample size it was not possible to conduct statistical analyses on these results. Thirdly, an anticipated but not statistically significant negative trend (explained in further detail in the discussion) was that experimental midwives felt less comfortable administering the risk assessment.

developed was based on current evidence-based risk factors. As predicted, it resulted in significantly more referrals to social work and was acceptable to patients and midwives. The increased referral rate to social work indicated better identification of psychosocially 'at risk' patients. Feedback from the social worker confirmed that all 'at risk' referrals had been appropriate and necessary. Contrary to the misconception amongst staff that w o m e n would find the psychosocial assessment invasive and threatening this was not the case with many expressing appreciation for the opportuniW to discuss personal issues. Most women, even those most 'at risk', did not object to the assessment. A small percentage voiced concerns about confidentiality issues in a regional setting. The trial demonstrated that the risk assessment was acceptable to most midwives. It was perceived as significantly more thorough and generally preferred to the traditional assessment although some midwives felt less comfortable administering it. Interestingly expectant w o m e n in the experimental group felt just as comfortable with the assessment as those in the control group, suggesting midwives felt less at ease discussing personal issues than expectant women. Further discussions about the underlying reason(s) for the m i d w i v e s d i s c o m f o r t i n d i c a t e d that inexperience and inadequate training in dealing with psychosocial issues were primary causes. These issues are being addressed with comprehensive training sessions.

Antenatal depression, postnatal depression, domestic violence and child abuse/neglect are problems of significant community concern. This project aimed to address this by introducing a system of routinely assessing expectant women's risk of these problems and offering social work assistance to those in need.

After completion of the randomised control trial the risk assessment was introduced 'across the board' for all antenatal bookings. This involved training over 50 midwives in the administration of the assessment. Some of the midwives attending these sessions perceived the Antenatal Risk Assessment Tool as being too invasive, time consuming and apt to 'open a can of worms' they felt inadequately educated to deal with. Others b e l i e v e d that investigating psychosocial issues was 'none of their business'. These responses support findings of domestic violence studies that indicate clinicians are frequently reluctant to embrace new practices that deal with sensitive psychosocial issues (Kilpatrick et al, 1997).

The intention of the project was to introduce a management practice that would be acceptable to expectant w o m e n and midwives alike. The results demonstrated this was achieved. The assessment

Despite this initial resistance from some staff the assessment has generally been well received and increasing in acceptance, as midwives have become familiar with it. O t h e r h o s p i t a l s c o n s i d e r i n g

DISCUSSION

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introduction of similar initiatives should recognise that midwives need to be well supported when introducing such a relatively new concept. In conclusion, the prevalence of psychosocial problems and the benefit of antenatal interventions clearly indicate the need for systematic antenatal assessment and management of psychosocial issues. The antenatal process is one of the few situations in a woman's lifetime where medical and paramedical care is routinely provided. This trial has shown that introduction of systematic assessment during the antenatal booking is an acceptable practice to patients and midwives and improves identification of psychosocial issues. Funding for a three year extension of this project in the Hume Region of North East Victoria has been provided by the Maternity Services Enhancement Strategy. At time of writing plans were underway to integrate the antenatal psychosocial and clinical assessments and incorporate a care pathway with defined management strategies. The tool will have broad-based application ensuring it is culturally sensitive and meets the needs of people from differing socioeconomic and ethnic backgrounds. Content validity, inter-rater reliability, predictive validity and efficacy of intervention will be determined during an extensive trial conducted in the Hume Region and selected interstate hospitals. Hospitals interested in participating in the trial or wishing to discuss the project are encouraged to contact the author. References

1. Brown S, Lnmley J, Small R, Astbury A. (1994) Missing Voices: Experience of Motherhood. Oxford University Press Australia 2. Curry MA, Campbell RA, Christian M. (1994) Validity and reliability testing of the Prenatal Psychosocial Profile. Res Nuts Health. 17:127-35 3. Forde R, Malterud K, Bruusgaard D. (1992) Antenatal care in general practice. A questionnaire as a clinical tool for collection of information on psychosocial conditions. Scandinavian Journal of Primary Health Care. 10:266-71 4. Jackson AC, Johnson B, MillarJ, Cameron N. (1999) High risk infants k n o w n to child protection services: literature review, annotation and analysis. Human Services, Vic. January 5. Kilpatrick DG, Resnick HS, Acierno R. (1997) SEPTEMBER 2000

