Background
International research has identified the potential for significant short and longer term negative health and social outcomes for women and their infants of poor mental health in pregnancy and after birth. Increasingly, policy makers and practitioners emphasise the importance of early identification and the need to offer services and appropriate treatment to women and their families. As a consequence, psychosocial assessment and depression screening is now recommended as part of routine clinical practice of midwives and nurses working in Australia and is increasingly being implemented internationally. Assessment of psychosocial risk factors such as domestic violence, substance misuse, past history of abuse or mental health concerns, lack of support, lower socio-economic status and a stressful pregnancy has become a key component of routine antenatal and postnatal care for Australian women in the state of New South Wales (NSW). The aim of the State policy known as 'Supporting Families Early'(SFE) is to identify women with known risk factors (see Table 1 for assessment domains and questions) and to provide women and their families with 'appropriate information and additional appointments or referral' p.69. The assessment process includes screening for depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS), domestic violence screening and questions about drug use and previous or existing mental health issues (see Table 1). The SFE policy recommends that women be assessed as a minimum, at two points in time: antenatal (approximately 12–14 weeks gestation) at their hospital booking visit and again approximately two–four weeks after birth at the time of the routine health home visit or at the six–eight week baby check in the clinic setting. In the NSW public health system, the first of these assessments is undertaken by a midwife at the hospital booking visit for pregnancy care and the second by the child and family health nurse (CFHN) who, similar to the health visitor in the United Kingdom, provide preventative health for children and families from birth to five years of age.
Studies in Australia and overseas report that most women find routine antenatal psychosocial assessment and depression screening to be acceptable offering them an opportunity to discuss sensitive issues. In telephone interviews with a large sample of community women, Leigh and Milgrom found 100% acceptability of screening for depressive symptoms by midwives using the EPDS in pregnancy. Buist et al. found a similarly high level of comfort with depression screening (85%) however, they reported that women with an EPDS ≥ 13 were more likely to find the screening process uncomfortable. Matthey et al. also conducted telephone interviews before after birth to ascertain acceptability of psychosocial assessment and depression screening. They found that 65% of English-speaking women thought the psychosocial questions were acceptable, with the remainder qualifying their response indicating that they or other women may not be happy to answer certain questions such as those related to domestic violence and were uncertain as to why some questions about their childhood were relevant. One fifth (19%) of women were ambivalent or negative about the questions.
Conversely, concerns have been raised both nationally and internationally about the use of assessment tools particularly with vulnerable women as they may feel judged or victimized by the questioning and may deny problems such as domestic violence or their own negative childhood experiences, paradoxically placing them at greater risk of reduced access to supportive services. Few studies have investigated the style and approach that midwives and nurses take to conducting the assessment or how women respond to the questions and make meaning of this experience.
This paper reports the findings of one part of a larger ethnographic study that sought to describe the process and the impact of psychosocial assessment and depression screening. The main focus of the study was; the approach midwives and nurses take to the assessment process and to report the midwives', nurses' and women's experiences. This paper describes women's experience of psychosocial assessment and depression screening examining the meaning they attribute to assessment and how this influences their response. The experiences of midwives and nurses have been reported separately.