Clinical Practice Guidelines Antenatal care - Module I
A number of factors affect mental health during pregnancy. Asking a woman about relevant psychosocial factors early in pregnancy enables her to access support if she chooses.
7.5.1 BackgroundSome women may be more vulnerable to mental health problems during pregnancy due to a combination of biological, genetic, physiological or social factors (Fisher et al 2002; Boyce 2003). Psychosocial factors that have been identified as influencing mental health during pregnancy include the following.
- Past mental health disorders — These increase the likelihood of depression developing and bipolar disorder recurring during pregnancy (NICE 2007). Family history of psychosis in the postnatal period also increases a woman’s risk of mental health disorder (NICE 2007). The risk associated with family history depends on the closeness of the relationship and the severity of the condition.
- Past or current physical, sexual or psychological abuse — Childhood sexual, emotional or physical abuse is associated with depression, anxiety and low self-esteem in the postnatal period (Buist 1998). Women exposed to abuse during pregnancy are also more likely to develop depression in the postnatal period (Bacchus et al 2003; Mezey et al 2005).
- Drug and/or alcohol use — There are clear associations between mental health issues and drug and alcohol abuse (eg drugs and alcohol may be used as a means of coping with mental health issues). There is frequently an association between physical and emotional abuse and drug and alcohol misuse (Oei et al 2009).
- Recent life stressors — High scores on ‘current life events’ scales are associated with depression in the perinatal period (Eberhard-Gran et al 2002; Dennis et al 2004) and may interact with vulnerability factors such as having low self-esteem or a negative outlook, or being a young mother at home with several children (O’Hara et al 1991). Important stressors include negative life events and stressful events associated with pregnancy (Eberhard-Gran et al 2002). Women who experience multiple pregnancies (Choi et al 2009), conceive through in vitro fertilisation (Gelbaya 2010; Volgsten et al 2010) or have polycystic ovarian syndrome (Mansson et al 2008; Deeks et al 2010) may be more likely to develop depression. Other events that may be considered as stressors include bereavement, illness, relationship problems, pregnancy loss, problems conceiving and moving house. Two or more stressful life events during the year prior to pregnancy have been associated with recurrent or sustained depressive symptoms in early pregnancy and the postnatal period (Rubertsson et al 2005).
- Quality of a woman’s attachment with her own mother — Insecure attachment with a woman’s own mother may contribute to depression in the perinatal period. A woman’s own experience as a child and the mental image of parental relationships that she brings to her role as mother is likely to affect how she anticipates, responds to and interprets her own infant’s attachment behaviour (NSW Dept Community Services 2006).
- Current practical and emotional support — The availability of support (Milgrom et al 2008; Dennis et al 2009), in particular, practical and emotional support from her mother and partner (Dennis & Ross 2006; Milgrom et al 2008), appears to be a crucial factor in protecting a woman against mental health disorders during pregnancy.
Factors contributing to mental health problems in specific population groups
Aboriginal and Torres Strait Islander womenIn general, Aboriginal and Torres Strait Islander people experience higher rates of social and emotional wellbeing problems and some mental health disorders than non-Indigenous Australians (Social Health Reference Group 2004). Factors such as lower life expectancy, child and family separations, incarceration and higher infant mortality rates contribute to the level of grief, loss, trauma and anger experienced by Aboriginal and Torres Strait Islander individuals, families and communities (ABS & AIHW 1999).
In addition to disrupted cultural well-being and the continuing inter-generational effects of trauma and loss, Aboriginal and Torres Strait Islander people experience high levels of recent life stressors. Respondents to the National Aboriginal and Torres Strait Islander Health Survey (2004–05) indicated that in the last year they, their family and/or friends had experienced the death of a family member or close friend (42%), serious illness or disability (28%) or alcohol-related problems (20%)(AIHW 2008).
In this context, it is clear that Aboriginal and Torres Strait Islander women are at higher risk of mental health problems, both generally and in the perinatal period, than women from the general population. High rates of maternal and infant morbidity and mortality, and high rates of Aboriginal and Torres Strait Islander infants taken into care within the first year of life, support the notion that rates of perinatal emotional distress and mental health disorder are high and the burden of care significant for Aboriginal and Torres Strait Islander communities (Swan & Raphael 1995; Perinatal Mental Health Consortium 2008). Additional emotional distress may be caused for Aboriginal and Torres Strait Islander women in remote areas if they cannot access regular antenatal care, or if they are from traditional communities and cultural birthing practices cannot be followed (Swan & Raphael 1995; Perinatal Mental Health Consortium 2008).
