**2. Screening for depression**

Screening is the application of an instrument to identify people at risk of a specific condition among people who have not sought medical attention because of symptoms of that condition to warrant further investigation or direct prevention [37]. Literature suggests that it is reasonable to consider screening when the condition in question is significant and prevalent, can be effectively treated and cannot be readily detected without screening [38]. Screening for depression encompasses the use of instruments for measuring symptoms of depression to identify patients who may have depression but who have not sought treatment and whose depression has not already been detected by clinicians [38].

For screening to be successful, it must detect a substantial number of individuals with undiagnosed depression and provide treatment to obtain sufficiently positive results to justify the costs and potential harms associated with screening [38]. It is documented that screening for depression in primary care requires the availability of a lot of resources [9]. In low resource settings, allocation of resources to screening activities could lead to a decline in the quality of care received by patients with more severe depression and who are more clearly in need [38]. More importantly, it is recommended that the WHO minimum criteria for screening should be met before screening is implemented [39].

According to Andermann et al. [39], the following is the aforementioned recommended minimum criteria for screening: [1] the screening programme should respond to a recognised need; [2] the objectives of screening should be defined at the outset; [3] there should be a defined target population; [4] there should be scientific evidence of screening programme effectiveness; [5] the programme should integrate education, testing, clinical services and programme management; [6] there should be quality assurance, with mechanisms to minimise potential risks of screening; [7] the programme should ensure informed choice, confidentiality and respect for autonomy; [8]; the programme should promote equity and access to screening for the entire target population; [9]; programme evaluation should be planned from the outset; and [10] the overall benefits of screening should outweigh the harm. This criteria clearly focuses at improving clinical outcomes of individuals who participate in screening programmes, including pregnant women.

This study complied with the minimum criteria for implementing screening in many ways. Firstly, the aim of this study to develope a screening protocol was response to a need for detecting antenatal depression and associated risk factors. Secondly, the study clearly indicated that pregnant women attending antenatal clinic as target population for the screening of depression. Thirdly, the evidence about effectiveness of the proposed screening protocol for antenatal depression was locally generated by this study some of it was gathered from literature. Fourthly, this study minimised harm and ensured quality by submitting the proposal for review to two research and ethics committees, allowing participants to give consent for their voluntary participation in the study and ensuring privacy by not collecting *Screening for Antenatal Depression by Midwives in Low Resource Settings in Primary Care… DOI: http://dx.doi.org/10.5772/intechopen.97411*

personal details that could identify them during data collection. Pregnant women who were diagnosed as having depression were refered to a psychiatric unit. Finaly the protocol will be piloted to assess its clinical application and benefits and cost before it is adopted for clinical use. It is hoped that the proposed screening protocol will be used for screening depression in all pregnant women after its adoption.

Screening for depression is useful if it improves patient outcomes beyond those of standard care [38]. However, the Canadian Task Force on Preventive Health Care asserted that there is insufficient evidence about the benefits of screening to recommend routine screening of depression in adults in primary care settings [40]. The fact that there is insufficient evidence to recommend routine screening of depression does not change the importance of depression as a condition that negatively affects quality of life [41]. As such, clinicians in primary care settings should be alert to the possibility of depression in patients with characteristics that may increase their risk of depression [40, 41]. The American College of Preventive Medicine upholds the United States Preventive Services Task Force (USPSTF) proposal that all adults should be screened for depression in primary care settings and that there should be collaboration between primary care providers and mental health specialists to ensure accurate diagnosis and treatment of depression [42].

#### **2.1 Screening for depression in antenatal clinics**

During antenatal care, midwives have a duty to screen pregnant women for various conditions [15]. Midwives are expected to routinely screen depression in all pregnant women [43] to improve detection of antenatal depression [44]. There is evidence that screening for depression during pregnancy may reduce depressive symptoms among these women [45]. The American College of Obstetricians and Gynaecologists recommended that pregnant women should be screened for antenatal depression using a standardised and validated instrument [46].

For the routine screening for depression in antenatal care to occur, there is a need for standardised instruments for screening of depression to be designated for use in antenatal clinics in Malawi. Internationally there is evidence that midwives can effectively use instruments for screening of depression during antenatal care [16]. Currently, there are reports which show that EPDS and SRQ are used in research to screen depression during antenatal care in low resource settings [10]. However, screening instruments such as EPDS and SRQ are considered to be too long and time consuming for routine screening [47]. This could present a problem in busy antenatal clinics. In Malawi, antenatal clinics are usually staffed by one or two midwives who attend to a multitude of pregnant women. Literature indicates that antenatal clinics in low resource settings are understaffed, lack infrastructure and do not have adequate instruments for assessing antenatal depression [19]. Screening protocols for antenatal depression could help midwives to implement effective interventions systematically without adding to their workload [9] in these busy antenatal clinics. Routine antenatal visits by pregnant women could provide an appropriate time for antenatal depression screening [48]. Protocols for screening antenatal depression which include instruments that are accurate, acceptable and easy to use in busy, low resource settings therefore are needed [49].

However, midwives may consider screening for antenatal depression to be too demanding and requiring too much effort and this may result in a decreased frequency of screening [50]. The ideal timing and interval for screening for depression is not known [51]. However, Wisconsin Association for Perinatal Care recommends that screening of depression should be done at first antenatal visit and the third trimester of pregnancy [52].
