**1.1 Postnatal mental health**

Postnatal mental ill-health refers to any mental health condition affecting the mood, behaviour, well-being and/or daily function of a new parent. Perinatal mental health affects around 100,000 families across Australia every year. Postnatal mental health disorders are increasingly prevalent; however, some mothers do manage, with varying degrees of support. Phua et al. [1] results showed that positive antenatal mental health

was uniquely associated with the children's cognitive, language and parentally rated competences, indicating that the effects of positive maternal mental health are likely to be distinct from only the absence of symptoms of depression or anxiety.

Internationally, postpartum depression is prevalent in 17% of the world's maternal population in 80 countries (see **Table 1**) [2]. In high-income countries (HICs), the prevalence of postnatal depression is reported to be 1:10 women. In low-middleincome countries, these prevalence rates are higher (19% during the postnatal period). The higher prevalence rates of maternal depression are often related to



*Perspective Chapter: Psychosocial Screening and Assessment in the Private Sector in Australia… DOI: http://dx.doi.org/10.5772/intechopen.113404*



*Perspective Chapter: Psychosocial Screening and Assessment in the Private Sector in Australia… DOI: http://dx.doi.org/10.5772/intechopen.113404*

#### **Table 1.**

*Subgroup analysis for PPD prevalence among women.*

various risk factors that are more prevalent in these countries, including intimate partner violence, poverty, childhood abuse, maternal low educational attainment, and lack of social support [3]. The current fertility rate for Australia (a high-income country) in 2021 was 1.794 births per woman [4]. In 2021, there were 309,996 registered births in Australia, and the birth rate was 61 births per 1000 women of reproductive age.

It has been estimated that in Australia, 7 to 15% of pregnant women and 6 to 20% of mothers of infants up to 4 months of age will experience depression [5].

Post-Traumatic Stress Disorder, anxiety and depression may co-occur, with differing exhibiting symptomatology and signs, requiring different treatments [6–8]. Postpartum depression is a form of severe depression after birth that inhibits daily functioning and requires management. It can occur within days, weeks, or months after childbirth and extend beyond the first postpartum year. A woman with postpartum depression may have feelings of anxiety, despair, irritability and sadness to a severe extent [9]. High levels of antenatal (state) anxiety and trait anxiety may be an important predictor of postnatal anxiety and mood disorders, while co-morbidity of depression and anxiety disorders are common [10–14]. Postnatal mood disorders include obsessive compulsive disorder, social phobia, specific phobia, panic disorder and post-traumatic Stress Disorder, generalised anxiety disorder (GAD), and are commonly reported as prevalent as depressive disorders in the postnatal period (Fairbrother et al., 2016, as cited in [15]). The long-term effects of maternal depression include delays in children's cognitive and social development [16]; and emotional and behavioural problems [17–25] and breakdown of relationships [21, 26]; Maternal anxiety and depression may adversely affect the pregnancy, birth and early motherinfant relationships [27].

The postnatal period is a demanding life stage with parental concerns about sleep deprivation, infant health, new additional responsibilities, breastfeeding and birth recovery. Various identified psychosocial risk factors (sleep, education and relationship quality) have been associated with maternal postnatal anxiety symptoms; therefore, there is an opportunity for early identification and intervention from various health professionals [28].

Postnatal psychosocial care promotes enabling women to make the emotional and social adaptations that are necessary for successful functioning as a mother. Any postnatal maternal maternity experience involves some degree of disturbed sleep, bodily changes, anxiety, fatigue, maternal changes, and may also include coping with deteriorations in physical health through various other health changes. Therefore, mental health issues such as anxiety and depression do not exist as silos: other important aspects of psychological well-being such as self-esteem, quality of life, a sense of control, worry, and sleep, birth history, early parenthood experiences with infant feeding have also been independently associated with psychological outcomes for postnatal women, and should be considered equivalently important during the assessment of women's maternal experiences [29].