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Women from culturally and linguistically diverse backgroundsWomen who were born in other countries and give birth in Australia may experience isolation due to a loss of usual female family and community support systems. There may also be a history of grief, loss and trauma in addition to migration (McCarthy & Barnett 1996).
Newly arrived humanitarian refugees are likely to have experienced multiple levels of trauma. Families who have been forced to flee from their country of origin may have been subject to many traumas and disrupted attachments, including the loss of one or both parents or other family members and/or separation from extended family. During times of upheaval and displacement, social structures break down and people have limited experience of the normal routines of culture and society. The challenges of the resettlement process can be overwhelming. These include adapting to a new country, learning a new language, the pressure to succeed, changes in family roles and concern for family members still overseas, and living in precarious circumstances. Newly arrived refugees may also experience posttraumatic stress disorders, grief and/or physical injury (State Perinatal Reference Group 2008).
For these women, the increased stress associated with the perinatal period can add to an already difficult and challenging situation (State Perinatal Reference Group 2008). An unfamiliar environment, language difficulties, absence of support and lack of opportunities related to birth rites may place new mothers and their infants at a higher risk of mental health problems (State Perinatal Reference Group 2008).
Adolescent womenResearch on adolescent mothers shows increasing rates of depressive symptoms in the postnatal period, particularly for young women with more family conflict, fewer social supports, and low self-esteem (Reid & Meadows-Oliver 2007). Guidelines for management of depression in young people are included in Section 7.5.4.
7.5.2 Assessing psychosocial risk factors
Summary of the evidenceWhile the use of psychosocial assessment tools in improving outcomes is not currently supported by evidence, enquiry related to certain psychosocial factors of a significant nature is endorsed by relevant clinical practice guidelines (SIGN 2002; British Columbia Perinatal Health Program 2003a; 2003b; WA Statewide Obstetric Unit 2006; NICE 2007; NSW Dept Health 2009; beyondblue 2011). These include:
- past history of mental health disorders;
- availability of practical and emotional support;
- current or past abuse/violence; and
- current life events (major stressors).
Some clinical practice guidelines also endorse enquiry relating to current drug and alcohol use (British Columbia Perinatal Health Program 2003a; 2003b; NSW Dept Health 2009; beyondblue 2011) and a woman’s attachment with her own mother (beyondblue 2011).
Consensus-based recommendationiv. As early as practical in pregnancy, ask all women questions about psychosocial factors, including previous or current mental health disorders. If a woman affirms their presence, ask whether she would like help with any of these issues.
Asking women about psychosocial factorsMany of the psychosocial factors outlined above are already explored as part of routine care (eg women are asked about domestic violence) and additional questions can be included in the clinical interview. The aim is to identify psychosocial factors without detracting from the normal experiences of pregnancy and motherhood or highlighting the potential for depression and related disorders to occur in the perinatal period.
Before asking women about psychosocial factors, health professionals need to identify local options for referral if required. Women should be given an explanation of the purpose of the questions (eg identifying any need for psychosocial support) and asked for their permission.
Women need to feel safe during the assessment, so consideration should be given to the other people who may be present. While the presence of a woman’s partner or other family members may be appropriate, sensitivity is required about whether it is appropriate to continue with psychosocial assessment while they are in the room (eg if domestic violence is suspected).
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Table 7.4: Example questions to identify psychosocial factors
|Past or current mental health problems|
|1. Have you ever had a period of 2 weeks or more when you felt particularly low or down?|
|2. Do you sometimes worry so much that it affects your day-to-day life?|
|3. Have you ever needed treatment for a mental health disorder such as depression, anxiety disorder, bipolar disorder or psychosis?|
|4. Has anyone in your immediate family (eg grandparents, parents, siblings) experienced severe mental health problems?|
|Previous or current abuse|
|5. When you were growing up, did you always feel cared for and protected?|
|6. If you currently have a partner, do you feel safe in this relationship?|
|Drugs and alcohol|
|7. Do you or others think that you (or your partner) may have a problem with drugs or alcohol?|
|Recent life stressors|
|8. Have you had any major stressors, changes or losses in the last 12 months (eg moving house, financial worries, relationship problems, loss of someone close to you, illness, pregnancy loss, problems conceiving)?|
|Practical and emotional support|
|9. When you were growing up, was your mother emotionally supportive of you?|
|10. If you found yourself struggling, what practical support would you have available? Who could help provide that?|
|11. If you found yourself struggling, what emotional support would you have available? Who could help provide that?|
Acting on the assessmentAssessing psychosocial factors provides information about a woman’s mental health and well-being and identifies women who may benefit from additional care. In the following situations, comprehensive mental health assessment is advisable:
- the woman has a past history of mental health disorder;
- the woman is experiencing abuse or has experienced abuse in the past;
- the woman or her partner has a problem with alcohol or drugs; or
- the woman requests further assessment.
