Perspective Chapter: Psychosocial Screening and Assessment in the Private Sector in Australia during the Postnatal Period

Abstract

This chapter is a perspective literature review of published policy and literature regarding psychosocial screening and assessment in the postnatal period. The postnatal period is considered from birth until 6 weeks postpartum. This chapter focuses on the postnatal period, although some resources discussed are for women perinatally. Psychosocial assessment allows the identification of circumstances that affect a woman’s mental health. Postnatal mental health is a contemporary challenge as its risks have long-term effects on the mother, infant and their family. The first year postpartum has the highest rate of maternal death by suicide, especially between nine and 12 months postpartum. Postnatally, the peak rate of hospitalisation for mental illness is within the first 3 months postpartum. The greatest risk for incident hospital admission specifically for primiparous women is 10–19 days postpartum. Psychosocial screening and assessment in the postnatal period are recommended internationally. However, in the private sector in Australia this is at the discretion of the private healthcare providers (postnatal midwife, child and family health nurse, obstetrician, paediatrician). Considering the potentially high morbidity related to postnatal mood disorders, it is crucial that women, either at risk or symptomatic of maternal depression and anxiety, be identified as early as possible in the postnatal period and be subsequently referred for appropriate local management.

1. Introduction

1.1 Postnatal mental health

Postnatal mental ill-health refers to any mental health condition affecting the mood, behaviour, well-being and/or daily function of a new parent. Perinatal mental health affects around 100,000 families across Australia every year. Postnatal mental health disorders are increasingly prevalent; however, some mothers do manage, with varying degrees of support. Phua et al. [1] results showed that positive antenatal mental health was uniquely associated with the children’s cognitive, language and parentally rated competences, indicating that the effects of positive maternal mental health are likely to be distinct from only the absence of symptoms of depression or anxiety.

Internationally, postpartum depression is prevalent in 17% of the world’s maternal population in 80 countries (see Table 1) [2]. In high-income countries (HICs), the prevalence of postnatal depression is reported to be 1:10 women. In low-middle-income countries, these prevalence rates are higher (19% during the postnatal period). The higher prevalence rates of maternal depression are often related to various risk factors that are more prevalent in these countries, including intimate partner violence, poverty, childhood abuse, maternal low educational attainment, and lack of social support [3]. The current fertility rate for Australia (a high-income country) in 2021 was 1.794 births per woman [4]. In 2021, there were 309,996 registered births in Australia, and the birth rate was 61 births per 1000 women of reproductive age.

