**10. A study on psychosocial risk assessment and support during pregnancy conducted in Gauteng Province, South Africa**

The aim of this study was to develop guidelines for the enhancement of psychosocial risk assessment of pregnant women, with a focus on the provision of psychosocial support.

It was hoped that the results of the study would provide evidence that could motivate interventions aimed at closing the gap between the routine assessment of physiological risks factors and the assessment of psychosocial risk factors during antenatal care. This would provide a basis for midwives to implement an appropriate action should any psychosocial risk be identified. Once formally tested, such guidelines could be incorporated into national guidelines for best practice.

#### **10.1. Ethical considerations**

rejecting both the new husband and the pregnancy. This was a reflection of another need for psychosocial support that could have been achieved through a proper psychosocial assess-

The concept of psychosocial stressors during pregnancy encompasses life experiences, including among others, changes in personal life, job status, family makeup, housing and domestic violence [1]. All these require adaptive coping mechanisms on the part of the pregnant

Risk screening, according to Refs. [1, 7], involves using a list of risk factors and some form of scoring system to classify pregnant women into specific risk categories, typically high risk or low risk, using cutoff points or thresholds. The focus of risk screening is to detect early symptoms and to predict the likelihood of complications. The intention of risk assessment is to predict problems before they occur and, as such, take appropriate action by providing optimal maternal care. Bibring (1959) as cited by Stahl and Hundley [16] was among the first psychoanalytic writers to claim that "pregnancy is a psychobiological crisis affecting all expectant mothers, no matter what their state of psychic health is. As [with] every normal crisis that constitutes a turning point in life, it precipitates an acute disequilibrium…may lead to a new level of psychological maturity and integration. The outcome of this crisis might have a profound effect not only on

A cross-sectional study to identify a relationship between life stress, perceived social support and symptoms of depression and anxiety was conducted by Waldenstrom [34]. Based on her findings, it was recommended that psychosocial assessment of pregnant women and their partners may facilitate interventions to augment support networks and as such reduce the

The New Antenatal Care Model proposed by WHO [35] recommends a set of activities during each visit for those women who are identified to be at low risk by screening for conditions likely to increase adverse outcomes of pregnancy, providing therapeutic intervention known to be beneficial and educating women about safe birth. However, the model does not emphasise psychosocial issues but proposes that some time should be set aside during each visit to discuss the pregnancy and related issues. Emphasis was put on the importance of

As a measure to promote psychosocial risk assessment, a new approach to psychosocial risk assessment during pregnancy (ANEW) was implemented in Australia during 2000, in a form of a project to provide an alternative way to psychological risk screening in pregnancy. A training programme in advanced communication skills and common psychosocial aspects of childbirth was offered to midwives and doctors at the Mercy Hospital for women, with the aim of improving the identification and support of women with psychosocial needs in pregnancy [36]. The outcome of the programme was that it improved the ability of the health care professionals to identify and care for women with psychosocial

**9. Why should psychosocial risks be screened during antenatal care?**

woman, which can be achieved through the support of the midwife.

the woman herself but also on the mother-child relationship".

risk of psychosocial stress.

communication.

needs.

ment by a midwife and appropriate referral offered.

24 Selected Topics in Midwifery Care

Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee, protocol number M081013. Participation was voluntary. Anonymity and confidentiality were maintained throughout the research process. The ethical principles of autonomy, beneficence, non-maleficence and justice were observed accordingly.

**10.5. An overview of study findings and discussion**

The findings confirmed that women experience stressful life events during pregnancy as illus-

The response from 300 participants was that 184 (61.3%) were experiencing stressful life events during the current pregnancy, whereas 116 (38.6%) did not experience any stressful life events. Among those who experienced stressful life events, 72 (24%) experienced two events and 44 (14%) experienced three or more stressful life events. This provides evidence of the importance of assessing women psychosocially as almost all women present with psy-

The SANC Regulations, the curriculum and learning guides display a broad approach to psychosocial care as the focus is on holistic care. Written tests, examinations and clinical tools implemented at the colleges address psychosocial care to a minimal level. The Gauteng antenatal care guideline policy, the Guidelines for Maternity Care in South Africa (2015) and the midwifery competency register do not reflect psychosocial content in their guidelines or psychosocial criteria to be met during antenatal care. The antenatal card does not reflect guidelines on psychosocial care, as midwives recorded what they perceived as relevant to be