Considerations beyond the first trimester
- Women should be asked about psychosocial factors again 6–12 weeks after the birth.
7.5.3 Practice summary — assessing psychosocial factorsWhen — At first antenatal visit
Who — Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health worker
- Provide information — Explain that pregnancy can be challenging and that some life factors make it more likely that a woman will experience symptoms of depression or anxiety.
- Seek informed consent — Explain that asking about psychosocial factors is a routine part of care during pregnancy and ask the woman for her consent.
- Offer support — If a woman has two or more psychosocial factors or one or more significant factors (past history of a mental health disorder, past or present abuse, drug and/or alcohol problems) ask if she would like help with any issues.
7.5.4 Resourcesbeyondblue (2011) Clinical Practice Guidelines Depression and Related Disorders — Anxiety, Bipolar Disorder and Puerperal Psychosis — in the Perinatal Period. A Guideline for Primary Care Health Professionals. Melbourne: beyondblue: the
national depression initiative. For more information please visit Beyond Blue website.
beyondblue (2011) Clinical Practice Guidelines: Depression in Adolescents and Young Adults. Melbourne: beyondblue: the national depression initiative. For more information please visit Beyond Blue website.
Online training — beyondblue provides online training in assessing and managing mental health disorders in the perinatal period. For more information please visit Think GP website .
7.5.5 ReferencesABS & AIHW (1999) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples. Canberra: Australian Government Printing Service.
AIHW (2008) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples. ABS Cat No 4704.0, AIHW Cat No IHW 21. Commonwealth of Australia.
Bacchus L, Mezey G, Bewley S (2003) Experiences of seeking help from health professionals in a sample of women who experienced domestic violence. Health Soc Care Comm 11(1): 10–18.
beyondblue (2011) Clinical Practice Guidelines Depression and Related Disorders — Anxiety, Bipolar Disorder and Puerperal Psychosis — in the Perinatal Period. A Guideline for Primary Care Health Professionals. Melbourne: beyondblue: the national depression initiative. For more information please visit Beyond Blue website.
Boyce PM (2003) Risk factors for postnatal depression: a review and risk factors in Australian populations. Arch Women Ment Health 6(suppl.): S43.
British Columbia Perinatal Health Program (2003a) Reproductive Mental Health Guideline 3. Identification and Assessment of Reproductive Mental Illness During the Preconception and Perinatal Periods. Vancouver: British Columbia Reproductive Care Program.
British Columbia Perinatal Health Program (2003b) Reproductive Mental Health Guideline 1. Principles and Framework. Vancouver: British Columbia Reproductive Care Program.
Buist A (1998) Childhood abuse, postpartum depression and parenting difficulties: a literature review of the associations. Aust NZ J Psychiatry 32: 370–78.
Choi Y, Bishai D, Minkovitz CS (2009) Multiple births are a risk factor for postpartum maternal depressive symptoms. Pediatrics 123(4): 1147–54.
Deeks AA, Gibson-Helm ME, Teede HJ (2010) Anxiety and depression in polycystic ovary syndrome: a comprehensive investigation. Fertility & Sterility 93(7): 2421–23.
Dennis C-L & Ross LE (2006) Women’s perceptions of partner support and conflict in the development of postpartum depressive symptoms. J Advanced Nursing 56(6): 588–99.
Dennis C-L, Janssen PA, Singer J (2004) Identifying women at risk for postpartum depression in the immediate postpartum. Acta Psychiatr Scand 110: 338–46.
Dennis C-L, Hodnett E, Kenton L (2009) Effect of peer support on prevention of postnatal depression among high risk women: multisite randomized controlled trial. Brit Med J 338: a3064 doi: 10.1136/bmj.a3064.
