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Vasilevski V, Graham K, McKay F, Dunn M, Wright M, Radelaar E, Vuillermin PJ, Sweet L. Barriers and enablers to antenatal care attendance for women referred to social work services in a Victorian regional hospital: A qualitative descriptive study. Women Birth 2024; 37:443-450. [PMID: 38246853 DOI: 10.1016/j.wombi.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 12/20/2023] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND Women referred to social work services during pregnancy are more likely to experience social disadvantage than those who are not, resulting in reduced antenatal care attendance. Lack of antenatal care engagement leads to poor identification and management of concerns that can have immediate and long-term health consequences for women and their babies. Identifying the barriers and enablers to antenatal care attendance for women referred to social work services is important for designing models of care that promote effective engagement. AIMS This study aimed to explore the barriers and enablers to antenatal care attendance by women referred to social work services from the perspectives of women, and clinicians who provide antenatal healthcare. METHODS A qualitative descriptive study using constructivist grounded theory methods was undertaken. Ten women referred to social work services and 11 antenatal healthcare providers were purposively recruited for interviews from a regional maternity service in Victoria, Australia. FINDINGS Continuity of care and healthcare providers partnering with women were central to effective engagement with antenatal care services. Three interrelated concepts were identified: 1) experiences of the hospital environment and access to care; 2) perceptions of care influence engagement, and 3) motivations for regularly attending services. CONCLUSIONS Continuity of care is essential for supporting women referred to social work services to attend antenatal appointments. Women are better equipped to overcome other barriers to antenatal service attendance when they have a strong partnership with clinicians involved in their care.
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Affiliation(s)
- Vidanka Vasilevski
- School of Nursing and Midwifery, Deakin University, Victoria, Australia; Centre for Quality and Patient Safety Research, Institute for Health Transformation, Western Health Partnership, Victoria, Australia.
| | - Kristen Graham
- School of Nursing and Midwifery, Deakin University, Victoria, Australia; Centre for Quality and Patient Safety Research, Institute for Health Transformation, Western Health Partnership, Victoria, Australia; College of Nursing and Health Sciences, Flinders University, Australia; National Centre for Epidemiology and Population Health, The Australian National University
| | - Fiona McKay
- School of Health and Social Development, Institute for Health Transformation, Deakin University, Victoria, Australia
| | - Matthew Dunn
- School of Health and Social Development, Institute for Health Transformation, Deakin University, Victoria, Australia
| | | | | | - Peter J Vuillermin
- Barwon Health, Victoria, Australia; School of Medicine, Deakin University, Victoria, Australia
| | - Linda Sweet
- School of Nursing and Midwifery, Deakin University, Victoria, Australia; Centre for Quality and Patient Safety Research, Institute for Health Transformation, Western Health Partnership, Victoria, Australia
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Wohrer F, Ngo H, DiDomenico J, Ma X, Roberts MH, Bakhireva LN. Potentially modifiable risk and protective factors affecting mental and emotional wellness in pregnancy. Front Hum Neurosci 2024; 18:1323297. [PMID: 38445095 PMCID: PMC10912531 DOI: 10.3389/fnhum.2024.1323297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/01/2024] [Indexed: 03/07/2024] Open
Abstract
Introduction Impaired mental and emotional wellness often co-occurs with prenatal substance use, and both affect infant socio-emotional, cognitive, language, motor, and adaptive behavioral outcomes. Guided by the modified biopsychosocial framework, this study examined the role of common substance exposures during pregnancy (i.e., alcohol and cannabis), socio-cultural factors (social support during pregnancy, adverse childhood experiences), and reproductive health factors on maternal mental health (MMH). Methods Data were obtained from a prospective cohort study-Ethanol, Neurodevelopment, Infant, and Child Health (ENRICH-2), and included 202 pregnant persons. Alcohol and cannabis exposures were assessed through repeated prospective interviews and a comprehensive battery of drug and ethanol biomarkers. MMH outcomes were evaluated during the third trimester through the Perceived Stress Scale, Edinburgh Depression Scale, Generalized Anxiety Disorders-7, and Post-traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders. Univariate and multivariable linear regression models evaluated significant predictors of MMH. Results Results of multivariable analysis indicate that both maternal adverse childhood experiences and alcohol exposure, even at low-to-moderate levels, during pregnancy were associated with poorer scores for most MMH measures, while higher level of social support and Spanish as the primary language at home (as a proxy of enculturation) had protective effects (all p's < 0.05). Conclusion These findings highlight the importance of assessing substance use, including periconceptional alcohol exposure, and mental health in pregnant persons as closely related risk factors which cannot be addressed in isolation. Our findings also emphasize a strong protective effect of socio-cultural factors on maternal mental and emotional wellbeing-a strong precursor to maternal-infant bonding and infant neurodevelopment.
