Identifying and supporting women with psychosocial issues during the postnatal period: Evaluating an educational intervention for midwives using a before-and-after survey
Introduction
Women may experience a range of psychosocial issues during pregnancy, childbirth and the postnatal period, such as depression, partner violence, social isolation, lack of social support, a history of sexual abuse, substance abuse and mental illness (Gunn et al., 2006). Midwives play an important role in supporting women who are experiencing these issues; however, there has traditionally been little formal education for care providers in managing these issues (Kurtz et al., 1998; Gunn et al., 2006). Women may feel reluctant to disclose issues and care providers may feel unprepared to discuss them (Ramsay et al., 2002).
A statewide review of hospital postnatal care conducted in Victoria, Australia (PinC: Postnatal in hospital Care) explored postnatal care provision from the perspective of care providers, and identified a range of practices by midwives in identifying and responding to women with psychosocial issues (Yelland et al., 2006). While there was awareness of the existence of psychosocial issues, most participants reported that psychosocial assessment was undertaken during pregnancy, with little understanding of how this translated to the postnatal episode. The most common response to the identification of issues during pregnancy was referral to a social worker. There were a range of views regarding midwives’ level of comfort and skills in supporting women with psychosocial issues. Participants reported that the context of postnatal care (i.e. the busy and sometimes chaotic nature of the ward environment) affected the provision of care and the level of psychosocial support offered to women (Yelland et al., 2006).
Studies in Australia and overseas have found that women consistently rate the care they receive in hospital following birth less favourably than antenatal and intrapartum care (Biro et al., 2000; Waldenström et al., 2000; Homer et al., 2002; Newburn, 2003; Brown et al., 2005; Dykes, 2005; Rudman and Waldenström, 2007). The Victorian Survey of Recent Mothers in 2000 found that only 51% of women considered the postnatal care they received in hospital to be ‘very good’ (Brown et al., 2005). Factors most strongly associated with poorer ratings of care were to do with women's experiences of caregivers, particularly related to issues including sensitivity of staff, the extent to which anxieties were taken seriously, the helpfulness of advice and support, and whether or not advice and support were offered (Brown et al., 2005).
Despite the prevalence of psychosocial issues that may impact on women during pregnancy, childbirth and the postnatal period, there is little evidence regarding interventions that are effective. A common method of assessing women who may be experiencing psychosocial issues during pregnancy is the use of psychosocial risk screening; however, there are limitations to this approach, with research suggesting that this may not be the best means of identifying the existence of psychosocial issues (Brown and Saqi, 1988; Ramsay et al., 2002; Austin and Lumley, 2003). A programme of advanced communication skills for health professionals called ‘ANEW’ was implemented in Melbourne in 2003 to provide an alternative to psychosocial risk screening during pregnancy. The programme increased the self-reported comfort of health professionals to identify and care for women with psychosocial issues (Gunn et al., 2006), and has since been funded by the Victorian Department of Human Services to be ‘rolled out’ across the state with a continued focus on antenatal care providers (personal communication, Julie Jenkin, Victorian Department of Human Services, October 2008).
Caring for women in the antenatal setting, however, is substantially different from care provision in the postnatal environment. The antenatal setting is characterised by a one-to-one interaction in a private space. In contrast, postnatal care in hospital is usually provided in a space shared with other mothers, infants and visitors (McLachlan et al., 2008). It is often a very busy environment, and postnatal care providers have described difficulties in tailoring care to individual women, particularly given the checking, education and documentation required during what are increasingly short hospital stays. Staffing constraints (Forster et al., 2006) and other factors, including visitors (McLachlan et al., 2008), add to the difficulties in providing individualised care.
The success of the ANEW programme, coupled with the findings of the statewide review of postnatal care in relation to psychosocial issues and the time-pressured nature and context of postnatal care, led to the recommendation that an ANEW-style programme be considered for midwives who care for women during the postnatal period (Forster et al., 2005).
The aims of this study were: to adapt the educational intervention previously designed for the antenatal setting to change its focus to postnatal care; and to evaluate the modified programme with postnatal care providers.
Section snippets
Methods
A before-and-after research design was used to evaluate the effects of the ‘PinC ANEW’ education programme. The programme was implemented at a Melbourne metropolitan tertiary referral hospital [Mercy Hospital for Women (MHW)] and a regional hospital (Barwon Health) between July and December 2006. These sites were selected because each had approached the research team and were interested in participating. Information and invitations to participate were disseminated to midwives by senior
Participants
Twenty-five midwives participated in the education programme, of whom 24 completed Questionnaire One (Q1, pre implementation) and 22 completed Questionnaire Two (Q2, post implementation). The mean age of midwives completing Q1 was 47 years (SD 9.5) and all were female. The mean number of hours worked per week was 31 (SD 8.2), equivalent to approximately four days per week. Midwives varied in their level of experience, with a median of 21 years as a midwife (range 1–45 years). Twenty-one
Discussion and conclusion
The PinC ANEW education programme increased the self-reported comfort and competence of midwives to identify and care for women with psychosocial issues during the postnatal period. Many of the changes before and after the programme are similar to the original ANEW study, which evaluated a new approach to supporting women with psychosocial issues during pregnancy (Gunn et al., 2006). Some aspects of care, such as talking about sexual issues when women ask, and discussing psychosocial issues
Acknowledgements
This study was funded by the Faculty of Health Sciences, La Trobe University. Thanks to Jenny Kelly (Barwon Health), and Margie Cass and Lisa Love (MHW) for implementing the education programme. Thanks also to the MHW and Barwon Health management (particularly Therese Cotter and Chris Watson) whose support was crucial to the success of implementation of the programme. Thanks to the midwives who took the time to participate in the study; investigators of the original ANEW programme; Stephanie
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