Subgroup	Studies	Prevalence		PPD	Participants	P value	I2
Country						<0.01
South Africa	6	38.79	(25.71–53.72)	1076	3144		98.00%
Malawi	3	13.57	(8.94–20.07)	116	830		77.50%
Zambia	1	9.71	(6.74–13.79)	27	278
Ghana	4	8.00	(1.90–28.13)	606	4294		99.30%
Cote d’Ivoire	1	14.13	(10.90–18.11)	51	361
Egypt	6	22.99	(12.99–37.38)	472	2218		97.50%
Sudan	2	7.56	(5.47–10.34)	35	467		0.00%
Zimbabwe	2	27.22	(16.52–41.41)	281	1137		94.80%
Ethiopia	13	22.79	(18.07–28.33)	2666	11,534		97.50%
Tanzania	3	12.30	(11.22–13.49)	407	3310		98.00%
Nigeria	7	17.93	(10.19–29.59)	1008	10,659		0.00%
Israel	12	12.90	(9.38–17.50)	1188	9158		96.60%
Japan	27	13.30	(12.25–14.41)	25,035	199,089		96.20%
India	14	18.81	(13.59–25.44)	1817	10,554		97.60%
Turkey	26	21.87	(18.12–26.15)	3038	12,370		96.30%
Malaysia	6	12.64	(6.97–21.86)	1021	10,402		98.80%
China	42	17.98	(15.32–20.99)	5946	31,517		97.10%
Taiwan	17	21.65	(17.56–26.38)	661	3141		88.00%
Vietnam	8	13.77	(8.54–21.47)	1009	7314		98.20%
Pakistan	3	35.45	(18.47–57.10)	440	1326		97.60%
United Arab Emirates	1	18.31	(10.94–29.03)	13	71		—
Nepal	11	16.41	(12.07–21.91)	538	2443		92.80%
Thailand	8	12.52	(8.02–19.01)	514	4547		96.10%
Singapore	6	14.24	(10.10–19.71)	402	2602		98.40%
Bangladesh	10	26.65	(20.00–34.56)	1329	4423		98.80%
Qatar	3	18.00	(16.90–19.16)	795	4417		91.70%
USA	66	18.56	(16.91–20.34)	34,380	242,105		96.70%
Canada	25	13.89	(11.43–16.79)	13,421	118,968		98.60%
Australia	23	11.22	(9.23–13.56)	6928	82,680		0.00%
Argentina	2	29.88	(19.30–43.14)	165	625		83.00%
France	8	14.63	(10.01–20.89)	493	3203		93.80%
Oman	2	16.38	(9.15–27.58)	160	874		90.60%
Brazil	31	20.51	(18.53–22.65)	19,960	88,955		98.00%
Poland	5	17.91	(9.19–31.97)	365	2013		97.60%
Spain	5	9.09	(6.97–11.78)	360	3704		84.10%
UK	13	21.50	(17.63–25.94)	25,786	219,769		98.40%
Sweden	14	12.18	(9.41–15.63)	2057	18,189		97.20%
Kuwait	1	11.72	(10.11–13.55)	158	1348		—
Norway	12	11.24	(8.31–15.03)	1711	12,557		97.00%
Iran	18	24.41	(17.18–33.43)	5834	15,753		99.20%
Kenya	3	25.20	(11.50–46.63)	70	391		90.50%
Jordan	4	39.78	(21.43–61.54)	539	1333		98.20%
Uganda	1	32.67	(27.60–38.18)	98	300		—
Indonesia	2	11.76	(3.73–31.43)	51	440		93.90%
Eswatini	1	47.37	(38.39–56.52)	54	114		—
Syria	1	28.24	(25.66–30.96)	312	1105		—
Saudi Arabia	7	20.08	(14.17–27.65)	457	2305		93.40%
New Zealand	5	10.58	(5.62–19.01)	681	8057		98.30%
Multi	3	20.21	(10.16–36.19)	233	1474		96.60%
Morocco	1	27.00	(19.22–36.51)	27	100		—
Subgroup	Studies	Prevalence		PPD	Participants	P value	I2
Portugal	4	18.28	(12.57–25.81)	115	663		77.90%
Italy	14	16.79	(11.63–23.64)	1283	10,800		97.70%
Netherlands	7	10.69	(5.76–18.98)	1222	13,069		99.10%
Ireland	3	11.14	(10.13–12.25)	1275	11,694		19.10%
Iraq	1	28.40	(25.69–31.28)	284	1000		—
Greece	4	12.26	(8.02–18.30)	155	1259		83.40%
Hungary	1	16.54	(12.54–21.50)	44	266		—
Lebanon	1	12.75	(8.28–19.13)	19	149		—
Korea	4	22.50	(12.01–38.17)	246	1263		96.10%
Finland	3	14.62	(9.83–21.20)	320	2513		92.20%
Denmark	2	6.48	(5.70–7.36)	219	3381		0.00%
Czech Republic	2	15.82	(7.08–31.66)	59	408		90.30%
Belgium	1	23.94	(15.44–35.19)	17	71		—
Philippines	1	16.36	(11.47–22.81)	27	165		—
Mexico	1	20.00	(15.13–25.96)	42	210		—
Hong Kong	4	16.96	(13.77–20.70)	321	1860		71.90%
Greenland	1	8.62	(5.26–13.81)	15	174		—
Germany	3	9.76	(5.26–17.40)	161	1760		92.90%
Bahrain	1	37.13	(31.21–43.46)	88	237		—
Serbia	3	23.66	(10.41–45.27)	134	573		95.60%
Peru	1	29.97	(28.00–32.02)	597	1992		—
Armenia	2	14.08	(11.48–17.14)	82	583		0.00%
Mongolia	1	9.10	(7.50–11.00)	95	1044		—
Russia	2	13.54	(1.71–58.45)	205	820		97.80%
Switzerland	1	21.93	(17.39–27.27)	59	269		—
Croatia	1	45.03	(37.74–52.54)	77	171		—
Slovenia	1	31.82	(19.84–46.81)	14	44		—
Afghanistan	1	60.93	(54.25–67.22)	131	215		—
Chile	3	28.27	(14.87–47.08)	177	629		95.10%
Timor-Leste	1	25.29	(19.33–32.36)	43	170		—
Jamaica	1	34.25	(24.31–45.79)	25	73		—
Continent						<0.01
Southern Africa	7	39.96	(27.81–53.48)	1130	3258		97.70%
Eastern Africa	26	20.21	(16.86–24.04)	3665	17,780		97.00%
Western Africa	12	13.62	(8.27–21.62)	1665	25,314		99.00%
Northern Africa	9	18.75	(11.40–29.26)	534	2785		96.90%
Western Asia	62	19.83	(17.33–22.58)	7133	34,950		97.20%
Eastern Asia	96	17.39	(16.09–18.77)	32,429	238,273		97.70%
Southern Asia	56	22.32	(18.48–26.70)	9964	35,227		98.80%
Southeastern Asia	33	13.53	(11.00–16.52)	3208	26,677		97.30%
Northern America	92	17.01	(15.68–18.44)	47,816	361,247		98.70%
Oceania	28	11.11	(9.27–13.25)	7609	90,737		98.30%
South America	37	21.71	(19.78–23.76)	20,899	92,201		97.80%
Western Europe	20	12.91	(9.44–17.40)	1952	18,372		97.90%
Eastern Europe	10	16.62	(10.95–24.43)	673	3507		96.50%
Northern Europe	47	13.78	(12.47–15.21)	31,368	268,103		97.20%
Southern Europe	31	16.34	(12.90–20.48)	1997	16,177		96.60%
Central America	1	20.00	(15.13–25.96)	42	210		96.70%
Caribbean	1	34.25	(24.31–45.79)	25	73		—
Multiple	3	20.21	(10.16–36.19)	233	1474		—
Development						<0.01
Developing	295	19.99	(18.76–21.27)	54,145	266,334		98.30%
Developed	276	14.85	(14.22–15.51)	118,197	970,031		98.20%
Country or regional income						<0.01
High	314	15.54	(14.90–16.20)	121,333	985,634		98.20%
Upper-middle	178	19.68	(18.26–21.19)	41,217	186,768		98.40%
Lower-middle	56	20.14	(16.39–24.50)	5769	39,108		98.50%
Low	23	20.02	(15.32–25.73)	4023	24,855		98.70%
Publication date						0.58
Before 2010	145	17.94	(15.79–20.30)	19,417	120,264		98.80%
After 2010	426	17.28	(16.54–18.05)	152,925	1,116,101		98.80%
Study size						<0.01
<1000	421	19.44	(18.40–20.51)	27,433	137,934		95.70%
>1000	150	12.97	(12.03–13.96)	144,909	1,098,431		99.50%
Diagnostic technique						<0.01
DSM-IV	7	12.94	(9.14–18.00)	378	3086		91.50%
SRQ	12	25.90	(21.16–31.27)	3681	12,948		97.70%
PHQ-9	19	18.59	(12.21–27.44)	2475	23,846		99.10%
EPDS	464	16.86	(16.04–17.72)	110,611	775,287		98.70%
CES-D	13	25.06	(19.55–31.50)	2763	19,702		97.80%
BDI	10	29.70	(23.07–37.31)	553	1767		89.30%
DASS	4	18.47	(16.43–20.70)	1234	6863		72.40%
SCID	5	10.11	(3.75–24.48)	1712	6360		98.90%
PDSS	5	37.23	(21.47–56.27)	471	1522		97.50%
SDS	4	28.17	(21.30–36.24)	1231	4248		95.90%
PHQ-2	5	18.47	(14.42–23.34)	14,461	105,902		99.30%
Others	23	14.94	(13.06–17.03)				96.10%
Study quality						0.41
>8	542	17.52	(16.80–18.27)	163,375	1,184,434		98.80%
<8	29	16.03	(12.98–19.63)	8967	51,931		98.90%
Study period						0.56
4 weeks–3 months	342	15.35	(14.10–16.70)	55,359	918,858		98.20%
3 months–6 months	89	15.92	(14.03–18.02)	26,031	277,293		99.10%
6 months–12 months	67	17.89	(13.32–23.59)	55,092	1,560,464		99.90%
Longer than 12 months	15	17.95	(13.80–23.01)	1781	11,374		96.60%

