Obstetric care providers assessing psychosocial risk factors during pregnancy: validation of a short screening tool – the KINDEX Spanish Version

A lifetime of healthy brain development starts long before birth, during pregnancy [1]-[3]. Moreover, there is ample evidence supporting the impact of different psychosocial risk factors on the unborn child [4],[5] and the newborns later brain development [6]. Nevertheless, the transfer of this research knowledge into practice only began in the past decade [7],[8]. Worldwide, there are only a few studies reporting the development, evaluation and implementation of screening tools for psychosocial risk factors in pregnant women and subsequent intervention and prevention programs in community health centers in the U.S. [9], Australia [10] and Canada [11].

Today, several risk factors have been identified as crucial for both maternal, fetal and later child development. Adverse neonatal and obstetric outcomes have been linked with maternal stress[12],[13], mental health problems of the mother [14]-[16], and intimate partner violence (IPV)[17]. Depression is the strongest predictor of poor psychological well-being in pregnant women [18] and of lower quality of maternal-fetal attachment [19]. In contrast, positively attached mothers have better prenatal health practices, such as abstinence from smoking, alcohol and drug abuse [20]. The severe impact of alcohol, tobacco and drug consumption during pregnancy is well-known [21],[22]. Several factors have been associated with elevated alcohol and drug consumption such as deteriorated mental health, physical health, peer and family relations, and educational status among others [23].

The presence of psychosocial risks produce higher perceived stress in women from low socioeconomic status[24], adolescent or very young mothers (<20 years of age)[25], in immigrant[26] and refugees from war-torn societies that often are diagnosed with PTSD [27],[28]. These social groups often lack social support [29], a stress mediating factor [30] present higher levels of IPV, drug abuse [31] child maltreatment and present worse parenting skills [32]; all the above conditions result in poorer birth outcomes [33]-[35].

Child neurodevelopment [36] and child behavioral problems linked to altered HPA activity [37] have been related to stress and maternal mood [38],[39]. Recent studies have also revealed long-term biological effects of IPV exposure during pregnancy; the methylation status of the GR gene in adolescent children is influenced by maternal experience of IPV during pregnancy [5]. Offspring’s poor behavioral trajectories and elevated physical abuse, separation from parents and changes in family composition have been reported in children of mothers that have experienced violence during childhood[40],[41], a frequently undisclosed risk for the etiology of depressive and posttraumatic stress symptoms in pregnant women [42]. Mediated pathways have been found between maternal childhood abuse (MCA) to substance abuse and offspring victimization, perpetrating the vicious cycle of violence [43],[44]. MCA also predict increase in offspring’s externalizing behavior, suggesting an impact in subsequent generations [45].

Early identification and appropriate intervention may work to ameliorate the adverse effects of such psychosocial risks [46],[47]. Nevertheless, very little research focuses on the development and evaluation of screening tools for psychosocial risk factors during pregnancy. As a consequence, up to 50% of depression cases will go unnoticed [48] and only 18% of women diagnosed with depression will seek professional help [49].

In Canada, a multidisciplinary team of health professionals developed an evidenced-based prenatal risk assessment program in order to identify and manage women and families in psychosocial risk using the Antenatal Psychosocial Health Assessment (ALPHA-Form) that uses 35 items to detect 15 risk factors for postnatal adverse psychosocial outcomes [50].

In a randomized control trial in four communities in Ontario, Canada, midwives, obstetricians and family physicians using the ALPHA form in place of traditional care procedures were more likely to detect risks in women that related to postpartum outcomes than health providers in the control group [50]. Another study that applied the ALPHA-Form, this time in Australia, both expectant women and midwives had a positive reception of the program and the identification of high-risk women was much more efficient than traditional assessments in obstetric care [51]. Despite its demonstrated feasibility in different cultural contexts, the specificity, sensitivity, positive and negative predictive values of the ALPHA Form have not yet been assessed [52].

The Antenatal Risk Questionnaire (ANRQ) was both developed through consultations with midwives and health professionals working in a maternity hospital and by Austin et al. (2013) [10]. Johnson et al., (2012) found this tool to fulfill more of the requirements than any of the others assessed [52]. The ANRQ is composed of 12 items retrieved from the original 23 Pregnancy Risk Questionnaire (PRQ) [53] and assesses seven psychosocial risk domains: emotional support from subject’s own mother in childhood, past history of depressed mood or mental illness and treatment received, perceived level of support available after birth of the baby, partner emotional support, life stresses in the past 12 months, personality (anxious or perfectionistic traits) and history of abuse (emotional, physical and sexual). It has a possible rating score from a minimum of 5 to a possible maximum of 62 and the authors suggest a clinically relevant cutoff of 23. The psychometric properties of the tool include acceptable sensitivity (0.62) and specificity (0.64), it has high face and construct validity of the factors assessed, and has high acceptability amongst midwives and pregnant women, nevertheless it has low positive and negative predictive values emotional support from subject’s own mother in childhood, past history of depressed mood or mental illness and treatment received, perceived level of support available after birth of the baby, partner emotional support, life stresses in the past 12 months, personality (anxious or perfectionistic traits) and history of abuse (emotional, physical and sexual). It has a possible rating score from a minimum of 5 to a possible maximum of 62 and the authors suggest a clinically relevant cutoff of 23. The psychometric properties of the tool include acceptable sensitivity (0.62) and specificity (0.64), it has high face and construct validity of the factors assessed, and has high acceptability amongst midwives and pregnant women, nevertheless it has low positive and negative predictive values [52]. The ANRQ conjunctly with the symptom-based Edinburgh Depression Scale has been used within the psychosocial risk assessment model (PRAM) embedded in the integrated perinatal care context at the Royal Hospital for Women in Sydney, Australia on 2,142 women. Based on this assessment, the researchers computed a Psychosocial Risk Index (PRI) in order to provide individualized care planning [7]. The follow-up study at 2 or 4 months postpartum revealed a positive predictive value for postnatal development of depression of 0.3, rather low. Authors conclude that the instrument could be used with a symptom-based instrument such as Edinburgh Postnatal Depression Scale or routine questions concerning drug and alcohol use and domestic violence to provide a “routine screening intervention” [10].

