\r\n\t \r\n\tComputer graphics are not entirely an original topic, because it defines and solves problems using some already established techniques such as geometry, algebra, optics, and psychology. The geometry provides a framework for describing 2D and 3D space, while the algebraic methods are used for defining and evaluating equality related to the specific space. The science of optics enables the application of the model for the description of the behavior of light, while psychology provides models for visualization and color perception. \r\n\t \r\n\t3D computer graphics (or 3D graphics, three-dimensional computer graphics, three-dimensional graphics) is a term describing the different methods of creating and displaying three-dimensional objects by using computer graphics. \r\n\tThe first types of graphic interpretations were put in the plane (two-dimensional 2D). Requirements for a universal interpretation led to a three-dimensional (3D) interpretation content. From these creations have arisen applied mathematics and information disciplines of graphic interpretation of content - computer graphics. It relies on the principles of Mathematics, Descriptive Geometry, Computer Science and Applied Electronics. \r\n\t \r\n\t3D computer graphics or three-dimensional computer graphics use a three-dimensional representation of geometric data (often in terms of the Cartesian coordinate system) that is stored on a computer for the purpose of doing the calculation and creating 2D images. The images that are made can be stored for later use (probably as animation) or can be displayed in real-time. \r\n\t \r\n\tObjects within the 3D computer graphics are often called 3D models. Unlike rendered (generated) images, data that are ""tied"" to the model are inside graphic files. The 3D model is a mathematical representation of a random three-dimensional object. The model can be displayed visually as a two-dimensional image through a process called 3D rendering or can be used in non-graphical computer simulations and calculations. With 3D printing, models can be presented in real physical form. \r\n\t \r\n\tComputer graphics have remained one of the most interesting areas of modern technology, and it is the area that progresses the fastest. It has become an integral part of both application software, and computer systems in general. Computer graphics is routinely applied in the design of many products, simulators for training, production of music videos and television commercials, in movies, in data analysis, in scientific studies, in medical procedures, and in many other fields.
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1. Introduction
Literally speaking, Biomechanics is the discipline that applies the principles and laws of Mechanics to biological systems. As for the human body and, more specifically, the human foot, biomechanics focuses on the understanding of those laws of the Physics by which the human being moves within the Earth gravitational environment by adopting a bipedal posture and using a complex interfacing structure such as the foot-and-ankle system. Keeping the focus on the most common human displacement activity, i.e., gait, we may state that the main target of a functional gait is to push the body centre of gravity forward. To do that, gait has to deal with a set of forces the body exchanges with the environment – especially with the ground – and with a set of movements which represent both causes and effects of force transmission. A thorough description of the foot biomechanics should then mainly rely on the observation of both kinematic and kinetic variables, namely, i) forces and moments of force external to the body; ii) forces and moments of force internally generated by the musculo-skeletal system; and iii) movements and timing of the movements in terms of linear and angular displacements, linear and angular velocities, linear and angular accelerations of the whole body or of specific body segments. On the other hand, the effects of loading under the sole of the foot in terms of plantar pressure have been reported since the late 1800’s; and since the first attempts to measure it, its use has been ever increasing worldwide. In fact, plantar pressure assessment alone is not enough to thoroughly investigate biomechanics – in terms of neither kinematics nor kinetics - being pressure related to the only component of the force vector which is normal to the examined surface. Plantar pressure, however, has great potentialities in the field of Research but even more in Clinics and Podiatry. When compared with other assessment devices typically used in gait analysis, pressure measurement systems are easier to implement and use, less time-consuming and cumbersome to the patient, less expensive than complex gait analysis equipment; measurements are more easily acquired, processed and interpreted, and – last but not least – they are meaningful and effective in the assessment or in the monitoring of any foot or ankle treatment. In the last ten years, a significant increase has been observed in peer-reviewed publications dealing with studies focussed on plantar pressure measurements. However, despite the great interest of the scientific world in this potentially valuable assessment tool, little evidence has been gathered so far of the effectiveness, appropriateness and generalisability of the plantar pressure measurement methodology. This fact is attributable to several reasons, the most important one being the lack of standardisation. In the following paragraphs, a brief literature overview will be given to better introduce the role pressure measurements have in the scientific and clinical context, but also to better explain how and to what extent the lack of standardisation of instrumentation and procedures has frustrated all researchers’ and clinicians’ efforts at giving this methodology the role it deserves in the investigation, understanding and management of foot biomechanics.