Table 1.

Subgroup analysis for PPD prevalence among women.

Source: [2].

It has been estimated that in Australia, 7 to 15% of pregnant women and 6 to 20% of mothers of infants up to 4 months of age will experience depression [5]. Post-Traumatic Stress Disorder, anxiety and depression may co-occur, with differing exhibiting symptomatology and signs, requiring different treatments [6, 7, 8]. Postpartum depression is a form of severe depression after birth that inhibits daily functioning and requires management. It can occur within days, weeks, or months after childbirth and extend beyond the first postpartum year. A woman with postpartum depression may have feelings of anxiety, despair, irritability and sadness to a severe extent [9]. High levels of antenatal (state) anxiety and trait anxiety may be an important predictor of postnatal anxiety and mood disorders, while co-morbidity of depression and anxiety disorders are common [10, 11, 12, 13, 14]. Postnatal mood disorders include obsessive compulsive disorder, social phobia, specific phobia, panic disorder and post-traumatic Stress Disorder, generalised anxiety disorder (GAD), and are commonly reported as prevalent as depressive disorders in the postnatal period (Fairbrother et al., 2016, as cited in [15]). The long-term effects of maternal depression include delays in children’s cognitive and social development [16]; and emotional and behavioural problems [17, 18, 19, 20, 21, 22, 23, 24, 25] and breakdown of relationships [21, 26]; Maternal anxiety and depression may adversely affect the pregnancy, birth and early mother-infant relationships [27].

The postnatal period is a demanding life stage with parental concerns about sleep deprivation, infant health, new additional responsibilities, breastfeeding and birth recovery. Various identified psychosocial risk factors (sleep, education and relationship quality) have been associated with maternal postnatal anxiety symptoms; therefore, there is an opportunity for early identification and intervention from various health professionals [28].

Postnatal psychosocial care promotes enabling women to make the emotional and social adaptations that are necessary for successful functioning as a mother. Any postnatal maternal maternity experience involves some degree of disturbed sleep, bodily changes, anxiety, fatigue, maternal changes, and may also include coping with deteriorations in physical health through various other health changes. Therefore, mental health issues such as anxiety and depression do not exist as silos: other important aspects of psychological well-being such as self-esteem, quality of life, a sense of control, worry, and sleep, birth history, early parenthood experiences with infant feeding have also been independently associated with psychological outcomes for postnatal women, and should be considered equivalently important during the assessment of women’s maternal experiences [29].

There is a direct link between postnatal maternal anxiety, stress and depression and poor obstetric and child outcomes. The early identification of women either at risk, or symptomatic of anxiety and depression, facilitates referral for timely and appropriate treatment [19]. There is substantial evidence internationally that all women during the postnatal period should be assessed for postnatal maternal stress, anxiety, and depression and their associated risk factors [6, 15, 30, 31, 32, 33, 34, 35]. Next, we explore postnatal mental health screening and assessment in Australia.

1.2 Postnatal mental health screening

1.2.1 The Australian context

The evidence of the benefit of antenatal psychosocial assessment and depression screening has been sufficient to lead the implementation of screening in public hospitals in all states of Australia and scarcely in private hospitals. In Sydney specifically, the SAFE START perinatal mental health policy directive and clinical practice guidelines have been in place in a number of large public maternity hospitals since 2010 [36] with the Integrated Perinatal Care (IPC) model of care implemented in some metropolitan settings. However, since 2010, there have been changes to the SAFESTART policy. SAFESTART has been mandated in all public hospitals in New South Wales, Australia and has been widely accepted and implemented. An Australian Commonwealth Government review and update of the Australian Perinatal Mental Health Guidelines was completed in 2017 and 2023 by the National Centre of Perinatal Excellence (COPE) [15, 37]. These guidelines accentuate the necessity to understand the evidence for screening and to identify and address barriers to implementing psychosocial screening in all healthcare sectors. Actions and procedures by appropriate health professionals are needed to provide solutions and resources for what has been identified by screening postnatal women. Improvements include improved detection of depression, improved treatment and, most importantly, to improved health outcomes [37].