Health impact of interpersonal violence 3: implications for clinical practice and public policy. Behavioural Medicine. Summer Vol 3. 79-85 6. Norwood SL. (1996) The Social Support APGAR: instrument development and testing. Res Nurs Health; 19:143-52 7. Nuckolls KB, Cassel J, Kaplan BH. (1972) Psychosocial assets, life crisis and the prognosis of pregnancy. American Journal of Epidemiology. 95(5):431-41 8. Oakley A. (1992) Measuring the effectiveness of p s y c h o s o c i a l i n t e r v e n t i o n s in p r e g n a n c y . International Journal of Techonology Assessment in Health Care. 8 Suppl. (1):129-38 9. Olds DL, Eckenrode J, Henderson CR, Kitzman H et al (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect. JAMA. 278(8):637-43 10. Orr ST, James SA et al. (1992) Psychosocial stressors and low birth weight: development of a questionnaire. J Dev Behav Pediatr.13:343-7 11. Parker B, McFarlane J, Soeken K, Torres S, Campbell D. (1993) Physical and emotional abuse in pregnancy: a comparison of adult and teenage women. Nursing Research. Vol 42. No. 3, 173178 12. Reid AJ, Biringer A, Carroll John Douglas, Midmer D, Wilson LM, Chalmers B, Stewart DE. (1998). Using the ALPHA form in practice to assess antenatal psychosocial health. Canadian Medical Association Journal. 159(6):677-84 13. Wilson LM, Reid AJ, Midmer DK, Biringer A, Carroll JC, Stewart DE. (1996) A n t e n a t a l psychosocial risk factors associated with adverse postpartum family outcomes. Canadian Medical Association Journal. 154:785-799 14. D e p a r t m e n t of H u m a n Services (1999) Maternity Services Enhancement Strategy: Three Year Plan. Health Outcomes International Pty Ltd. Kent Town, South Australia. April. 15. NSW Health Postnatal Depression Services Review. (1994) Family and Child Health Unit Planning and Performance Branch. NSW Health Department, North Sydney. APPENDIX RISK FACTORS FOR POSTNATAL DEPRESSION, CHILD ABUSE/NEGLECT AND DOMESTIC VIOLENCE

'Depression' this pregnancy Domestic violence

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Other children removed from care

Limited supports

Substance abuse (illicit drugs or excess alcohol in

No telephone

pregnancy)

Non-English speaking background (born overseas,

Unwanted pregnancy (after 20 weeks)

Australia < 3years, limited English)

Significant stressful life events (eg death, divorce,

Physical disability that may impact on ability to parent

relationship difficulties, parenting difficulties, housing difficulties, problematic children)

Poor relationship with parents in childhood

Childhood abuse

Psychiatric/psychological history (including PND) Relationship problems

Age 20 or less

Single parent (defacto not included)

Financial difficulties

Unstable housing (more than 3 moves inpast 2years)

Intellectual disability Late/limited antenatal care (not started til third

trimester)

B O O K RBVIBW S i m k i n P a n d A n c h e t a R ( 2 0 0 0 ) The Labour Progress Handbook. Blackwell Science: Melbourne.

in the context of the content, this is not a reason to dismiss the book.

Price $64.00 (plus GST)

The book is well set out and very comprehensive. It offers practical solutions to very common variations of normal labour, and places the woman's instincts at the beginning of many of these solutions. A path from simple to more complex interventions follows, and the emphasis is always on the physiology and i n t e r a c t i o n s b e t w e e n the w o m a n a n d h e r environment. The inclusion of flow charts and decision trees assist the reader to conceptualise actions. The accompanying text contains references so the reader can evaluate the evidence basis for the suggested actions. Each topic is dealt with in a page or two, and dot points assist in clarity and brevity.

This is a compact and concise little b o o k that is nevertheless comprehensive in scope. It is easily accessible to all levels of midwife, from student to experienced, and could be suitable for medical students and others interested in providing a balanced approach to care of w o m e n in labour. It has a c o m p r e h e n s i v e contents list and index, m u c h crossreferencing and logical progression in topics. As such it is easy to use. A glossy cover, matte pages, well-drawn illustrations and well set out text enhance the quality of the publication. The only impediment to use in-vivo would be the perfect binding. A spiral bound volume would allow hands-free reading. The style of writing is respectful of w o m e n and their attendants, though with the trans-Atlantic focus the primacy of the midwife in labour care is somewhat watered down. Having said that, the focus of the text is on what any care-giver can do to enhance a w o m a n ' s p h y s i o l o g y , thus m a n a g e s to a v o i d ideological debates over w h o is the most appropriate care-giver. My only real concern with the style of text is the reproduction of some of the worst of obstetric language, such as 'inadequate contractions', 'dysfunctional labour' and Tailure to progress'. But PAGE 12

I would recommend all midwives have access to this little book, whether that means buying it for personal libraries, or perhaps as a 'ward' copy. 1 will certainly purchase it for my university library, but it is an expensive volume for most midwives, though the discount will make it more accessible. It has m o s t a p p l i c a t i o n for s t u d e n t s a n d n e w practitioners, and those wanting to refresh their 'low tech' labour care skills. But more experienced midwives will also find the b o o k of interest in validating their care. Patricia David RM FACM University of Tasmania

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