2. Literature overview
The main source this brief literature overview relies on is the PubMed Web Resource, the specific tool to search in databases of peer-reviewed scientific literature in the biomedical field. PubMed is freely accessible on the web (http://www.ncbi.nlm.nih.gov/pubmed/), and its more than 20 million citations for biomedical literature come from MEDLINE – the biomedical database of the U.S. NLM -, life science journals, and online books. This precious free resource has been developed and is maintained by the National Center for Biotechnology Information (NCBI), at the U.S. National Library of Medicine (NLM), located at the National Institutes of Health (NIH).
Search combination
Search date
Total number of publications
Publications in the last ten years
Year of the first publication
„foot“ & „biomechanics“
Jan 17th, 2011
3975
2132 (54%)
1950
„foot“ & „biomechanics“ & „pressure“
Jan 17th, 2011
767
470 (61%)
1966
„foot“ & „pressure“
Jan 17th, 2011
5605
2807 (50%)
1918
„foot pressure“
Jan 17th, 2011
473
275 (58%)
1980
„foot biomechanics“
Jan 17th, 2011
58
40 (69%)
1973
„plantar pressure“ or „plantar loading“ or „foot pressure“ or „foot loading“
Jan 17th, 2011
1124
748 (66%)
1976
Table 1.
Publications cited in PubMed resulting from different combinations of search terms that regard foot biomechanics and plantar pressure.
The Author has used a few research combinations just to understand whether and how human plantar pressure measurements are used and associated with the concepts of foot biomechanics and gait. Table 1 briefly indicates the most interesting combinations of search terms, and the main results obtained for each of them up to January 2011 in terms of: i) the overall number of papers found that contain the search terms in all PubMed fields of research; ii) the subset of papers published in the last ten years; iii) the year of the first publication.
Table 1 clearly shows that, generally speaking, foot biomechanics is quite a recent field of scientific investigation which is rapidly gaining interest worlwide. All search combinations proved in fact that at least 50% of the literature is concentrated in the last ten years. With special attention to pressure, it is worth noticing that 20% of all the publications containing “foot” & “biomechanics” also contain “pressure”; the percentage rises to 22% when referred to the last ten years, showing a more frequent association of the concept of “pressure” with the concept of “biomechanics”. As for the great number of publications found for the “foot” & “pressure”combination, it should be noted that some of them do not deal with foot pressure proper, being sometimes focussed on clinical applications and/or on patients with concurrent blood pressure pathologies. Thus, the literature overview was finally focussed on the search combination reported in the last row of Table 1, i.e., „plantar pressure“ or „plantar loading“ or „foot pressure“ or „foot loading“, which turned out to be wide enough and appropriate. From now on, the paper will only deal with this combination of literature research.
As shown in Table 1, the first peer-reviewed publication is quite recent (Gordon, 1976). Actually, the very first paper resulting from the PubMed research is dated 1953 (Cram, 1953), but it is a misprint since the true title is “A sign of sciatic nerve root pressure” rather than “A sign of sciatic nerve foot pressure” as stored in the database, and it has nothing to do with plantar pressure measurement. In about 35 years, 1124 publications have been produced in all, 66% of which in the last ten years. The brief literature overview that follows is based on only 119 publications dated 2010, so as to give an idea of the most recent issues taken into account in this field. Here is a summary of a few interesting observations:
86 out of the 119 papers (72% of the total amount) indeed deal with plantar pressure measurements; they have been listed in the Reference section from (Morrison et al, 2010) to (Tessutti et al, 2010).