The recommendations of the National Guideline [37] is that women should be provided with universal routine screening for depression postnatally in all Australian hospitals, both private and public [5, 36]. In addition, screening could be incorporated into obstetric shared care offered in general practice by G.P’s. However, currently, the extent of implementation of screening in private health services in Australia is unknown. The Australian Institute of Health and Welfare [38] stated that 28% of women who give birth in Australia will choose to do so as private patients in private hospitals, yet little is known about the utilisation of psychosocial screening and assessment in the private sector [39]. In Australia, the main dissimilarity between public and private healthcare are the choice of an admitting obstetrician or doctor, admissions to private rooms, and fees charged for services rendered. Private providers offer various models of obstetric care, and despite Australian National guidelines recommending the implementation of screening in all sectors, it is concerning that standards for perinatal mental health remain chiefly absent from private sector policies and processes [40].

A proportion of women will access health care services in the postnatal period. This is the ideal opportunity for health professionals to identify those at risk of depression, anxiety, or other psychosocial issues, if health professionals are educated to identify risk factors effectively, are confident in questioning women and discussing symptoms, and that an appropriate local referral process is in place. Routine postnatal mental health screening has the capacity to act as a potential preventive strategy for postnatal mental illness in women [8], and is a clear strategy for health promotion and early intervention for the woman, her partner and the infant [6].

Postnatal emotional/mental health disorders are a significant public health issue because of their potential to negatively affect infant attachment security, the maternal-infant relationship, and increase the risk of affective disorders, social behavioural problems, and cognitive delays in young children [19]. Anxiety and depression often remain undetected in childbearing women despite health professionals being available during the postnatal period to identify, prevent, and treat emotional/mental health disturbances [19]. Further, efficient psychosocial care may be affected by service or systematic issues including lack of appropriate training and support, limited staff numbers, and unfamiliarity with screening tools. Within the Australian National Health and Medical Research Council’s (NHMRC) Clinical Practice Guidelines for Depression and Related Disorders in the Postnatal Period, universal screening for postnatal depression is anticipated to be completed by relevant health professionals [41]. In private obstetric care, obstetricians are the responsible clinician for ensuring that postnatal psychological screening, assessment, referral and the Edinburgh Postnatal Depression Scale (EPDS) is offered.

Postnatal psychosocial assessment is crucial for the provision of comprehensive clinical care and the development of customised maternal management plans, requiring the clinician to have adequate information with which to make shared clinical decisions/referrals. The universal application and routine use of psychosocial risk and depression assessment/screening has developed as a significant health initiative [42]. Postnatal Psychosocial risk assessment and depression screening can be readily integrated into postnatal care but involves skilled clinical evaluation of the identification of psychological, demographic, social, and physical factors known to affect postnatal mental health for mother and infant, including current distress/depressive symptoms that may be identified in the mother [6, 43]. As important, and underpinning the implementation of universal psychosocial assessment, is the identification of adequate local referral pathways. Appropriate services to address the identified needs of women as experiencing mild or moderate issues, being at risk, or experiencing severe and/or complex mental illness need to be reachable and available to all women identified by assessment or screening. The broad range of services and sectors required for appropriate and timely referral involves developing care that is effectively networked, collaborative and receptive to the involved family [6].

1.2.2 The private sector in Australia

As the prevalence of anxiety or depression and substance use increases in the general population, these issues are likely to become more evident in postnatal care and in both the public and private obstetric settings [44]. Substance use, anxiety and depression can be effectively treated postnatally; however, these conditions are often not identified and therefore remain undertreated. Private obstetricians are often the first, and sometimes the sole provider of healthcare to women and alike primary care providers, have an increasing role in the early detection of postnatal mental health/mood disorders. Although postnatal depression and anxiety are recognised as frequent complications of pregnancy and childbirth, screening and detection of depression by private obstetric prenatal care providers is currently insufficient [44].

Women are not routinely or universally screened postnatally for psychosocial risk factors, depression and anxiety in the private sector in Australia [44]. There are limited studies that explore health professionals’ views on screening or perceived barriers to the screening process. In one study, however [10], health professionals were interviewed about their perceptions of psychosocial screening in the private sector. Suggestions were made that appropriate education and training of midwives was needed, that high-risk women needed to be flagged to the midwives, to initiate more in-house resources and external resources/community links and to employ a key midwife with interest and expertise in psychosocial screening. Health professionals interviewed in the private sector identified the benefits of psychosocial screening for women but also the barriers to screening. Midwives had various views on psychosocial screening and assessment in the private sector. Some midwives indicated concern about a woman’s postnatal mental health/psychosocial risk factors; however, others expressed apprehension that this was not part of their midwifery role. Some midwives were fearsome of what may be revealed by the woman and how to deal with it. There was an identified concern that obstetricians did not take seriously any concerns highlighted by the midwife about a woman’s psychosocial issues when reported to them. There was a sense of a lack of ‘ownership’ of the women and, therefore, a feeling of powerlessness in addressing their needs. This emphasises the need to educate and support midwives working in the private sector on their important role in enriching the postnatal mental health of women within their direct care. Their role includes capability for prevention, health promotion and early intervention to benefit not only the woman, but her whole family. In response to this, as the developer of the Australian National Guideline, the Centre of Perinatal Excellence [37] provides free, accredited online training for frontline health professionals to support their training needs and ensure confidence, and competence in screening and having the conversation, as well as identifying timely and appropriate postnatal mental health pathways.