There is a direct link between postnatal maternal anxiety, stress and depression and poor obstetric and child outcomes. The early identification of women either at risk, or symptomatic of anxiety and depression, facilitates referral for timely and appropriate treatment [19]. There is substantial evidence internationally that all women during the postnatal period should be assessed for postnatal maternal stress, anxiety, and depression and their associated risk factors [6, 15, 30–35]. Next, we explore postnatal mental health screening and assessment in Australia.

#### **1.2 Postnatal mental health screening**

#### *1.2.1 The Australian context*

The evidence of the benefit of antenatal psychosocial assessment and depression screening has been sufficient to lead the implementation of screening in public hospitals in all states of Australia and scarcely in private hospitals. In Sydney specifically, the SAFE START perinatal mental health policy directive and clinical practice

#### *Perspective Chapter: Psychosocial Screening and Assessment in the Private Sector in Australia… DOI: http://dx.doi.org/10.5772/intechopen.113404*

guidelines have been in place in a number of large public maternity hospitals since 2010 [36] with the Integrated Perinatal Care (IPC) model of care implemented in some metropolitan settings. However, since 2010, there have been changes to the SAFESTART policy. SAFESTART has been mandated in all public hospitals in New South Wales, Australia and has been widely accepted and implemented. An Australian Commonwealth Government review and update of the Australian Perinatal Mental Health Guidelines was completed in 2017 and 2023 by the National Centre of Perinatal Excellence (COPE) [15, 37]. These guidelines accentuate the necessity to understand the evidence for screening and to identify and address barriers to implementing psychosocial screening in all healthcare sectors. Actions and procedures by appropriate health professionals are needed to provide solutions and resources for what has been identified by screening postnatal women. Improvements include improved detection of depression, improved treatment and, most importantly, to improved health outcomes [37].

The recommendations of the National Guideline [37] is that women should be provided with universal routine screening for depression postnatally in all Australian hospitals, both private and public [5, 36]. In addition, screening could be incorporated into obstetric shared care offered in general practice by G.P's. However, currently, the extent of implementation of screening in private health services in Australia is unknown. The Australian Institute of Health and Welfare [38] stated that 28% of women who give birth in Australia will choose to do so as private patients in private hospitals, yet little is known about the utilisation of psychosocial screening and assessment in the private sector [39]. In Australia, the main dissimilarity between public and private healthcare are the choice of an admitting obstetrician or doctor, admissions to private rooms, and fees charged for services rendered. Private providers offer various models of obstetric care, and despite Australian National guidelines recommending the implementation of screening in all sectors, it is concerning that standards for perinatal mental health remain chiefly absent from private sector policies and processes [40].

A proportion of women will access health care services in the postnatal period. This is the ideal opportunity for health professionals to identify those at risk of depression, anxiety, or other psychosocial issues, if health professionals are educated to identify risk factors effectively, are confident in questioning women and discussing symptoms, and that an appropriate local referral process is in place. Routine postnatal mental health screening has the capacity to act as a potential preventive strategy for postnatal mental illness in women [8], and is a clear strategy for health promotion and early intervention for the woman, her partner and the infant [6].

Postnatal emotional/mental health disorders are a significant public health issue because of their potential to negatively affect infant attachment security, the maternal-infant relationship, and increase the risk of affective disorders, social behavioural problems, and cognitive delays in young children [19]. Anxiety and depression often remain undetected in childbearing women despite health professionals being available during the postnatal period to identify, prevent, and treat emotional/mental health disturbances [19]. Further, efficient psychosocial care may be affected by service or systematic issues including lack of appropriate training and support, limited staff numbers, and unfamiliarity with screening tools. Within the Australian National Health and Medical Research Council's (NHMRC) Clinical Practice Guidelines for Depression and Related Disorders in the Postnatal Period, universal screening for postnatal depression is anticipated to be completed by relevant health professionals [41]. In private obstetric care, obstetricians are the responsible clinician for ensuring

that postnatal psychological screening, assessment, referral and the Edinburgh Postnatal Depression Scale (EPDS) is offered.