Of the 86 publications, 75 (87%) deal with clinical or research applications, while the remaining 11 (13%) address methodological issues. On one hand, this shows the great potential of plantar pressure measurements in the Clinics or in the field of Applied Research; on the other hand, however, the presence of more than 10% of methodological papers may be read as a sign of a moderate but increasing interest towards methodological and standardisation issues. For a more detailed description of Clinical, Sport or Research applications, Table 2 classifies the 86 papers according to the main pathology or issue treated. It is worth highlighting that some pathologies are almost always investigated with the support of plantar pressure measurements – i.e., foot, ankle and hip pathologies, foot surgery, orthosis design and assessment, musculo-skeletal performance -, some do not require pressure measurement investigation as is the case with Parkinson’s disease, a few others are partly investigated by involving pressure measurements and partly only relying on different investigation methods – i.e. balance control, diabetes, gait biomechanics, foot injuries -. As for Diabetes, it should be observed that in the last years most scientific studies on Diabetes and foot biomechanics did rely almost exclusively on plantar pressure measurements, both barefoot and inside prescribed footwear and orthoses. The main reason for this is probably the interest of researchers on the most evident effect of biomechanical alterations, i.e. abnormal peak pressures so often associated with the ulceration process. Only recently has the need been felt for a more complete investigation of biomechanical alterations Diabetes induces in all the structures involved in gait i.e. joints, muscles, tendons, soft tissues, skin, bone, cartilage, peripheral vascular system, motor and sensory nervous system.
Back to Table 2, it is also extremely important to underline that all 2010 methodological studies are related to pressure measurements.
With respect to the specific field of application, the 86 papers can be grouped as follows: 69 papers strictly related to the clinical context; 1 to the military environment; 8 to sports; 8 to technology.
Only 45 out of the 86 publications do report absolute pressure values. This concept is critical indeed, and will be further discussed later on; however, it is worth anticipating that reporting absolute pressure values obtained within a certain study may help understand the appropriateness of the whole methodological setup designed and used in the study, and surely helps researchers to better judge the comparability of his/her own results with those reported in the study.
As for the technology used in the 86 publications, an increasing interest in wearable devices has been observed with respect to previous years. In detail: in 46 studies a pressure platform was used, i.e. a rigid sensor matrix made integral with the floor; 32 used an in-shoe wearable pressure system; 2 used a custom-made platform purposely designed for pressure and shear measurements; 1 used a footprinting mat; 5 used discrete pressure sensors.
Still on technology, in a commercial versus prototype pressure devices context, it can be observed that about 60% of the 86 studies used commercial pressure measurement devices. The involved Companies/Products ordered according to a decreasing number of citations are: Novel; Tekscan; Rsscan; Biofoot/IBV(®) in-shoe system; Zebris; Medilogic; Harris footprinting mat; Vista Medical. Only 5 studies described and used prototypes among which a quite new in-shoe prototype of a textile device (Shu L et al, 2010) is worth citing. In the remaining cases, the device was not clearly described, which, together with the lack of absolute pressure values, might represent an obstacle for correct data interpretation and comparison.
As for the pressure-related parameters used, the situation is quite confusing. Just a few comments to give the reader a rough idea of the need for standardisation, and to well justify the current difficulty in performing proper comparisons among studies:
Some “conventional” parameters are frequently cited and used in the papers, e.g., peak pressure, mean pressure, pressure-time integral, peak force, force-time integral, center of pressure, stance period, and symmetry indices, but almost none of the studies describe the way each parameter has been obtained; thus, while some of them are undoubtedly always obtained in the same manner, for others critical differences in the computation algorithm surely lead to different results. Mean pressure is a clear example: its value changes dramatically according to whether it is based on the whole stance period or only on the period of each sensor activation.
Meaningful regional masks are used in several papers but they are hardly defined, and even rarer is the detailed description of the algorithm used to select the foot sub-areas.
There is an increasing interest towards pressure-derived quantities and novel numerical analysis: while acknowledging the great potential of such computational approach, the risk to obtain poorly comparable results is in this case even greater than when traditional parameters are used, unless comparison is assured and proved with respect to the source datasets. Besides this aspect, derived quantities should be even better described than traditional ones because sometimes their clinical association, relevance and meaning are not straightforward for an effective worldwide use.
