**3. The importance of psychosocial care during pregnancy**

violence [1]. While risks cannot be totally eliminated once pregnancy is established, they can be reduced through effective, accessible and affordable maternity health care. Numerous studies reveal significant depressive symptoms in pregnant women that are associated with sociodemographic and economic status and that depression during pregnancy may negatively influence psychosocial adjustment [2, 3]. Research findings also recommend an integrated approach

Antenatal care has been described as one of the effective forms of preventative care. It involves screening symptomatic and asymptomatic pregnant women, with the aim of detecting and thereby preventing both maternal and neonatal adverse events. The introduction of antenatal care in 1910 in the Royal Adelaide Hospital in Australia has played an important role in preventing high maternal and perinatal mortality rates. Antenatal care should ideally be geared towards the promotion of health and the prevention of physical and psychosocial problems [16]. The psychopathology of pregnancy needs to be understood in terms of the adjustment that all women have to make when they conceive, as pregnancy is also an adaptive process. A pregnant woman should carry the baby safely through to delivery and adjust to the sacrifices that motherhood demands. The challenges that face her, include the acceptance of the pregnancy by the family; development of an attachment to the baby and preparation for birth; and adjustment to the changes in her physical appearance, and to development and maintenance of a positive relationship with the father of the baby. Many women respond to this complex process with grief and anger, especially when the pregnancy is unplanned and unaccepted.

to antenatal care that focuses on both the physiological and psychosocial dimensions.

Unmanaged grief or anger might ultimately lead to maternal depression [17].

Pregnancy can be enhanced through a coordinated antenatal care programme, which includes both medical and psychosocial care. As such, pregnant women's mental health should be a primary concern for all midwives due to a reported high prevalence of depressive and anxiety disorders in women. Hollander and Langer [18, 19] reported a 21% incidence of depression and 34% anxiety disorders in women, which may be exacerbated by pregnancy. Pregnancy-specific anxiety may occur as the woman worries about her pregnancy, physical changes and delivery.

Antenatal preparation should be offered to all women during pregnancy as a national policy. Screening during pregnancy is crucial, with the aim of detecting and preventing both maternal and neonatal adverse events and instituting early intervention. During screening, midwives should actively listen to the concerns and needs of pregnant women to be able to assess

The findings of a cross-cultural survey by Namagembe [20] on the extent of physical and emotional abuse on African American, White American and Hispanic women during pregnancy indicated that one in four women gave a history of battering and physical abuse. The implication for this was that many women's community subsystems of safety and physical environment are not in harmony and that battering and physical abuse during pregnancy might lead to a significant delay in obtaining antenatal care by 6.5 weeks as compared to non-abused women.

**2. Antenatal care as a process**

16 Selected Topics in Midwifery Care

them comprehensively.

Psychosocial morbidity is not given enough recognition, it is not thought to be self-limiting as it is the care that is attributed to normal emotionality of pregnancy, and it is less frequently identified, especially if there is no continuity of care by the same midwife or clinician. Pereira et al. [4] reported that antenatal depression affects 4–16% of women, domestic violence during pregnancy rates at 16% and postnatal depression affects 15–20% of postpartum women.

Historically and contemporarily [4], much of what constitutes antenatal care throughout the world remains strongly rooted in the medical model within which it developed. Widespread, institutionalised routine antenatal care began around 80 years ago, focusing on mass screening with the aim of reducing maternal and perinatal morbidity and mortality under medical supervision [5] What is of concern within the context of antenatal care are the beliefs and assumptions that continue to underpin the structure and content of antenatal care.

Traditionally, antenatal care consists of a prescribed set of acts with a focus on the clinical physiological monitoring and screening of pregnant women. This approach was based on the notion by Oakley (1984) that pregnancy is a state of pathology rather than a normal physiological and developmental stage [5]. As further stated by Chitra and Gnanadurai [1], "antenatal care is usually offered in a form of routine physical assessment and care with limited or no psychosocial assessment and care".

Inadequate psychosocial risk assessment may lead to lack of psychosocial support afforded to the pregnant women. Pregnant women who lack psychosocial support may experience stress during their pregnancy and childbirth. These changes may increase the woman's vulnerability to depression, which may in turn have adverse effects on both maternal and foetal well-being [6]. Unrelieved stress can also increase vulnerability to physical and emotional problems, for example, insomnia, fatigue, development of ulcers and heart problems [7].

Supportive care during childbirth may have long-term positive effects and may protect some women from a long-lasting negative birth experience. The latter was found in a longitudinal cohort study on "why some women change their opinions about childbirth over time" [8]. Mixed feelings were elicited from women regarding their attitude towards childbirth, changing from positive to less-positive opinions based on, for instance, dissatisfaction with intrapartum care and lack of support for psychosocial problems such as single marital status or the presence of depressive symptoms. Changing from negative to less-negative feelings was associated with less worry about birth in early pregnancy and a more positive experience of support by the midwife.

According to O'Keane and Marsh [9], psychosocial support not only lowers prematurity and low birth weight rates but also inspires healthier behaviours and lifestyle among pregnant women and discourages behaviours like smoking, substance abuse and poor nutritional intake, which can have other detrimental effects on the mother and baby. Psychosocial support calls for a multi-level approach, consisting of strengthening partners and families and enhancing system capacity by ensuring the availability of resources. Interventions need to bolster the support provided within the woman's existing social network in order to maintain the woman's cultural beliefs and values.

Conventional medicine must also accept other health care practices such as midwifery-led maternity care as a valid source of healthcare, especially to address psychosocial risk factors.