**Yes No**

Psychosocial Antenatal Care: A Midwifery Context http://dx.doi.org/10.5772/intechopen.80394 27

**Pregnancy stressful life events Women's responses n (%)**

**Table 1.** Stressful life events experienced by respondents during the current.

1.1. Have you experienced death of a spouse or family member? 82(27) 218(73) 1.2. Have you gone through a divorce or marital separation? 26(9) 274(91) 1.3. Were you retrenched or fired from work? 37(12) 264(88) 1.4. Have you been a victim of rape or sexual assault? 15(5) 286(95) 1.5. Have you ever experienced any pregnancy loss? 60(20) 242(80) 2. Was the pregnancy planned? 140(46) 162(54) 3. Have you been sick during this pregnancy? 141(47) 160(53) If yes, what was the illness? Note response to the questions below 4. Have you ever attempted suicide? 15(5) 285(95) 5. Have you ever been diagnosed with a mental health condition? 14(5) 286(95) 6. Have you been hospitalised for a mental health problem? 16(5) 284(95) 7. Did you attend any mental health counselling session? 27(9) 274(91)

*10.5.1. Quantitative results*

trated in **Table 1**.

chosocial problems.

assessed psychosocially.

#### **10.2. Research context and methods**

A mixed-method research was used for this study. A sequential explanatory design was employed, whereby quantitative data were first collected and analysed, followed by qualitative data collection and analysis in two consecutive phases [38]. The investigation was conducted within the following contexts:

### **10.3. Sampling and data collection**

Sampling was purposive for all data sources, which were midwifery education and training regulations from the South African Nursing Council; midwifery education and training records of the three nursing colleges providing basic nurse education in Gauteng Province in South Africa; records of antenatal care for women attending government antenatal facilities in Gauteng Province were reviewed to establish the inclusion of psychosocial care; the administration of questionnaires to pregnant women attending antenatal care in Gauteng Province clinics; focus group discussions with both midwives and pregnant women at the antenatal care clinics; a survey to establish the extent of psychosocial assessment and psychosocial care by midwives during pregnancy, through a self-administered questionnaire; and in-depth interviews conducted with midwifery experts from various settings at which midwifery was offered, for example, universities, nursing colleges and midwifery obstetric units (MOUs).

#### **10.4. Data analysis**

#### *10.4.1. Quantitative data analysis*

Quantitative data were analysed using Stata Release 10 statistical software. Data analysis generally included summary statistics (mean, standard deviation for continuous variables, frequencies and percentages for discrete variables) and Cronbach's alpha for internal consistency. Confidence intervals of 95% were used to report for discrete variable.

#### *10.4.2. Qualitative data analysis*

Qualitative data analysis occurred concurrently with data collection. To enhance the depth of qualitative analysis, multiple approaches to data analysis were used (e.g., constant comparison, thematic analysis and framework analysis) comparing themes and categories as a form of across-case analysis technique [38]. The stages that were involved in reducing data were examining, categorising and tabulating data [39].

Data analysis was systematic, sequential, verifiable and continuous in order to minimise potential bias. A "Framework Analysis" was mostly used in qualitative data analysis.

#### **10.5. An overview of study findings and discussion**

#### *10.5.1. Quantitative results*

confidentiality were maintained throughout the research process. The ethical principles of

A mixed-method research was used for this study. A sequential explanatory design was employed, whereby quantitative data were first collected and analysed, followed by qualitative data collection and analysis in two consecutive phases [38]. The investigation was conducted

Sampling was purposive for all data sources, which were midwifery education and training regulations from the South African Nursing Council; midwifery education and training records of the three nursing colleges providing basic nurse education in Gauteng Province in South Africa; records of antenatal care for women attending government antenatal facilities in Gauteng Province were reviewed to establish the inclusion of psychosocial care; the administration of questionnaires to pregnant women attending antenatal care in Gauteng Province clinics; focus group discussions with both midwives and pregnant women at the antenatal care clinics; a survey to establish the extent of psychosocial assessment and psychosocial care by midwives during pregnancy, through a self-administered questionnaire; and in-depth interviews conducted with midwifery experts from various settings at which midwifery was offered, for example, universities, nursing colleges and midwifery obstetric

Quantitative data were analysed using Stata Release 10 statistical software. Data analysis generally included summary statistics (mean, standard deviation for continuous variables, frequencies and percentages for discrete variables) and Cronbach's alpha for internal consis-

Qualitative data analysis occurred concurrently with data collection. To enhance the depth of qualitative analysis, multiple approaches to data analysis were used (e.g., constant comparison, thematic analysis and framework analysis) comparing themes and categories as a form of across-case analysis technique [38]. The stages that were involved in reducing data were

Data analysis was systematic, sequential, verifiable and continuous in order to minimise poten-

tency. Confidence intervals of 95% were used to report for discrete variable.

tial bias. A "Framework Analysis" was mostly used in qualitative data analysis.

autonomy, beneficence, non-maleficence and justice were observed accordingly.