In spite of substantial research on the development and evaluation of prenatal psychosocial risk factors, the literature is not without its limitations. The need for longitudinal research examining the predictive validity of the tools for child development is outstanding. The severe effects the presence of psychosocial risks present during the perinatal period to maternal mental health and infant development have been replicated many times. These findings point to the emergent need for the development of easy to apply and efficient tools in order to boost prevention of negative outcomes in maternal-infant/child populations.

In this study we evaluate the Spanish Version of the KINDEX. Originally the KINDEX was developed in German after a critical review of evidence-based literature on psychosocial risk factors during pregnancy that have an adverse effect on both the maternal mental health and child development later on. Historically, assessment tools have been focused on the presence of risks that could screen or predict maternal mental health and influence the infant [52], in change the KINDEX was developed by a panel of experts through a comprehensive literature review on risk factors for the maternal mental health and child development in the long run. The tool assesses 11 risk areas during pregnancy and is designed to be used by medical staff in their everyday clinical practice. Similarly to the ANRQ, it assess presence of psychological factors and the experience of adversities in the past such as mother’s sexual and physical abuse, but, it additionally assess the maternal and paternal fetal attachment and takes into account social risks, such as financial difficulties, immigrant/refugee origin of the parents, maternal age and medical risks. Cross-sectional and longitudinal validation studies in Germany showed good psychometric properties, high prospective validity and a good implementation feasibility Schauer, M., Ruf-Leuschner M.: KINDEX: Prenatal assessment of psychosocial risk factors for development – the Konstanz INDEX, submitted.

The aim of our study was two-fold. First, we want to explore whether the use of the KINDEX is feasible in the daily practice of medical staff providing prenatal care in Spain in a representative sample of the general population.

Second, we wanted to examine the criterion-related concurrent validity of the KINDEX by assessing the relation of the KINDEX interview with the validation interview carried out by an expert clinical psychologist.

The final objective was to achieve the cultural adaptation of the KINDEX Spanish Version and to offer a valid tool for the psychosocial risk assessment to the obstetric care providers.

Although there is sufficient and convincing scientific evidence that prenatal risk factors can have a lifelong adverse impact on the unborn, this information is still not routinely collected within antenatal health care. Although some outcomes indicated the efficacy of the use of specific screening tools and prevention programs [51], to our knowledge, there is no other short instrument than the KINDEX that has been applied in European countries and is able to identify risks from eleven psychosocial areas known to threaten the healthy development of individuals over their life span. Most of the assessment tools developed so far have focused on risk factors for the maternal mental health in the postpartum period.

In our study, we present the cultural adaptation of the KINDEX to the Spanish public health setting. This is a new prenatal assessment tool for psychosocial risk factors for both the maternal mental health and the child development in the long run. This tool was originally developed and validated in Germany [65] and has been designed as a short interview (20–30 min) that can be conducted by midwives and gynecologists without any specific training in psychosocial concepts. The medical staff included in our study reported experiencing no problems in carrying out the KINDEX interviews throughout the project and continued the interviews assigned to them until the conclusion of the study. Even though the time required for its use in the German population was 20–30 minutes, the majority of the medical collaborating in the Spanish study stated an approximate time of 15 minutes and noted that it did not interrupt the normality of their clinical praxis. Midwives and gynecologists facilitated the interview process during outpatient consultations. The interviews carried out with hospitalized pregnant women were demonstrated feasible since midwives could arrange the interview at a more “relaxed” time during their shift. Midwives who interviewed women undergoing special medical screening (eg. gestational diabetes, high blood pressure) in the fetal medicine unit did not report any problems with the time spent administering the KINDEX. None of the interviewers dropped-out from the project, which indicates acceptance of the KINDEX tool by midwives and gynecologists in the public health setting. The high feasibility and acceptance of the KINDEX is relevant for its application in the hospital setting. The structure of the hospital and the involvement of the four units in the interviews bolster our conclusion that the KINDEX can be embedded in public health centres successfully. Likewise, the involvement of pregnant women in the interview was very satisfactory, since no dropouts were registered once the women joined the study. Based on this, we conclude that the implementation of the KINDEX, as a prenatal screening tool in the Spanish public health sector is quite feasible. We recommend further research in a variety of health contexts regarding the feasibility and acceptance of the application of the Kindex, especially for General Practitioners of primary care, who often have first contact with the women.