Women birthing in the private sector would also benefit from being able to access the array of resources provided in the public sector to support their postnatal mental health care. Collaborative partnerships between public, private and non-government service providers can help support the delivery of appropriate obstetric care and ensure that privately insured women have just access to appropriate mental health care services. As private obstetric providers meet the contemporary challenges of addressing postnatal mental health, there is a substantial demand on the duty of care and capacity of these workforces to undertake universal mental health screening/assessment, to access training programmes, to identify and access relevant referral pathways for and follow-up care, and to ensure organisational and professional policies exist to sustain this process and the staff involved. It is extraordinary that Australian National standards for postnatal mental health are not yet endorsed or incorporated into the private sectors continuous quality improvement processes, including the Australian private hospital accreditation standards. As a result, patient who are paying for a higher level of care are in fact receiving a lower level of care, with respect to emotional and mental health at this vulnerable life stage [44].

However, it is generally established that postnatal screening should not occur without appropriate evidence-based interventions, adequate training and support for staff, and adequate local referral pathways [45]. A vast range of services are required to meet the diverse needs of women identified as being at mild or moderate risk of postnatal depression and or anxiety [6, 46], or experiencing complex or severe mental illness. Referral processes for women with an existing or previous psychiatric disorder also need to be available [47]. An effective model for enhancing communication and continuity between primary and specialist/community-based health services and midwives, is essential to ensure that women who may gain from early intervention and treatment programmes or prevention [42, 48, 49] have 24-hour access to psychiatric or psychological advice and support if they develop symptoms between each obstetric appointments.

In addition to the substantial and still emerging postnatal mental health evidence-base endorsing improved outcomes for mother and infant, these findings support the case for the universal implementation of postnatal screening of depression and anxiety [15, 50], regardless of which health sector a woman chooses to receive obstetric care. The profile of women in the private sector in NSW, Australia is not dissimilar to women choosing to birth in the public sector (Tables 2 and 3). It is crucial through screening/assessment, to identify postnatal risk factors and symptoms of anxiety or depression and to provide appropriate support to assist women who need help. However, the identification of women experiencing symptoms and risk factors of anxiety or depression postnatally, implies that resources, education and support will be offered throughout the postnatal period, and that referral to appropriate services and support systems will be offered [42]. Barriers exist for postnatal mental health screening, that must be addressed.

Maternal profile comparisons State-wide (NSW); Midwives Data Collection*	Local regional data (from NSW; Midwives Data Collection)		Local public hospital		Study site audit
N = 98,141 n (%); 95% CI	N = 3823 n (%); 95% CI		N = 376 n (%); 95% CI		N = 407; N (%); 95% CI
Age (years)	15–19	3144 (3.2); 3.1–3.3	169 (4.4); 3.8–5.1	25 (6.6); 4.5–9.6	1 (0.2); Not applicable
20–24	12,694 (12.9); 12.7–13.1	616 (16.1); 15.0–17.3		81 (21.5); 17.7–26.0	11 (2.7); 1.5–4.8
25–29	26,769 (27.3); 27.0–27.6	1128 (29.5) 28.1–31.0		118 (31.4); 26.9–36.2	106 (26.2); 22.1–30.7
30–34	32,385 (33.0); 32.7–33.3	1140 (29.8) 28.4–31.3		90 (23.9); 19.9 28.5	163 (40.2); 35.6–45.1
35–39	18,534 (18.9); 18.6–19.1	610 (16.0); 14.8–17.2		43 (11.4); 8.6–15.1	107 (26.4); 22.4–30.9
40–44	4314 (4.4); 4.3–4.5	153 (4.0); 3.4–4.7		18 (4.8); 3.0–7.4	16 (4.0); 2.4–6.3
> 45	266 (0.3) .2–.3	6 (0.2) .1–.3		1 (0.3) Not applicable	3 (0.7); 0.3–2.2
Born outside Australia	34,342 (35); 34.7–35.3	252 (6.6); 5.8–7.4		54 (14.5); 11.2–18.3	46 (11.4); 8.6–14.8
Primipara#	43,140 (44.0); 43.6–44.3	missing		52 (19.8); 15.5–25.1	164 (40.5); 35.8–45.3
Multipara#	54,985 (56.0); 55.7–56.3	Missing		210 (80.2); 74.9–84.5	241 (59.5); 34.7–64.2
Did not smoke during pregnancy	87,580 (89.2); 89.0–89.4	3398(88.9); 87.8–89.8		319 (84.8); 80.9–88.1	407 (100)

Table 2.

Compares local and NSW data.

^#

Denominator for Local Public Hospital for primipara and multipara n = 262, missing values not included.

Centre for Epidemiology and Evidence. New South Wales Mothers and Babies 2012. Sydney: NSW Ministry of Health, 2014 (Midwives data collected in 2012).