**10.2. Research context and methods**

within the following contexts:

26 Selected Topics in Midwifery Care

units (MOUs).

**10.4. Data analysis**

*10.4.1. Quantitative data analysis*

*10.4.2. Qualitative data analysis*

examining, categorising and tabulating data [39].

**10.3. Sampling and data collection**

The findings confirmed that women experience stressful life events during pregnancy as illustrated in **Table 1**.

The response from 300 participants was that 184 (61.3%) were experiencing stressful life events during the current pregnancy, whereas 116 (38.6%) did not experience any stressful life events. Among those who experienced stressful life events, 72 (24%) experienced two events and 44 (14%) experienced three or more stressful life events. This provides evidence of the importance of assessing women psychosocially as almost all women present with psychosocial problems.

The SANC Regulations, the curriculum and learning guides display a broad approach to psychosocial care as the focus is on holistic care. Written tests, examinations and clinical tools implemented at the colleges address psychosocial care to a minimal level. The Gauteng antenatal care guideline policy, the Guidelines for Maternity Care in South Africa (2015) and the midwifery competency register do not reflect psychosocial content in their guidelines or psychosocial criteria to be met during antenatal care. The antenatal card does not reflect guidelines on psychosocial care, as midwives recorded what they perceived as relevant to be assessed psychosocially.


**Table 1.** Stressful life events experienced by respondents during the current.

#### *10.5.2. Qualitative findings*

The findings from the focus group discussions within this study also indicated that psychosocial assessment and care were important during pregnancy. The respondents further highlighted the importance of an appropriate guideline and a record for psychosocial assessment and care as reflected within the following responses:

**Respondent 1:** *"If you look now the state of affairs of our antenatal card it just says social…(***emphasizing***), and you can ask anything… there is nowhere psychosocial issues are recorded".*

**Respondent 2:** *"Yes, something like TICK, TICK, will help maybe something like a checklist to ask relevant questions, with a checklist I think we would be made aware of the things that we normally don't ask".*

*"Yes, (***All participants***) the checklist will remind us to go deeper, you know beyond the surface, to go deeper than the care that we normally give because it's useless to pretend as if everything is fine whereas the patient has a big problem that can lead to complications, but once we have something that will guide us to ask something, even if you don't ask all the questions, but you know maybe you can highlight, and maybe you pick up something, that will be very helpful".*

**Respondent 3:** *"There must be a tool because on the green card is just a small line, where we ask for example, it is not written clear, just says "social"… therefore if there was a guideline regarding what should be done it will be appropriate for the pregnant women".*

The concern about the need for training and support for midwives and other health professionals undertaking care to pregnant women [40] led to the development of a psychosocial risk assessment tool that was also based on the findings of the study. Furthermore, there are few studies worldwide reporting the development, evaluation and implementation of screening tools for psychosocial risk factors in pregnant women and subsequent intervention and prevention programs [45]. The assessment tool developed from the findings of this study is currently being piloted in 21 Community Health Centers in Gauteng Province as a 3-year project (2017–2019). The aim of the pilot study is to evaluate the tool, modify it and incorporate it as part of routine antenatal care. The long-term plan is to have a policy developed that integrates psychosocial risk assessment and support with routine physical care.

able to validate and sort information within the group and it also allows a midwife to devote more time to pregnant women by saving about 3 hours per woman [47]. Groups may address common psychosocial problems, and those who need further individual consultation can be

Group antenatal care (Centering Pregnancy, USA) Consist of a group facilitated by the clinician that lasts

Hawaiian-style "Talkstory" The talk-story is integrated into the woman's antenatal and

ALPHA tool (Canada) 35 items used to detect 15 risk factors for postnatal adverse

women [45].

pregnancy risks [46].

KINDEX (University of Konstanz, Germany) Assess 11 risk arears during pregnancy, the presence of

Antenatal risk questionnaire (ANQR) Composed of 12 items retrieved from the original 23

psychosocial issues [43].

custom and culture.

postpartum women [44].

psychosocial outcomes [31].