Many studies have supported the fact that prenatal screening for and management of depression and anxiety are very important to prevent adverse maternal mental health [66],[47],[48] and psychosocial screenings to identify women at risk [67],[10]. Determining the level of risk (measured as number of risks) triggering the initiation of referral pathways to the corresponding mental and social services of each health centre is a challenging task. Psychosocial assessments leading to the referral of women in high risk involve several health sectors. The delivery of appropriate interventions requires proactive collaboration of a multidisciplinary group of professionals. Nevertheless the activation of this referral system and intervention with women in risk is beyond the aims of this study, while this was examined in the validation of the KINDEX in Greek, developed in public health centres in Crete Island [68]. In the Greek study, medical staff was encouraged, based on the KINDEX assessment, to refer pregnant women that presented 2 or more risks. Results showed that the medical staff correctly identified women at risk, and referred them to mental health services, though these women did not follow through. Because of this, we believe that a successful assessment, referral and intervention program can provide only the frame of general perinatal clinical guidelines. In Australia such guidelines have been recently been established for the treatment of perinatal mental health conditions [69], these are yet not established in Spain and in many other European countries.

To assess the validity of the data collected with the KINDEX a randomized subsample of pregnant women was additionally interviewed by a trained clinical psychologist using different standardized instruments to assess three major risk areas, namely stress, psychopathology and trauma load. Moderately high, positive correlations between the KINDEX sum score and the global stress, global psychopathology and global trauma load assessed in the validation interview, indicate that the KINDEX has good concurrent validity. In addition, exploratory analysis of single items in our study showed that women who reported a history of a psychiatric diagnosis (KINDEX assessment) report current higher levels of somatization, PTSD symptoms and higher levels of depression in the validation interview and as expected, participants who reported childhood physical maltreatment in the KINDEX presented higher scores in the Checklist of Family Violence subscales of physical violence, witnessed violence and verbal emotional violence in the validation interview. In summary, these results corroborate the validity of the data collected by medical staff when using the KINDEX instrument in a public health setting.

In addition to our statistically determined results, participants frequently reported in validation interviews with the clinical psychologist that even though the KINDEX interview conducted by midwives and gynecologists came as unexpected health service to them, they felt more cared for by the medical staff. Many also stated such enquiries made the medical treatment experience more holistic and patient-centered. This not only underlines the feasibility of the KINDEX in the public health setting but also shows that pregnant women are open to discussing their problems with medical experts and hope for support.

The present study contains numerous clinical implications. Results of the validation interviews indicate that women who have suffered adverse experiences in the past (global trauma load) still show higher levels of current stress and psychopathology. It is therefore evident that pregnant women who are at risk due to past and current adverse experiences should receive adequate interventions in order to prevent further mental health problems and unfavorable development of their offspring. The KINDEX therefore can serve as a module to identify women in need not only concerning mental health problems but other social disadvantages and allow for the establishment of early support services that meet psychosocial risk situations during gestation and after birth. Appropriate cost-effective interventions during this early stage would mean a revolution in preventive medicine as well as create a significant impact in primary care, creating a more integrative comprehensive health attention towards pregnant women, neonates, and the family.

^a On Monday the first pregnant woman, on Tuesday the second, etc.

Andria Spyridou, Dr. Nat. Sc. in Clinical Psychology is a Postdoctoral Fellow in the University of Konstanz, in the past 3 years she has coordinated and has carried out field studies in hospital settings in Spain, Greece and Peru. Principal aim of her research is the cultural adaptation of the KINDEX in the different languages of the countries where it has been used and the integration of psychosocial assessment in the everyday obstetrical care, in order to prevent future adverse outcomes in childhood and adulthood.

Dr. Martina Ruf-Leuschner Phd; Clinical Psychologist is an Assistant Professor at the University of Konstanz and member of the non-governmental organization vivo (www.​vivo.​org). She is working at the Centre of Excellence for Psychotraumatolgy at the University of Konstanz. Together with Maggie Schauer, Thomas Elbert and Frank Neuner she run one of the first studies on the feasibility and effectiveness of Narrative Exposure Therapy for children. She also was part of different research projects on the effectiveness of Narrative Exposure Therapy in adult trauma survivors. Beside her work in Germany she worked with the NGO vivo in different mental health projects in Ethiopia, Uganda, Tansania and Sri Lanka.

She is a founding member of vivo (victim voice international, www.​vivo.​org) and coordinates the scientific advisory committee of this international organization for psychotraumatology. From 2004–2008 she was vice-president of vivo Germany

Since 2009 she is an elected board member of the NGO ‘Babyforum’ (www.​babyforum-landkreis-konstanz.​de)