**8. Psychosocial care as a missing piece of the antenatal care puzzle**

Traditionally and in many contemporary contexts, including in South Africa, antenatal care consists of a prescribed set of acts based around the clinical monitoring and screening of all pregnant women. This establishment of routine care was based on the notion that pregnancy is a state of pathology rather than normal physiology. There is evidence of a focus on technological dominance and a focus on the detection of obstetric and medical conditions occurring during pregnancy. This is based on a review of seven guidelines for antenatal care from the USA, Canada, Australia and Germany and mostly reflects expert opinion rather than scientific evidence [21].

For example, antenatal care in South Africa is provided at the primary, secondary and tertiary levels of care in both the public and private health care systems. Basic antenatal care services include physical examination, weight measurement, urinalysis, blood pressure monitoring, blood investigations and health information and are supposedly provided at all levels of antenatal care as routine practice.

The ongoing debate on antenatal care regarding its frequency, content, continuity, quality and effectiveness in reducing maternal and neonatal morbidity and mortality led to a new evidence-based protocol on the frequency of antenatal care. This is the result of randomised trials carried out in the United Kingdom and Zimbabwe and of the World Health Organisation trials in Thailand, Argentina, Cuba and Saudi Arabia during 1996 [31].

Recommendations from a survey by Namagembe [20] were that a search for battering and abuse should be carried out during the antenatal assessment of pregnant women and midwives should have knowledge of the appropriate interventions and be familiar with the resources for referral. The increased cost and complications that may arise as a result of any delays should be a concern for maternal-child health professionals. Routine antenatal and postnatal screening for psychosocial distress has been supported by investigators as a preven-

Psychosocial assessment is defined by Chitra and Gnanadurai [1] as an evaluation of an individual's mental health, social status and functional capacity. The individual's physical status, appearance and modes of behaviour are observed for factors that may indicate or contribute to emotional distress or mental illness. Observation includes posture, facial expressions, manner of dress, speech and thought patterns, degree of motor activity and level of consciousness. The individual is questioned concerning patterns of daily living, including work schedule and social and leisure activities. Data should include the individual's response to and methods of coping with stress, relationships, cultural orientation, unemployment or change of

The above-listed risk factors can directly or indirectly affect the outcome of pregnancy in a negative way [7]. A meta-analysis of perinatal depression identified depression as a major complica-

Traditionally and in many contemporary contexts, including in South Africa, antenatal care consists of a prescribed set of acts based around the clinical monitoring and screening of all pregnant women. This establishment of routine care was based on the notion that pregnancy is a state of pathology rather than normal physiology. There is evidence of a focus on technological dominance and a focus on the detection of obstetric and medical conditions occurring during pregnancy. This is based on a review of seven guidelines for antenatal care from the USA, Canada, Australia and Germany and mostly reflects expert opinion rather than scientific evidence [21].

For example, antenatal care in South Africa is provided at the primary, secondary and tertiary levels of care in both the public and private health care systems. Basic antenatal care services include physical examination, weight measurement, urinalysis, blood pressure monitoring, blood investigations and health information and are supposedly provided at all levels of ante-

The ongoing debate on antenatal care regarding its frequency, content, continuity, quality and effectiveness in reducing maternal and neonatal morbidity and mortality led to a new evidence-based protocol on the frequency of antenatal care. This is the result of randomised

employment, change of residence, marriage, divorce or death of a loved one [30].

**8. Psychosocial care as a missing piece of the antenatal care puzzle**

tion of pregnancy affecting 14.5% of pregnant women [19].

tive measure for postnatal depression [28].

**7. Psychosocial assessment**

22 Selected Topics in Midwifery Care

natal care as routine practice.

The new schedule, as recommended by WHO [30], consists of four visits during pregnancy, the first one being early in pregnancy, with subsequent visits at 26, 32 and 36 weeks. This schedule is designed for the pregnant woman at low risk. These fewer antenatal visits led to poorer psychosocial outcomes and drew attention to greater maternal satisfaction with the routine care that was previously provided. The question is whether there would be an opportunity for the midwives to address psychosocial care within this regime.