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Eberhard-Gran M, Eskild A, Tambs K et al (2002) Depression in postpartum and non-postpartum women: prevalence and risk factors. Acta Psychiatr Scand 106(6): 426–33.
Fisher JRW, Feekery CJ, Rowe-Murray HJ (2002) Nature, severity and correlates of psychological distress in women admitted to a private mother-baby unit. J Paediatr Child Health 38: 140–45.
Gelbaya TA (2010) Short and long-term risks to women who conceive through in vitro fertilization. Human Fertility 1391: 19–27.
Mansson M, Holte J, Landin-Wilhelmsen K et al (2008) Women with polycystic ovary syndrome are often depressed or anxious — a case-control study. Psychoneuroendocrinology 33: 1132–38.
McCarthy S & Barnett B (1996) Highlighting Diversity: NSW Review of Services for Non-English Speaking Background Women with Postnatal Distress and Depression. Paediatric Mental Health Service, South Western Sydney Area Health Service.
Mezey G, Bacchus L, Bewley S (2005) Domestic violence, lifetime trauma and psychological health of childbearing women. Brit J Obstet Gynaecol 112(2): 197–204.
Milgrom J, Gemmill AW, Bilszta JL et al (2008) Antenatal risk factors for postnatal depression: a large prospective study.J Affective Disorders 108(1–2): 147–57.
NICE (2007) Antenatal and Postnatal Mental Health: The NICE Guideline on Clinical Management and Service Guidance.Leicester: The British Psychological Society & The Royal College of Psychiatrists.
NSW Dept Community Services (2006) Research to Practice Notes (a) Attachment: Key Issues. Sydney: NSW Department of Community Services.
NSW Dept Health (2009) Families NSW Supporting Families Early Package. Sydney: NSW Department of Health.
O’Hara MW, Schlechte JA, Lewis DA et al (1991) Controlled prospective study of postpartum mood disorders: psychological, environmental, and hormonal variables. J Abnorm Psychology 100: 63–73.
Oei JL, Abdel-Latif ME, Craig F et al; NSW and ACT NAS Epidemiology Group (2009) Short-term outcomes of mothers and newborn infants with comorbid psychiatric disorders and drug dependency. Aust NZ J Psychiatry 43(4): 323–31.
Perinatal Mental Health Consortium (2008) National Action Plan for Perinatal Mental Health 2008–2010 Full Report. Melbourne: beyondblue: the national depression initiative. For more information please visit Beyond Blue website.
Reid V & Meadows-Oliver M (2007) Postpartum depression in adolescent mothers: an integrative review of the literature. J Pediatr Health Care 21(5): 289–98.
Rubertsson C, Wickberg B, Gustavsson P et al (2005) Depressive symptoms in early pregnancy, two months and one year post-partum: prevalence and psychosocial risk factors in a National Swedish sample. Arch Women’s Ment Health 8: 97–104.
SIGN (2002) Postnatal Depression and Puerperal Psychosis: A National Clinical Guideline. Edinburgh: Royal College of Physicians.
Social Health Reference Group (2004) Social and Emotional Wellbeing Framework. A National Strategic Framework for Aboriginal and Torres Strait Islander Mental Health and Emotional and Social Well-being 2004–2009. Prepared for the National Aboriginal and Torres Strait Islander Health Council and National Mental Health Working Group 2004.
State Perinatal Reference Group (2008) Social and Emotional Experience of the Perinatal Period for Women from Three Culturally and Linguistically Diverse (CALD) Communities. Perth: Department of Health of Western Australia.
Swan P & Raphael B (1995) Ways Forward. National Aboriginal and Torres Strait Islander Mental Health Policy. National Consultation Report. Commonwealth of Australia.
Volgsten H, Skoog Svanberg A, Ekselius L et al (2010) Risk factors for psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment. Fertility & Sterility 93(4): 1088–96.
WA Statewide Obstetrics Support Unit (2006) Perinatal Depressive and Anxiety Disorders. Women and Newborn Health Service, King Edward Memorial Hospital. Perth: Department of Health Western Australia.
The information in this section, including the consensus-based recommendation, is based on Sections 1.3 and 3.2 in beyondblue (2011) Clinical Practice Guidelines on Depression and Related Disorders in the Perinatal Period. For more information please visit Beyond Blue website.