Postnatal psychosocial assessment is crucial for the provision of comprehensive clinical care and the development of customised maternal management plans, requiring the clinician to have adequate information with which to make shared clinical decisions/referrals. The universal application and routine use of psychosocial risk and depression assessment/screening has developed as a significant health initiative [42]. Postnatal Psychosocial risk assessment and depression screening can be readily integrated into postnatal care but involves skilled clinical evaluation of the identification of psychological, demographic, social, and physical factors known to affect postnatal mental health for mother and infant, including current distress/depressive symptoms that may be identified in the mother [6, 43]. As important, and underpinning the implementation of universal psychosocial assessment, is the identification of adequate local referral pathways. Appropriate services to address the identified needs of women as experiencing mild or moderate issues, being at risk, or experiencing severe and/or complex mental illness need to be reachable and available to all women identified by assessment or screening. The broad range of services and sectors required for appropriate and timely referral involves developing care that is effectively networked, collaborative and receptive to the involved family [6].

#### *1.2.2 The private sector in Australia*

As the prevalence of anxiety or depression and substance use increases in the general population, these issues are likely to become more evident in postnatal care and in both the public and private obstetric settings [44]. Substance use, anxiety and depression can be effectively treated postnatally; however, these conditions are often not identified and therefore remain undertreated. Private obstetricians are often the first, and sometimes the sole provider of healthcare to women and alike primary care providers, have an increasing role in the early detection of postnatal mental health/ mood disorders. Although postnatal depression and anxiety are recognised as frequent complications of pregnancy and childbirth, screening and detection of depression by private obstetric prenatal care providers is currently insufficient [44].

Women are not routinely or universally screened postnatally for psychosocial risk factors, depression and anxiety in the private sector in Australia [44]. There are limited studies that explore health professionals' views on screening or perceived barriers to the screening process. In one study, however [10], health professionals were interviewed about their perceptions of psychosocial screening in the private sector. Suggestions were made that appropriate education and training of midwives was needed, that high-risk women needed to be flagged to the midwives, to initiate more in-house resources and external resources/community links and to employ a key midwife with interest and expertise in psychosocial screening. Health professionals interviewed in the private sector identified the benefits of psychosocial screening for women but also the barriers to screening. Midwives had various views on psychosocial screening and assessment in the private sector. Some midwives indicated concern about a woman's postnatal mental health/psychosocial risk factors; however, others expressed apprehension that this was not part of their midwifery role. Some midwives were fearsome of what may be revealed by the woman and how to deal with it. There was an identified concern that obstetricians did not take seriously any concerns highlighted by the midwife about a woman's psychosocial issues when reported to them. There was a sense of a lack of 'ownership' of the women and, therefore,

#### *Perspective Chapter: Psychosocial Screening and Assessment in the Private Sector in Australia… DOI: http://dx.doi.org/10.5772/intechopen.113404*

a feeling of powerlessness in addressing their needs. This emphasises the need to educate and support midwives working in the private sector on their important role in enriching the postnatal mental health of women within their direct care. Their role includes capability for prevention, health promotion and early intervention to benefit not only the woman, but her whole family. In response to this, as the developer of the Australian National Guideline, the Centre of Perinatal Excellence [37] provides free, accredited online training for frontline health professionals to support their training needs and ensure confidence, and competence in screening and having the conversation, as well as identifying timely and appropriate postnatal mental health pathways.

Women birthing in the private sector would also benefit from being able to access the array of resources provided in the public sector to support their postnatal mental health care. Collaborative partnerships between public, private and non-government service providers can help support the delivery of appropriate obstetric care and ensure that privately insured women have just access to appropriate mental health care services. As private obstetric providers meet the contemporary challenges of addressing postnatal mental health, there is a substantial demand on the duty of care and capacity of these workforces to undertake universal mental health screening/ assessment, to access training programmes, to identify and access relevant referral pathways for and follow-up care, and to ensure organisational and professional policies exist to sustain this process and the staff involved. It is extraordinary that Australian National standards for postnatal mental health are not yet endorsed or incorporated into the private sectors continuous quality improvement processes, including the Australian private hospital accreditation standards. As a result, patient who are paying for a higher level of care are in fact receiving a lower level of care, with respect to emotional and mental health at this vulnerable life stage [44].