The final observation is rather a criticism to the superficial attitude and the lack of attention shown by the main actors of a publication, i.e. authors, reviewers, editors, and even readers: peer-reviewed 2010 publications, similarly to the publications of previous years, sometimes present data that may not be, in any way, related to a properly conducted study. Five examples of dubious measurements are briefly reported below. papers are not clearly cited in order to be respectful with colleagues who did not pay the proper attention while preparing, reviewing or simply reading them. Example 1: according to a study, electronic footprints do not match ink footprints: it is reasonable to hypothesize that the statement came out from comparison with a platform which was not well calibrated or not sensible enough, or even with a very low spatial resolution, but none of these aspects was taken into account in the paper. Example 2: a platform made of resistive sensors is used for static tests lasting more than 30s. Since resistive sensors suffer from hysteresis and creep, their use under static conditions is usually not recommended, unless a preliminary assessment proved that the device can be reliably used for a long loading time. Again, the issue is not discussed in the paper. Example 3: a paper dealing with obese patients (BMI > 35kg/m2) reported dynamic peak pressures not greater than 250kPa. These values are suspiciously low: for comparison, consider that a paper published in 2001 (Hills AP et al, 2001) reported more than 500kPa of averaged peak pressure values for both men and women. Example 4: a paper reports peak pressures under the forefoot not greater than 35kPa, which is almost impossible: even if the authors meant mean rather than peak pressure – mean being obviously much lower than peak pressure – the result would have been obtained from a person with a body mass of about 35kg standing on a support surface of 100cm2, thus greater than the EU size 38 or US size 7. Example 5: a paper deals with pressure measurements obtained with a pressure platform while wearing shoes: this means that the measurements are inconsistent for they refer to the interface between the platform and the sole of the shoe.
Main Pathology/Issue
Number of papers dealing with pressure measurements (% of 86)
Publications dealing with pressure measurements
Number of papers in 2010 -not all dealing with pressure measurements (% of 119)
Ankle pathology
2 (2.3%)
Morrison et al, 2010 Rouhani et al, 2010 a
2 (1.7%)
Anthropology
1 (1.2%)
Hirasaki et al, 2010
3 (2.5%)
Balance control
2 (2.3%)
Hirata et al, 2010 Vuillerme & Boisgontier, 2010
10 (8.4%)
Children
4 (4.6%)
Pau et al, 2010 Bosch et al, 2010 Bosch & Rosenbaum, 2010 Pauk et al, 2010
5 (4.2%)
Diabetes
8 (9.3%)
do Carmo Dos Reis et al, 2010 Zequera & Solomonidis, 2010 Cisneros Lde et al, 2010 Hastings et al, 2010 See et al, 2010 Z. Pataky et al, 2010 Chen et al, 2010 Rao et al, 2010
14 (11.8%)
Elderly
1 (1.2%)
Battaglia et al, 2010
1 (0.8%)
Falls
2 (2.3%)
Abu-Faraj et al, 2010 Mickle et al, 2010
2 (1.7%)
Foot injuries
4 (4.6%)
Goffar et al, 2010 Hirschmüller et al, 2010 Schepers et al, 2010 Hetsroni et al, 2010
7 (5.9%)
Foot pathology, anatomy and function
15 (17.4%)
Navarro et al, 2010 Yalçin et al, 2010 Kaipel et al, 2010 Lee et al, 2010 Hyslop et al, 2010 Ribeiro et al, 2010 Mackey et al, 2010 Yavuz et al, 2010 Martínez-Nova et al, 2010 Gu et al, 2010 Barberà i Guillem et al, 2010 Yavuz & Davis, 2010 Nordsiden et al, 2010 Putti et al, 2010 b Menz et al, 2010
17 (14.3%)
Foot surgery
7 (8.1%)
Schuh et al, 2010 a Bayomy et al, 2010 Wagenmann et al, 2010 Yoon et al, 2010 Ellis et al, 2010 Jeans & Karol, 2010 Najafi et al, 2010
7 (5.9%)
Table 2.
Part A. 2010 Publications dealing with plantar pressure measurement, classified according to the main pathology or the main issues investigated.