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Affiliation(s)
- Fiona Wohrer
- School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Helen Ngo
- College of Pharmacy Substance Use Research and Education Center, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Jared DiDomenico
- College of Pharmacy Substance Use Research and Education Center, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Xingya Ma
- College of Pharmacy Substance Use Research and Education Center, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Melissa H. Roberts
- College of Pharmacy Substance Use Research and Education Center, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Ludmila N. Bakhireva
- College of Pharmacy Substance Use Research and Education Center, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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Howard LM, Abel KM, Atmore KH, Bick D, Bye A, Byford S, Carson LE, Dolman C, Heslin M, Hunter M, Jennings S, Johnson S, Jones I, Taylor BL, McDonald R, Milgrom J, Morant N, Nath S, Pawlby S, Potts L, Powell C, Rose D, Ryan E, Seneviratne G, Shallcross R, Stanley N, Trevillion K, Wieck A, Pickles A. Perinatal mental health services in pregnancy and the year after birth: the ESMI research programme including RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/ccht9881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background
It is unclear how best to identify and treat women with mental disorders in pregnancy and the year after birth (i.e. the perinatal period).
Objectives
(1) To investigate how best to identify depression at antenatal booking [work package (WP) 1]. (2) To estimate the prevalence of mental disorders in early pregnancy (WP1). (3) To develop and examine the efficacy of a guided self-help intervention for mild to moderate antenatal depression delivered by psychological well-being practitioners (WP1). (4) To examine the psychometric properties of the perinatal VOICE (Views On Inpatient CarE) measure of service satisfaction (WP3). (5) To examine the clinical effectiveness and cost-effectiveness of services for women with acute severe postnatal mental disorders (WPs 1–3). (6) To investigate women’s and partners’/significant others’ experiences of different types of care (WP2).
Design
Objectives 1 and 2 – a cross-sectional survey stratified by response to Whooley depression screening questions. Objective 3 – an exploratory randomised controlled trial. Objective 4 – an exploratory factor analysis, including test–retest reliability and validity assessed by association with the Client Satisfaction Questionnaire contemporaneous satisfaction scores. Objective 5 – an observational cohort study using propensity scores for the main analysis and instrumental variable analysis using geographical distance to mother and baby unit. Objective 6 – a qualitative study.
Setting
English maternity services and generic and specialist mental health services for pregnant and postnatal women.
Participants
Staff and users of mental health and maternity services.
Interventions
Guided self-help, mother and baby units and generic care.
Main outcome measures
The following measures were evaluated in WP1(i) – specificity, sensitivity, positive predictive value, likelihood ratio, acceptability and population prevalence estimates. The following measures were evaluated in WP1(ii) – participant recruitment rate, attrition and adverse events. The following measure was evaluated in WP2 – experiences of care. The following measures were evaluated in WP3 – psychometric indices for perinatal VOICE and the proportion of participants readmitted to acute care in the year after discharge.