Variable	Local Public Hospital N = 376 n (%)	Study Site Audit N = 407 n (%)	Significance	Effect size
Age (years)a; Mean SD	28.3; 6.0	32.0; 4.4	p < .001	.70y
Born outside Australiac; Yes; No	54 (14.5); 322 (85.6)	46 (11.4); 359 (88.6)	χ2(1) = 1.7; p = .194	-.05z
Intention to breastfeedc; Yes; No	331 (88.0); 45 (12.0)	400 (98.8); 5 (1.2)	χ2(1) = 37.5; p < .001	-.22z
Parityc; 0; 1; 2; 3; 4; Missing#	52 (19.8); 111(42.4); 64 (24.4); 28 (10.7); 7 (2.7); 114	164 (40.5); 158 (39.0); 68 (16.8); 11 (1.6); 4 (1.0); 0	χ2(4) = 46.1; p < .001	.26z
Attended antenatal classesc; Yes No	142 (37.8); 234 (62.2)	117 (28.9); 288 (71.1)	χ2(1) = 6.9; p = .008	.094z
Non- Smokerc; Yes No; Missing#	319 (86.2); 51 (13.8); 6 (1.6)	407 (100); 0 (0); 0 (0)	χ2(1) = 59.7; p < .001	.28z
Non-Drinkerc; Yes No; Missing#	360 (97.0); 11 (3.0); 5 (1.3)	407 (100); 0 (0); 0 (0)	χ2(1) = 12.2; p < .001	.12z
History of depression/or anxietyc; Yes No; Missing#	116 (31.4); 253 (68.6); 7 (1.3)	59 (14.8); 346 (85.4); 0 (0)	χ2(1) = 30.4; p < .001	.20z

Table 3.

Profile of women choosing local public and private obstetric care.

^a

t test.

^c

Chi-square test.

^#

Missing values not included in the denominator for calculation of proportions of valid data reported in table or Chi-square tests. The proportion Missing is based on the total sample size.

^y

d effect size .2 = small, .5 = medium, .8 = large.

^z

Phi and Cramer’s V effect size .1 = small, .3 = medium, .5 = large.

1.3 Barriers to postnatal mental health screening

The evidence of value and need for antenatal psychosocial assessment and depression screening has been abundant to lead to the implementation of screening in public hospitals in all states of Australia. However, details of the implementation of postnatal screening in private obstetric settings is unknown [44]. As any successful implementation depends on the identification of local barriers it is essential to identify actual or perceived barriers that may exist for the implementation of evidence-based postnatal screening interventions in private obstetric care [40]. Women who experience the stressors that are related to an increased risk, or an indication of postnatal mental health disorders should be assessed and offered referral to appropriate services, regardless of their chosen health sector.

1.4 Health care provider barriers

There are identified health care provider barriers to psychosocial screening and assessment. These include patient barriers: stigma, fear, denial. Provider and system barriers; time, a lack of skills, confidence or facilities, managerial support, the authority to implement change and a failure to follow-up referral recommendations. Feelings of discomfort are salient in the literature, in fact, midwives, obstetricians, physicians and paediatricians all report being uncomfortable with screening [40]. While different health professionals (midwives, obstetricians, General Practitioners, paediatricians, health visitors) are interested in the psychosocial well-being of women, and they acknowledge that it is a significant part of their role, screening is not being universally achieved [5]. Although psychosocial and depression screening is mandated in the public sector in Australia, a recent study of 30 Women’s Healthcare Australasia (WHA) members found that only 70% were using the EPDS in the antenatal period [5]. Of the 30 members who had implemented antenatal screening, 70% screened for risk of developing depression [5], but only two (20%) used the recommended antenatal risk questionnaire (ANRQ) [5].

1.5 Barriers to antenatal psychosocial assessment and depression screening in private hospital settings

Sources of barriers to the implementation of psychosocial and depression screening in private obstetric settings include barriers for women and their families, Health professional barriers, Organisation or provider barriers [40].

Collaborative postnatal care pathways have been suggested for improving liaison between mental health maternity, and primary care services [51], with a specific point of contact enabling this process by providing specialist information and advice. Therefore, a sustainable model of postnatal mental health care in private obstetrics may involve psychoeducation provided by the midwife at the various clinic appointments and during antenatal classes and a postnatal liaison nurse to screen/assess, support, refer and follow-up women identified as at risk and correspond with women who decline help. Working within a collaborative care model with a postnatal liaison nurse and mental health care providers could guide treatment options to ensure women’s support. There is also some evidence that nurse-led counselling, peer support models of care and home visitors may also be effective supports for women [52]. Additionally, the Australian Government initiative “My Health Record” may be able to connect additional information regarding women’s health for their various healthcare providers [53].

Women who have private obstetric care have a continuity of care with their obstetrician; however, obstetric appointments are mainly focused on physiological factors associated with the pregnancy rather than psychosocial/mental health factors. Given the known prevalence of antenatal depression, anxiety and other risk factors, it is essential that health care providers view the assessment of mental health as being equally important as the assessment of physical health [13]. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) have recommended that all obstetricians screen and assess women for postnatal mental health risks and disorders [54]. Since obstetricians see women consistently during the perinatal period, they are in a prime position to assess, screen and refer women, partially because they have built a rapport with the woman and may notice changes in her circumstances, or psychosocial/mental health risk factors. Although there are identified barriers, there are solutions/recommendations to address these barriers.