Has been applied in European countries.

approximately 90–120 minutes. This allows a discussion of a wide range of pregnancy-related issues that include

Psychosocial Antenatal Care: A Midwifery Context http://dx.doi.org/10.5772/intechopen.80394 29

postnatal assessment and care and involves an exchange of thoughts between the woman and midwife. It is based on the woman's values, beliefs and experiences, acknowledging

Offers a conceptual framework, measures and methods suitable for a brief psychosocial assessment of pregnant and

psychosocial factors and the experience of adversities by

The Schindler-Rising model of "centering pregnancy", one of the recommended models for

offered the same, which will probably not be often, with routine individualised care.

antenatal care, is presented in **Figure 1**.

**Figure 1.** "Centering pregnancy".

**Table 2.** Interventions to enhance psychosocial care.

A psychosocial risk assessment model (PRAM)

Australia

**Type of intervention Description**

Based on the increasing international move to standardise as routine the psychosocial assessment and depression screening of all pregnant women and offer relevant support [40–42], different options need to be considered in order to enhance psychosocial care. Some of the interventions that are applied in certain countries globally are reflected in **Table 2**.

#### **10.6. Group antenatal care**

Based on the shortage of midwives or clinicians reported in this and other studies, and coupled with a limitation in psychosocial care, group antenatal care might be another option.

Group antenatal care originated a decade ago in Minnesota, USA, during the early 1970s. It was introduced in Denmark in 1998, followed by Sweden in 2000. It is offered concurrently with traditional antenatal care. Antenatal visits are carried out in groups of 6–8. There is evidence that this approach increases networking between pregnant women, women are


**Table 2.** Interventions to enhance psychosocial care.

*10.5.2. Qualitative findings*

28 Selected Topics in Midwifery Care

**10.6. Group antenatal care**

*don't ask".*

and care as reflected within the following responses:

*maybe you pick up something, that will be very helpful".*

*should be done it will be appropriate for the pregnant women".*

The findings from the focus group discussions within this study also indicated that psychosocial assessment and care were important during pregnancy. The respondents further highlighted the importance of an appropriate guideline and a record for psychosocial assessment

**Respondent 1:** *"If you look now the state of affairs of our antenatal card it just says social…(***empha-**

**Respondent 2:** *"Yes, something like TICK, TICK, will help maybe something like a checklist to ask relevant questions, with a checklist I think we would be made aware of the things that we normally* 

*"Yes, (***All participants***) the checklist will remind us to go deeper, you know beyond the surface, to go deeper than the care that we normally give because it's useless to pretend as if everything is fine whereas the patient has a big problem that can lead to complications, but once we have something that will guide us to ask something, even if you don't ask all the questions, but you know maybe you can highlight, and* 

**Respondent 3:** *"There must be a tool because on the green card is just a small line, where we ask for example, it is not written clear, just says "social"… therefore if there was a guideline regarding what* 

The concern about the need for training and support for midwives and other health professionals undertaking care to pregnant women [40] led to the development of a psychosocial risk assessment tool that was also based on the findings of the study. Furthermore, there are few studies worldwide reporting the development, evaluation and implementation of screening tools for psychosocial risk factors in pregnant women and subsequent intervention and prevention programs [45]. The assessment tool developed from the findings of this study is currently being piloted in 21 Community Health Centers in Gauteng Province as a 3-year project (2017–2019). The aim of the pilot study is to evaluate the tool, modify it and incorporate it as part of routine antenatal care. The long-term plan is to have a policy developed that

Based on the increasing international move to standardise as routine the psychosocial assessment and depression screening of all pregnant women and offer relevant support [40–42], different options need to be considered in order to enhance psychosocial care. Some of the

Based on the shortage of midwives or clinicians reported in this and other studies, and coupled with a limitation in psychosocial care, group antenatal care might be another option.

Group antenatal care originated a decade ago in Minnesota, USA, during the early 1970s. It was introduced in Denmark in 1998, followed by Sweden in 2000. It is offered concurrently with traditional antenatal care. Antenatal visits are carried out in groups of 6–8. There is evidence that this approach increases networking between pregnant women, women are

integrates psychosocial risk assessment and support with routine physical care.

interventions that are applied in certain countries globally are reflected in **Table 2**.