Results
WP1(i) – the population prevalence estimate was 11% (95% confidence interval 8% to 14%) for depression and 27% (95% confidence interval 22% to 32%) for any mental disorder in early pregnancy. The diagnostic accuracy of two depression screening questions was as follows: a weighted sensitivity of 0.41, a specificity of 0.95, a positive predictive value of 0.45, a negative predictive value of 0.93 and a likelihood ratio (positive) of 8.2. For the Edinburgh Postnatal Depression Scale, the diagnostic accuracy was as follows: a weighted sensitivity of 0.59, a specificity of 0.94, a positive predictive value of 0.52, a negative predictive value of 0.95 and a likelihood ratio (positive) of 9.8. Most women reported that asking about depression at the antenatal booking appointment was acceptable, although this was reported as being less acceptable for women with mental disorders and/or experiences of abuse. Cost-effectiveness analysis suggested that both the Whooley depression screening questions and the Edinburgh Postnatal Depression Scale were more cost-effective than with the Whooley depression screening questions followed by the Edinburgh Postnatal Depression Scale or no-screen option. WP1(ii) – 53 women with depression in pregnancy were randomised. Twenty-six women received modified guided self-help [with 18 (69%) women attending four or more sessions] and 27 women received usual care. Three women were lost to follow-up (follow-up for primary outcome: 92%). At 14 weeks post randomisation, women receiving guided self-help reported fewer depressive symptoms than women receiving usual care (adjusted effect size −0.64, 95% confidence interval −1.30 to 0.06). Costs and quality-adjusted life-years were similar, resulting in a 50% probability of guided self-help being cost-effective compared with usual care at National Institute for Health and Care Excellence cost per quality-adjusted life-year thresholds. The slow recruitment rate means that a future definitive larger trial is not feasible. WP2 – qualitative findings indicate that women valued clinicians with specialist perinatal expertise across all services, but for some women generic services were able to provide better continuity of care. Involvement of family members and care post discharge from acute services were perceived as poor across services, but there was also ambivalence among some women about increasing family involvement because of a complex range of factors. WP3(i) – for the perinatal VOICE, measures from exploratory factor analysis suggested that two factors gave an adequate fit (comparative fit index = 0.97). Items loading on these two dimensions were (1) those concerning aspects of the service relating to the care of the mother and (2) those relating to care of the baby. The factors were positively correlated (0.49; p < 0.0001). Total scores were strongly associated with service (with higher satisfaction for mother and baby units, 2 degrees of freedom; p < 0.0001) and with the ‘gold standard’ Client Service Questionnaire total score (test–retest intraclass correlation coefficient 0.784, 95% confidence interval 0.643 to 0.924; p < 0.0001). WP3(ii) – 263 of 279 women could be included in the primary analysis, which shows that the odds of being readmitted to acute care was 0.95 times higher for women who were admitted to a mother and baby unit than for those not admitted to a mother and baby unit (0.95, 95% confidence interval 0.86 to 1.04; p = 0.29). Sensitivity analysis using an instrumental variable found a markedly more significant effect of admission to mother and baby units (p < 0.001) than the primary analysis. Mother and baby units were not found to be cost-effective at 1 month post discharge because of the costs of care in a mother and baby unit. Cost-effectiveness advantages may exist if the cost of mother and baby units is offset by savings from reduced readmissions in the longer term.
Limitations
Policy and service changes had an impact on recruitment. In observational studies, residual confounding is likely.
Conclusions
Services adapted for the perinatal period are highly valued by women and may be more effective than generic services. Mother and baby units have a low probability of being cost-effective in the short term, although this may vary in the longer term.
Future work
Future work should include examination of how to reduce relapses, including in after-care following discharge, and how better to involve family members.
Trial registration
This trial is registered as ISRCTN83768230 and as study registration UKCRN ID 16403.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Louise M Howard
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Kathryn M Abel
- Centre for Women’s Mental Health, The University of Manchester, Manchester, UK
| | - Katie H Atmore
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Debra Bick
- Division of Women and Children’s Health, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - Amanda Bye
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sarah Byford
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Lauren E Carson
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Clare Dolman
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Margaret Heslin
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Myra Hunter
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Stacey Jennings
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Ian Jones
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | | | - Rebecca McDonald
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jeannette Milgrom
- Department of Clinical and Health Psychology, Parent–Infant Research Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Nicola Morant
- Division of Psychiatry, University College London, London, UK
| | - Selina Nath
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Susan Pawlby
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Laura Potts
- Biostatistics and Health Informatics, King’s College London, London, UK
| | - Claire Powell
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Diana Rose
- Service User Research Enterprise, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Elizabeth Ryan
- Biostatistics and Health Informatics, King’s College London, London, UK
| | | | - Rebekah Shallcross
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nicky Stanley
- School of Social Work, Care and Community, University of Central Lancashire, Harrington, UK
| | - Kylee Trevillion
- Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Angelika Wieck
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Andrew Pickles
- Biostatistics and Health Informatics, King’s College London, London, UK
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Abstract
Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high-income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.
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Affiliation(s)
- Louise M. Howard
- Section of Women's Mental Health, Health Service and Population Research DepartmentInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Hind Khalifeh
- Section of Women's Mental Health, Health Service and Population Research DepartmentInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
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