2. Solutions/recommendations

2.1 iCOPE

An initiative in Victoria, Australia is currently being used to improve psychosocial screening and assessment uptake in the public sector. iCOPE screening was initially piloted in Victoria and following its positive outcomes has been fully funded to be made available nationally to every public maternity hospital in Australia. Victoria was the first state to take up this state-wide, and in the first year of implementation screening is being digitally implemented across 90 locations and over 20,000 screens conducted across maternity (90% of public hospitals) and postnatal settings (85% MCH settings). In line with best practice [15, 37] the Antenatal Risk Questionnaire/Post Risk Questionnaire (ANRQ/PNRQ) have been implemented. There has been development of iCOPE Digital psychosocial screening under the Commonwealth’s Perinatal Mental Health Check up until July 2025. This includes administration of the Edinburgh Postnatal Depression Scale (EPDS) and the ANQR/PNQR screening tools. This has been initiated in 75% of public hospitals and child and family health services in Victoria. The digital screening tool is available in 25 different languages. As part of the development of the 2023 Guideline, recommendations were given with respect to screening for fathers and partners. Here adaptions were made to the ANRQ/PNRQ and lower cut-off scores applied to the EPDS or use of the K10. These tools and scoring algorithms have been programmed into iCOPE and also digitally available. However, since they are not deemed to be ‘the patient’ if screening was positive, they would need to access their General Practitioner for follow-up. iCOPE is one example of an initiative in Australia (a high-income country). The digital tool is also available, and is being used within the private sector by OBGYNS. As this is not funded under the Perinatal Mental Health Check Program, access to iCOPE at the expense of the private obstetrician or hospital, however costs can be off-set by Medicare Benefits Schedule (MBS) item number for screening antenatally (16,590/16591 and 16,522) and Postnatally (16407). More information can be found here—https://www.cope.org.au/perinatal-mental-health-check/digital-screening-in-the-private-sector/

2.2 Australian midwifery models of care

Within Australia there are various midwifery models of care including; public hospital care, team midwifery, midwifery group practice case load care and private midwifery care [55]. Midwives may be able to address implementation gaps by providing postnatal psychosocial screening and assessment for women in the private sector, especially since there are financial initiatives via a Medicare rebate for obstetricians for screening. Collaborative obstetric care models that employ midwives with expertise and interest in psychosocial screening as key contacts for postnatal integrated care may offer a successful future solution. The difficulty for midwives working in the private sector is that they often do not have an ongoing relationship with the woman and therefore have a limited opportunity to assess/screen or identify risk factors/disorders [44]. Contributing factors that may influence the approach a midwife takes towards psychosocial screening and assessment include organisational support for continuing education, their experience as a midwife, training and exposure to the practice of others, their own personal life experience, clinical supervision opportunities, and the model of midwifery care within their setting or organisation. Midwives seem willing to have a more substantial role in recommending appropriate psychosocial treatment strategies to women with postnatal depression, however, further training is often required to ensure both confidence and competence in their psychosocial assessment and management of women [10]. Similarly, the majority of obstetricians and/or gynaecologists consider that they have a responsibility to identify depression but may not have the appropriate training and resources to screen for and treat depression. It is also evident that some maternity care providers may be reluctant to ask about depression, and women themselves may be unwilling to disclose their experiences [10, 14].

3. Training and support

Reviews of both the SAFESTART and Beyond Blue guideline implementations indicate that additional training and support are required for primary health care staff, including midwives and child and family health nurses to undertake psychosocial and depression screening and to provide a more psychosocial emphasis in their work. A comprehensive schedule of recommended psychosocial screening and assessment training at basic, intermediate and advanced [37].

A training model must include the further education of as many midwives as possible on psychosocial screening and risk factors, implementing the assessment/screening process, processes for follow-up, and the establishment of referral pathways, with ongoing professional development workshops to support staff attrition. However, this will only be successful if the individual health care service is supportive of the intervention, including making a substantive commitment. The private sector will be required to engage and facilitate interdisciplinary collaboration and interest and make a financial commitment to additional resources (including time) for psychosocial screening within their private model of obstetric care [44].

4. Access to services

Women who chose to give birth in the private sector may also sporadically require access to mental health resources within the public sector to support their care. However, questions regarding private insurance, private providers, and equity of access to community-based public postnatal mental health services have consistently been concluded and not dealt with. The formation of impending collaborative partnerships between public, private, and Non-Government Organisation service providers will be key to appropriately supporting the mental health care of postnatal women who choose to give birth in the private sector. In order to access equitable and adequate postnatal mental health care, Australian women must be able to transfer straightforwardly between a broad range of services and sectors [44].

Key mental health partner organisations working with the private sector (such as St John of God Health Care) express the possibilities for collaborative partnerships to promote the wider implementation of mental health care plans between private settings. While concern for personal privacy is undoubtedly important, the introduction of electronic health records across Australia further increases opportunities for discussion on the appropriate and timely sharing of health information. Similarly, the upholding of collaborative practices and partnerships will be crucial for ongoing and sustained change. COPE has developed a national perinatal mental health directory of services to support timely and accurate referral that is funded by the Commonwealth Government [37].

5. Workforce

As the Australian private health sector continues to expand, service accountability for identifying and supporting postnatal mental health care will continue to challenge the capacity of these organisations to ensure their workforces are maintained to undertake routine universal postnatal screening and assessment [5, 15]. Australian National standards for perinatal mental health have already been developed and endorsed [6, 15, 37, 45, 46] and currently need to be introduced into the continuous quality improvement processes of private sector facilities in order to meet the Australian hospital accreditation requirements. In addition, private sector providers must increase staff access to continuous professional education/development programmes, to find relevant pathways to collaborative care and ensure that professional and organisational policies and procedures are developed to support this ongoing process [6, 15, 45, 46].