Psychosocial Antenatal Care: A Midwifery Context http://dx.doi.org/10.5772/intechopen.80394 19

Parry [15] in a study exploring whether Canadian women's choice of midwifery care identifies a resistance to the medicalisation of pregnancy and childbirth came to the conclusion that women have a desire for personal control of their pregnancy as reflected in this comment:

*"I just wanted to be in control of what was going on with my body, It scares me that they will push you when you are in your most vulnerable state, because it is more convenient for their schedule". Participants further related how midwifery care met their needs for control over their bodies, their pregnancies and their experiences with childbirth, notwithstanding a sentiment that medical interventions* 

An ideal option for effective antenatal care is the incorporation of psychosocial care as a component of antenatal care, acknowledging the women's own experiences of pregnancy [2]. Midwifery, which means "to be with women", is based upon a philosophy of care in which the management of pregnancy is shared between the midwife and the woman, with a focus on informed choice, shared responsibility, mutual decision making and women articulating

According to Baldo [7], maternal risk is defined as the probability of experiencing various levels of injuries or even dying as a result of pregnancy or childbirth. Physiological and psychosocial risk screening should therefore be conducted during the first and subsequent visits

The opinions of Handwerker (1994), Lupton (1999) and Saxell (2000) as cited by Refs. [1, 21] were that risk assessment during childbirth is made more complex by the differences in the perceptions of risks between midwives and pregnant women, as risk from a midwife's perspective is based on her specialised knowledge and training, epidemiology, personal values and experience, whereas a woman's understanding of risk is far more contextual, individual-

Historically, the definition of maternal risk emphasises mainly medical factors and includes few psychological and socioeconomic factors. To add to this, the interest of midwives seems to be directed towards foetal well-being and the newborn child, ignoring the psychosocial needs of the mother. Furthermore, when a woman reports for delivery, her family member's concern is mostly on the well-being of the newborn rather than on the maternal well-being.

Psychosocial factors are an important area to assess during pregnancy. Various studies, for example, those of [12, 22–24] demonstrate that stress, depression, alcohol abuse and lack of social support during pregnancy are commonly associated with low birth weight and perinatal morbidity and mortality. Furthermore, in this era of HIV/AIDS, psychosocial problems are common among affected populations. These issues may have an indirect influence by affecting antenatal care attendance, the woman's coping capacity and the physiology of pregnancy.

of antenatal care as part of a comprehensive assessment during antenatal care.

ised and embedded in her social environment and everyday life experience.

Women's health problems, including pregnancy, should cease to be medicalised.

*also have a place in pregnancy and childbirth.*

**4. Maternal risks during pregnancy**

their health needs.

Dodd et al. [10] tested a hypothesis on the relationship between psychosocial stress, social support, self-efficacy and circulating pro- and anti-inflammatory cytokines in women throughout pregnancy. Pregnant women within the study completed the Denver Maternal Health Assessment. The conclusion was that high social support was associated with low stress scores. Elevated stress scores positively correlated with higher levels of pro-inflammatory cytokine interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α).

A longitudinal community-based study conducted by Gelder et al. [11] through the use of the Edinburgh Postnatal Depression Scale (EPDS) revealed that women who lacked social support showed more symptoms of depressed mood. The maternal depressive mood had a negative impact on breastfeeding, the experiences of motherhood and the relationship with partners.

Appropriate psychosocial assessment is important for designing relevant intervention strategies and for public health policy formulation [12]. Ethically, psychosocial risk assessment should be linked to a plan of care through the provision of appropriate psychosocial support. The plan of care should ensure that the maternal referral arrangements are in place at the participating facilities. The plan of care should be coordinated with all appropriate disciplines.

Irrespective of how maternity care providers perceive antenatal care, the important issue to be taken into consideration is the woman. From a psychosocial point of view, for midwives using a midwifery model, antenatal care is a time of building a relationship with each woman and her family. It is a time when a partnership is developed and negotiated; expectations, roles and responsibilities are identified; options are discussed and choices are made by women and supported by midwives.

While not neglecting physical safety, antenatal care should be emotionally, socially, culturally and religiously acceptable to the woman. Physical care alone is not sufficient for the woman, as her needs and expectations are unique. The effectiveness of antenatal care as a central focus is still being discussed by midwives, obstetricians, medical anthropologists, sociologists and women's organisations. Handley [13] cited Oakley (1984) in her book "Captured Womb" and wrote extensively on pregnancy, antenatal care and childbirth. She argues the importance of antenatal care but also believes that antenatal care is something that is done in an attempt to control the behaviour of women's bodies, an intervention offered to women that does not benefit all women, but probably a few who do not know what to expect from an antenatal care service.

Purdy (2001) as cited by Woodward [14] defines medicalisation as the process that transpires when health practitioners treat natural bodily functions as if they were diseased. Purdy further stated that it is essential that conventional medicine re-evaluates its health care model towards the needs of patients and not its own.

Conventional medicine must also accept other health care practices such as midwifery-led maternity care as a valid source of healthcare, especially to address psychosocial risk factors. Women's health problems, including pregnancy, should cease to be medicalised.

Parry [15] in a study exploring whether Canadian women's choice of midwifery care identifies a resistance to the medicalisation of pregnancy and childbirth came to the conclusion that women have a desire for personal control of their pregnancy as reflected in this comment:

*"I just wanted to be in control of what was going on with my body, It scares me that they will push you when you are in your most vulnerable state, because it is more convenient for their schedule". Participants further related how midwifery care met their needs for control over their bodies, their pregnancies and their experiences with childbirth, notwithstanding a sentiment that medical interventions also have a place in pregnancy and childbirth.*

An ideal option for effective antenatal care is the incorporation of psychosocial care as a component of antenatal care, acknowledging the women's own experiences of pregnancy [2]. Midwifery, which means "to be with women", is based upon a philosophy of care in which the management of pregnancy is shared between the midwife and the woman, with a focus on informed choice, shared responsibility, mutual decision making and women articulating their health needs.