Baldo [7] in a review of the antenatal care debate quoted Mcllwaine (1980) highlighting that he was amazed that pregnant women came for antenatal care and waited in the clinic for 2 hours, only to be seen for 2 minutes by someone laying his or her hands on them, and then leave. The reason for this is the traditional focus on the biophysiology of pregnancy. The author recommended that antenatal care appointments should be structured, focused and advocated for longer first appointments to allow comprehensive assessment in order to address both physiological and psychosocial risk factors.

The Changing Childbirth report explicitly confirmed that women should be the focus of antenatal care to enable a woman to make informed decisions based on her needs, having discussed her matters with the midwife involved. Key aspects of care valued by women are reported to be respect, competence, communication, support and convenience [32].

The above are supported by the researcher's findings from a phenomenological study on the expectations of antenatal care by pregnant women. Most women were happy with the physical health care but were dissatisfied with interpersonal aspects, for example, involvement, guidance and communication from the health care providers [33].

As a midwifery lecturer, the researcher often accompanied students for clinical facilitation. On guiding students on psychosocial care of women in the antenatal care clinic, women frequently verbalised social and emotional concerns. The researcher's further experience is that if psychosocial assessment is indeed conducted on a pregnant woman, it usually elicits the woman's current active and significant psychosocial challenges.

The following are common remarks that were expressed by women during their antenatal visits while the researcher was engaged in student accompaniment.

A woman carrying her first pregnancy at age 25, gravida 1 para 0, from one of Gauteng's provincial hospital's antenatal clinic remarked:

*"No one ever asked me this. Why don't everyone do like this? I think I am lucky today, I had so much to ask or discuss previously but there was just no one to listen to me. I moved from a black hospital to a one for whites thinking things will be better but it's the same. We come here, they quickly check the baby, and within 30 minutes you are gone with so much to share, as if the baby is the only one important". She then asked for the lecturer's and the student's contact numbers for further consultation.*

A pregnant woman, 42 years old, was asked if the pregnancy was planned at this vulnerable age as her first child was 20 years old. Her response was that she had lost a husband 5 years ago and had recently remarried. She was coping but her challenge was that the first child was 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 assessment by a midwife and appropriate referral offered.

A randomised controlled trial examining the effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial risk factors in pregnant women revealed that 72.7% of the women in the ALPHA group showed interest in discussing psychosocial issues The experimental group was twice as likely to declare psychosocial problems as the

Psychosocial Antenatal Care: A Midwifery Context http://dx.doi.org/10.5772/intechopen.80394 25

Two-thirds of health care providers in the ALPHA group found the form easy to use, and 86% said they would use it if it were recommended as standard practice. The conclusion of the trial showed that the assessment of psychosocial well-being during antenatal care was acceptable to both women and health care professionals [4, 31] in a project on antenatal psychosocial risk assessment in Australia, stating that antenatal depression, domestic violence and postnatal depression occurred more frequently than gestational diabetes, placenta praevia, pre-eclampsia and other obstetric and medical conditions, but most midwifery care settings still do not

As stated in Ref. [5] and other literature, for example, Hall (2001) as cited in Ref. [5], the procedures that are commonly undertaken to monitor pregnancy are aimed at reducing morbidity and mortality, but have been found to often cause physical, social and emotional harm. The physiological care that is routinely offered during antenatal care clearly illustrates that the scope of antenatal care is primarily derived from a medical perspective. The implication is that routine antenatal care fails to meet reasonable expectations and the needs of women. Midwives are urged to overcome the perception in literature and media that health care providers are unkind, rude, unsympathetic and uncaring, as negative emotions such as anger may arise when a woman receives insensitive care. Delwo [37] concluded her study of Swedish women's satisfaction with medical and emotional aspects of antenatal care by urging midwives working in antenatal care to support pregnant women and their partners in a professional and friendly way in order to increase their satisfaction with care. They also advised that identifying and responding to women who are dissatisfied with their antenatal care could help

**10. A study on psychosocial risk assessment and support during** 

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.

Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee, protocol number M081013. Participation was voluntary. Anonymity and

**pregnancy conducted in Gauteng Province, South Africa**

control group (based on odds ratio 1.8, 95% confidence interval and 1.1–3.0, ρ = 0.02).

routinely screen for psychosocial problems.

to improve their satisfaction.

**10.1. Ethical considerations**