While privately funded obstetric services providers are recommended to encompass the recommendations of the National Guidelines [37] for universal postnatal screening, it appears that application has been widely lacking. The most recent National Perinatal Mental Health Guideline from the Centre of Perinatal Excellence (COPE) [37] has now superseded the initial Beyond Blue Guidelines that were developed and endorsed by NHMRC [6, 45, 46] and this new guideline recommends that ALL hospitals screen and assess women for postnatal mental health risk factors and issues including private obstetric providers. The postnatal period offers an opportunistic time for prevention, promotion, identification, and early intervention of women’s mental health. However, there have been inequitable opportunities to support women postnatally within existing systems in training, assessment and referral pathways to continuing care, other than iCOPE training since 2013 [5, 15]. Future private provider services that implement the National Perinatal Health Guideline will necessitate enhanced engagement with specialist postnatal mental health services and also community healthcare and primary healthcare services for sustaining fundamental approaches, functions and activities.

6. Health sector regulations

The private sector is not governed by the same regulations, governance or policies of the Australian Government public sector. Local level decisions are made within each individual hospital, Board of Directors or company electing to prioritise a woman’s psychosocial well-being through risk assessment, management and referral. Nonetheless, as stated by Gemmill [56], electing not to perform postnatal screening and assessment due to a lack of mental health resources, or the perception that it is too complex, is discounting the surmountable evidence-based international literature on the pertinent role of psychosocial well-being on maternal and infant outcomes. The administration of a postnatal screening assessment that identifies women at risk of postnatal anxiety and depression/currently experiencing anxiety/depression should be considered best (evidence-based) practice in order to support the long-term well-being of mother and baby [6, 15, 45, 46, 57].

Within private obstetric care, obstetricians are the answerable health professional for ensuring that psychosocial assessment and screening with the EPDS is utilised. Relevant health care providers, including midwives at the hospital at which the woman will give birth, need to be informed if there are concerns and relevant information consistently and clearly documented in the women’s notes and discharge summary [15].

It is clearly recommended that existing state-wide midwifery databases be made able to link private and public hospital data with community or General Practitioner services across Australia to identify women at risk of/with postnatal mental health problems [6, 45, 46]. The federal government’s introduction of an electronic health record may be useful, contributing to improved data sharing and linkage between service providers. iCOPE is also integrated with My Health Record in Australia.

7. Solutions/recommendations conclusion

In conclusion, a sustainable model of postnatal mental health care in private obstetrics might include screening, assessment referral and psychoeducation provided by a midwife. Alternatively, a committed postnatal liaison nurse (midwife) to screen, refer, support and follow up women identified as at risk/concern and also engage with women who decline help. The role of the midwife could be advanced further to provide improved continuity in relation to screening and support for mental health. This could be through the development of a role for Advanced Midwifery Practitioners, who are named and regulated as specialised mental health midwives. This could additionally be endorsed by specialist postgraduate or other higher education programmes for both midwives and obstetricians. There are also online training and face to face training programmes available for midwives – on perinatal screening and assessment. These include the COPE Basic Skills in Perinatal Mental Health, KMMS module for screening Australian First Nations (now also part of iCOPE) women and perinatal loss in practice. The perinatal loss in practice is a practical, comprehensive course for Therapists, including Psychologists, Psychiatrists, Social Workers, Counsellors, and Mental Health Nurses, who work with clients who have experienced miscarriage, stillbirth, and newborn loss.

More experienced midwives and child and family health nurses [58] are known to utilise a variety of strategies to make clinical decisions and to utilise critical thinking to detect women who require follow-up support for postnatal mental health disorders [59]. Midwives who have more experience in psychosocial screening and assessment and who have developed effective screening and problem-solving abilities are in the idyllic position to mentor and support less experienced midwives, however, it is uncertain whether this peer-mentoring occurs.

More support markedly required to identify and promote family and community-centred approaches to mental well-being for postnatal women, and all Australian families would gain from improved information regarding the benefits, purpose and aims of postnatal mental health screening and assessment. A wide-based educational communication strategy is advised to enhance awareness of postnatal mental health issues, particularly the impact on infant well-being and development and the needs of the family unit. A simultaneous consultation strategy is necessary to identify additional tactics to engage key stakeholders, including private obstetric service providers, in the implementation and evaluation of this essential health promotion campaign. In addition, universal routine psychosocial screening/assessment should be conducted postnatally, regardless of the outcome of antenatal screening.

The Centre of Perinatal Excellence (COPE) has developed an e-directory to assist women in finding local support for emotional and mental health problems perinatally. It includes over 700 services. This includes services and professionals that have a special focus on emotional and mental health during pregnancy and following the birth of a baby. This directory could be promoted to postnatal women by health care professionals. There is also a preparation for parenthood psychoeducation programme through COPE for women. In addition, there is a free ready-to-cope psychoeducation app available for women called, ‘Ready to Cope’. This provides weekly updates for pregnant woman, men and non-birthing partners until the completion of their first year of parenting. Monash University have also demonstrated that iCOPE can be successfully used with refugee women by offering screening in their own language [60].

8. Conclusion

In conclusion, postnatal mental health is clearly a contemporary challenge as the risks associated with this have long-term effects on the mother, infant and their family. Projected costs for not treating depression and anxiety in 2013 were estimated to be $538 million during the perinatal period; however, detection and early intervention can reduce costs. Appropriate and timely psychosocial screening and assessment in the postnatal period is essential for postnatal women, their families, and outcomes. However, there are identified barriers to psychosocial assessment and screening globally – many of which have now been rectified through the development and application of innovative digital solutions to psychoeducation, screening referral and health professional training. These barriers need to be identified and addressed locally. Health care professionals are responsible for psychosocial screening and assessment of postnatal women. This contemporary challenge needs to be addressed urgently.