Main Pathology/Issue
Number of papers dealing with pressure measurements (% of 86)
Publications dealing with pressure measurements
Number of papers in 2010 -not all dealing with pressure measurements (% of 119)
Footwear and/or insoles
6 (7.0%)
Hong et al, 2010 Deleu et al, 2010 Stöggl et al, 2010 Schuh et al, 2010 b Tong & Ng, 2010 Queen et al, 2010
7 (5.9%)
Gait strategy/biomechanics
6 (7.0%)
Putti et al, 2010 b Teyhen et al, 2010 C.M. Senanayake & S.M. Senanayake, 2010 a C.M. Senanayake & S.M. Senanayake, 2010 b Rouhani et al, 2010 b M. D\'Amico et al, 2010
8 (6.7%)
Knee pathology
4 (4.6%)
Bek et al, 2010 Wang et al, 2010 Lidtke et al, 2010 Aliberti et al, 2010
4 (3.4%)
Lower limb amputees
2 (2.3%)
Kendell et al, 2010 Tura et al, 2010
2 (1.7%)
Lower limb injuries
1 (1.2%)
Kelly et al, 2010
1 (0.8%)
Muscolo-skeletal performance
5 (5.8%)
Braz & Carvalho, 2010 Girard et al, 2010 Stolwijk et al, 2010 No authors, 2010 Tessutti et al, 2010
5 (4.2%)
Postmenopausal women
4 (4.6%)
Monteiro et al, 2010 a Monteiro et al, 2010 b Faria et al, 2010 Monteiro et al, 2010 c
4 (3.4%)
Pregnancy
1 (1.2%)
Karadag-Saygi et al, 2010
1 (0.8%)
NONE (research; methodology;..)
11 (12.8%)
Giacomozzi, 2010 a Natali et al, 2010 Oliveira & Tavares, 2010 Giacomozzi, 2010 b Zammit et al, 2010 Miller, 2010 Ramanathan et al, 2010 Giacomozzi, 2010 c Shu et al, 2010 Chevalier et al, 2010 Keijsers et al, 2010
11 (9.2%)
Total
86 (100%)
119* (100%)
Table 3.
Part B. 2010 Publications dealing with plantar pressure measurement, classified according to the main pathology or the main issues investigated.
\n\t\t\t
the list of 2010 papers also included papers – not related to pressure measurements - dealing with: gait rehabilitation (1); ground interfaces (1); obesity (2); Parkinson’s disease (4).
\n\t\t
3. Pressure measurement devices (PMDs): Technical and performance issues
In 2010 great attention was paid to the technical aspects of plantar pressure measurement. Awareness is growing in the scientific environment about the key point: in order to render pressure measurements appropriate, comparable, meaningful and effective, the process towards standardisation has to start with the assessment of the technical performance of the pressure measurement devices (PMDs) through which pressure is quantified. Some proposals have been published and disseminated so far through publications (Giacomozzi C, 2010 a; Giacomozzi C, 2010 b; Giacomozzi C, 2010 c), meetings, on-line forums[1] -, and an ongoing attempt within the Pedobarographic Group of the International Foot and Ankle Biomechanics Community (i-FAB-PG) for a Consensus Document on the topic. The following paragraphs aim at giving the reader a brief description of the currently available pressure sensor technology, the technical features which mainly interfere with overall PMD performance, some suggestions for implementing an adequate PMD technical assessment.
3.1. Basic concepts on PMD sensor technology
Generally speaking, the measurement of pressure can be obtained with a transducer that quantifies the effect of a force acting perpendicularly to a certain surface. This definition must be clearly kept in mind when investigating foot biomechanics with a PMD because, independently of sensor technology, a pressure sensor alone cannot measure the effect of forces which are not oriented perpendicularly to its surface. Even more important is the concept that, if the sensor surface is not parallel to the ground – as it may happen with in-shoe systems or when the floor is not rigorously horizontal -, the measured quantity is not only, or not completely, related to the vertical component of the Ground Reaction Force (GRF).
Along the years valuable reviews have been delivered on the available sensor technology, novel prototypes, their main features and quality of performance. The first interesting and thorough review was written by Lord in 1981 (Lord M, 1981). Another very good technical review was disseminated by Cobb and Claremont in 1995 (Cobb J, Claremont DJ, 1995): interestingly enough, it also addressed transducers applied to the measurement of shear forces. Albeit highly desirable, none of them have been successfully integrated into commercial pressure measurement systems yet. A further very useful review on the issue of plantar assessment was published in 2000 (Orlin MN, McPoil TG, 2000): it contains not only a thorough review of the available pressure measuring techniques, but also a stimulating discussion on most used parameters and potential clinical applications.