However, it is generally established that postnatal screening should not occur without appropriate evidence-based interventions, adequate training and support for staff, and adequate local referral pathways [45]. A vast range of services are required to meet the diverse needs of women identified as being at mild or moderate risk of postnatal depression and or anxiety [6, 46], or experiencing complex or severe mental illness. Referral processes for women with an existing or previous psychiatric disorder also need to be available [47]. An effective model for enhancing communication and continuity between primary and specialist/community-based health services and midwives, is essential to ensure that women who may gain from early intervention and treatment programmes or prevention [42, 48, 49] have 24-hour access to psychiatric or psychological advice and support if they develop symptoms between each obstetric appointments.

In addition to the substantial and still emerging postnatal mental health evidencebase endorsing improved outcomes for mother and infant, these findings support the case for the universal implementation of postnatal screening of depression and anxiety [15, 50], regardless of which health sector a woman chooses to receive obstetric care. The profile of women in the private sector in NSW, Australia is not dissimilar to women choosing to birth in the public sector (**Tables 2** and **3**). It is crucial through screening/assessment, to identify postnatal risk factors and symptoms of anxiety or depression and to provide appropriate support to assist women who need help. However, the identification of women experiencing symptoms and risk factors of anxiety or depression postnatally, implies that resources, education and support will be offered throughout the postnatal period, and that referral to appropriate services and support systems will be offered [42]. Barriers exist for postnatal mental health screening, that must be addressed.


*Centre for Epidemiology and Evidence. New South Wales Mothers and Babies 2012. Sydney: NSW Ministry of Health, 2014 (Midwives data collected in 2012).# Denominator for Local Public Hospital for primipara and multipara n = 262, missing values not included.*

#### **Table 2.**

*Compares local and NSW data.*


*Perspective Chapter: Psychosocial Screening and Assessment in the Private Sector in Australia… DOI: http://dx.doi.org/10.5772/intechopen.113404*


*a t test.*

*c Chi-square test.*

*# Missing values not included in the denominator for calculation of proportions of valid data reported in table or Chisquare tests. The proportion Missing is based on the total sample size.*

*y d effect size .2 = small, .5 = medium, .8 = large.*

*z Phi and Cramer's V effect size .1 = small, .3 = medium, .5 = large.*

#### **Table 3.**

*Profile of women choosing local public and private obstetric care.*

#### **1.3 Barriers to postnatal mental health screening**

The evidence of value and need for antenatal psychosocial assessment and depression screening has been abundant to lead to the implementation of screening in public hospitals in all states of Australia. However, details of the implementation of postnatal screening in private obstetric settings is unknown [44]. As any successful implementation depends on the identification of local barriers it is essential to identify actual or perceived barriers that may exist for the implementation of evidence-based postnatal screening interventions in private obstetric care [40]. Women who experience the stressors that are related to an increased risk, or an indication of postnatal mental health disorders should be assessed and offered referral to appropriate services, regardless of their chosen health sector.

#### **1.4 Health care provider barriers**

There are identified health care provider barriers to psychosocial screening and assessment. These include patient barriers: stigma, fear, denial. Provider and system barriers; time, a lack of skills, confidence or facilities, managerial support, the authority to implement change and a failure to follow-up referral recommendations. Feelings of discomfort are salient in the literature, in fact, midwives, obstetricians, physicians and paediatricians all report being uncomfortable with screening [40]. While different health professionals (midwives, obstetricians, General Practitioners, paediatricians, health visitors) are interested in the psychosocial well-being of women, and they acknowledge that it is a significant part of their role, screening is not being universally achieved [5]. Although psychosocial and depression screening is mandated in the public sector in Australia, a recent study of 30 Women's Healthcare Australasia (WHA) members found that only 70% were using the EPDS in the

antenatal period [5]. Of the 30 members who had implemented antenatal screening, 70% screened for risk of developing depression [5], but only two (20%) used the recommended antenatal risk questionnaire (ANRQ ) [5].