**sizing***), and you can ask anything… there is nowhere psychosocial issues are recorded".*

able to validate and sort information within the group and it also allows a midwife to devote more time to pregnant women by saving about 3 hours per woman [47]. Groups may address common psychosocial problems, and those who need further individual consultation can be offered the same, which will probably not be often, with routine individualised care.

The Schindler-Rising model of "centering pregnancy", one of the recommended models for antenatal care, is presented in **Figure 1**.

**Figure 1.** "Centering pregnancy".

A "centering pregnancy" model is an innovative model for prenatal care. It focuses on "woman-centred care" by integrating antenatal care, health information and group support. It acknowledges a woman as an expert regarding her needs. The approach is practised, for example, in Canada, where women are involved in their basic assessment by weighing one another, checking one's own urine sample, and intragroup checking of blood pressure. Each woman also records results in her own antenatal card [47].

Although the "centering pregnancy" model might free midwives or clinicians from routine investigations and as such allow them more time to address issues like psychosocial care, it carries a limitation in a sense that women should be literate, and the process should still be supervised by a midwife or a clinician until women are familiar with all aspects.

## **10.7. The Hawaiian-style "talkstory"**

A Hawaiian-style "talkstory" originated from a needs-assessment project undertaken in Hawaii during 2000, where women indicated that their psychosocial needs were largely unmet.

A Hawaiian-style "talkstory" could offer an ideal approach in offering culturally focused antenatal care as it is a culturally based interactive communication approach, aimed at addressing the pregnant woman's psychosocial needs. It could be mostly effective during the initial antenatal care booking as the woman is taking the lead in sharing her childbirth experiences. **Figure 2** explains the talkstory process as a guideline for midwives who might be interested in its implementation.

**10.8. The success of the "talkstory" approach**

**Figure 3.** Outcomes achieved through the "talkstory process".

offering her autonomy and a right to informed choice [48].

challenge in institutions experiencing the shortage of staff.

**11. Conclusion**

The "talkstory" approach, as illustrated in **Figure 3**, served as an ideal way of assessing women psychosocially. It offers an opportunity to provide the woman with relevant health information and to validate myths or misconceptions about childbirth that the woman might be having, while also addressing her expectations. This is a type of psychosocial assessment and care that is women-centred, through placing an emphasis on a woman's own beliefs,

Psychosocial Antenatal Care: A Midwifery Context http://dx.doi.org/10.5772/intechopen.80394 31

A "talkstory" is an ideal approach during the initial contact of the woman and the midwife or a clinician, and as such it might promote communication between the two; it needs some time and requires a midwife or clinician who is skilled in listening and who has an ability to convey compassion, acceptance and encouragement to the woman. This approach might be a

The implementation of psychosocial care incorporates adherence to the following principles: human rights and equality, justice and confidentiality. Measures to be put in place as part of psychosocial support are availability of referral resources (social, mental, economic and judicial); the assessor should be well informed about the options of referral and to consider the possibility of the accompaniment of the woman throughout the process as a form of continuity of care and as stated by the United Nations Entity for Gender Equality and the Empowerment of Women.

The issue of psychosocial risk assessment and support seems to be a concern both nationally and internationally. The process of adapting to pregnancy and the resulting life changes are often difficult, even if the pregnancy is planned as pregnancy involves intense emotional, spiritual, psychological and social factors that need a midwife's caring awareness and responsiveness.

**Figure 3.** Outcomes achieved through the "talkstory process".

#### **10.8. The success of the "talkstory" approach**

The "talkstory" approach, as illustrated in **Figure 3**, served as an ideal way of assessing women psychosocially. It offers an opportunity to provide the woman with relevant health information and to validate myths or misconceptions about childbirth that the woman might be having, while also addressing her expectations. This is a type of psychosocial assessment and care that is women-centred, through placing an emphasis on a woman's own beliefs, offering her autonomy and a right to informed choice [48].

A "talkstory" is an ideal approach during the initial contact of the woman and the midwife or a clinician, and as such it might promote communication between the two; it needs some time and requires a midwife or clinician who is skilled in listening and who has an ability to convey compassion, acceptance and encouragement to the woman. This approach might be a challenge in institutions experiencing the shortage of staff.

The implementation of psychosocial care incorporates adherence to the following principles: human rights and equality, justice and confidentiality. Measures to be put in place as part of psychosocial support are availability of referral resources (social, mental, economic and judicial); the assessor should be well informed about the options of referral and to consider the possibility of the accompaniment of the woman throughout the process as a form of continuity of care and as stated by the United Nations Entity for Gender Equality and the Empowerment of Women.