Right now -at the beginning of 2011- commercial PMDs and most prototypes are still focussed on pure pressure measurements, and are essentially based on optical devices, pneumatic discrete sensors, discrete -or matrices of- resistive sensors, and discrete -or matrices of- capacitive sensors. Worthy of note is a novel textile sensor prototype. Low-cost, semiquantitative pressure measurement solutions are not taken into account here, while they are discussed in (Orlin MN, McPoil TG, 2000). Each of the above sensing solutions will be briefly described here below, but a first important aspect -which is common to all PMDs with the only exception of optical technology- is sensor size. In fact, the smaller the sensor, the higher its sensitivity and its potential to accurately detect localized peak pressures – otherwise underestimated because averaged over the entire surface of a wider sensor. Conversely, the electrical noise of extremely small sensors may increase owing to the necessary greater amplification of the signal, and may thus interfere with sensor accuracy and repeatability. Besides this, the simultaneous electrical management of a very high number of sensors on the same sensor matrix at a high scanning rate might become a critical issue to cope with. For a proper detection of localized peak pressures under the human foot, a linear size of 2-3mm might be reasonable for a sensor, basing this estimation on location and dimension of the metatarsal heads and on the expected local pressure curve.
Brief description of current sensor technologies.
Optical devices
Obviously, they are only aimed at measuring pressures through platforms fixed to the measurement environment, thus this kind of technology is not usable for in-shoe assessment. A good example of an optical pedobarograph – namely the Sheffield pedobarograph - was first described in 1982 (Duckworth T et al, 1982). Basically, the pedobarograph is made of an illuminated glass plate covered with a plastic sheet. When the sheet is pressed on the glass, light scatters and generates a foot image which is captured by a camera at the bottom of the device, and then digitized. Pressure variations are thus measured by quantifying the variations of voltage level in the camera output, which are associated with the variations of intensity of the captured image. It is worth noting here that spatial resolution -further discussed in the following paragraphs as a critical PMD technical feature- is in this case extremely high. The relevance of the use of the optical device in Clinics was reported soon after (Duckworth T et al, 1985), and is still reported in the lastest papers (Ramanathan AK et al, 2009).
Pneumatic discrete sensors
A hydrocell-based technology is used within the commercial in-shoe Parotec System. Unlike the optical technology, this one is only used for in-shoe pressure measurements under specific local foot areas. Basically, each sensor is made of a small volume of an incompressible fluid contained in a small polyurethane pack, integral with a microsensor placed just beneath it, and isolated by a thin dielectric foil. An interesting technical paper which analyses some aspects of the performance of the Parotec system was published in 2000 (Chesnin KJ et al, 2000). The paper reports the following relevant technical features: 24 sensors on each insole; pressure range up to 625kPa; pressure resolution 2.5kPa; good accuracy (2%FS); high precision (0.4%FS); negligible hysteresis and drift; very low temperature drift, humidity drift and non-linearity; insole height 3mm; sampling rate 100Hz.
Textile sensor
An interesting novel prototype of a fabric pressure sensor is described in Shu’s 2010 paper (Shu L et al, 2010). In brief, each pressure sensor is obtained by fixing a conductive sensing fabric onto a conductive yarn and on a top-bottom conversion layer made of different silicon rubbers. The paper illustrates the main technical features of a prototype insole containing 6 sensors, suggesting it for sports and fitness assessment, i.e.: sampling rate 100Hz; pressure range 0-1000kPa; pressure resolution 1kPa; life-time > 100000 cycles; negligible temperature and humidity effects; low cost. The height of the insole is not reported in the paper, which might be a relevant issue to be taken into account.
Resistive sensors
One of the two most widely used sensor technologies (the other being the capacitive technology briefly discussed soon after), which may be arranged under the form of arrays of discrete sensors, platforms, or in-shoe systems. Available commercial systems are delivered worldwide by the following Companies: Diagnostic Support (platforms), Imago (platforms), Loran (platforms and in-shoe systems), Medilogic (platforms), Rsscan (platforms), Tekscan (platforms and in-shoe systems), Vista Medical (platforms). There are other brands on the market, but the products are usually made by one of the above Companies. A common functioning principle of the different resistive sensors is that they rely on an electrical current flow whose intensity depends on the pressure exerted on the sensor surface. When the effective contact area of the sensor increases due to pressure, electrical conductivity increases as well, in a roughly linear fashion, within a certain range of pressure. In some cases the change of conductivity is due to a volume effect rather than a contact surface effect, and an elastic deformation takes place in the conductive material. In general, manufacturers have to deal with low-impedance sensors – hence the good performance with respect to noise immunity –, but with some drawbacks such as hysteresis, fast ageing, instability. A special type of resistive devices is also on the market, i.e. long platforms which only act as resistive “contacts” and which are addressed to the measurement of spatial and temporal parameters of gait. Even though some of them – as for example the GaitRite (www.gaitrite.com) – deliver some “pressure” levels rather than only an on-off answer, it is extremely important to keep in mind that they only represent a qualitative output, in no way appropriate for quantitative pressure analysis.
Capacitive sensors
Their functioning principle is the variation of capacitance induced by a variation of pressure exerted on the sensor surface. The different commercial products use two types of capacitive sensors:
Platforms and in-shoe systems by Novel, and platforms by Zebris use elastomer-based capacitive sensors, thus exploiting the variation of thickness of an elastic dielectric material: the higher the pressure, the smaller the thickness and the higher the capacitance, according to a linear law. In general, manufacturers have to deal with greater difficulties than with resistive sensors to obtain fast measurements, and cope with high impedance, which may entail noise or interference. On the other hand, this kind of sensors show higher stability, lower hysteresis, higher resistance to the deteriorating effects of ageing.
Platforms by AMCube and Loran use air-based capacitive sensors also known as “touch mode” sensors: air separates the upper part of the capacitor from the lower part, which is covered by a thin dielectric sheet. The whole system is more rigid than with elastomer-based sensors, and usually the range of linear answer is smaller.
Capacitive technology is also used in the Biofoot in-shoe system by the Institute of Biomechanics of Valencia, Spain (IBV). The system was first described in 2008 (Martínez-Nova A et al, 2008). Its main technical features are: thickness insole 0.7mm; 64 capacitive sensors for each insole; lifetime 3000 steps; pressure range 0-1220kPa; calibration range 0-500kPa; pressure resolution 0.1kPa, measurement uncertainty 10% of calibration range; in-factory calibration; suggested re-calibration after two years. Unfortunately, no further details are available as for the sensor technology they use.
3.2. Basic concepts on PMD technical assessment
Technical assessment of PMD performance is desired, and worldwide claimed to verify appropriateness, reliability and comparability of pressure measurements. It becomes mandatory when such measurements are used for clinical purposes, since in this case the PMD is addressed as a medical device with measuring function, and must comply with specific market regulations. On the other hand, when used in a research or sports context, or if it is a prototype, the device may or may not be considered a medical device – the classification depending on the specific intended use -, but it must always remain safe for users (i.e. minimisation of electrical and mechanical risks, toxicity,… ).
PMD performance should be fully characterised in-factory before the device is delivered, or in the research lab in case of prototypes. Owing to ageing effects, however, it is not sufficient to guarantee its appropriate use over time. Thus, the periodic, simplified checking of some technical features should also be implemented on-site, so as to early detect any deterioration of the device entailing the worsening of its measuring performance.
Pressure output of PMDs may significantly differ due to the above-discussed variability in pressure sensor technology, but also due to several equally important factors like the number and arrangement of sensors, the material used to cover, sustain and seal the sensors, the hardware and software used to supply or calibrate the sensors and to acquire data. Thus, PMDs technical performance should be assessed accounting for their final arrangement. In case of in-shoe systems, assessment is even more complex since the devices should also be tested under flexed but repeatable conditions, and with respect to surfaces with adequate elasticity so as to reproduce as much as possible their most frequent working conditions.
With respect to pressure platforms, they may essentially differ for size; thickness; material the mechanical frame is made from; individual sensor technology and performance; individual sensor size; spatial resolution; pressure resolution and range; sampling rate; hardware and software supply and data acquisition equipment. Almost the same holds for in-shoe systems, but for size which is almost always fixed, and for the material of mechanical frame – actually the cover material - which should have specific elastic characteristics and should be appropriate for sealing procedures.
A suitable testing equipment should perform equally well with different sensor technologies and different arrangements. Basically, it should be able to apply a well-controlled and uniform load/pressure over defined PMD areas for a given time period and, in case of dynamic loading, at a controlled and proper rate. Its precision and accuracy should be higher than those expected for the PMD.
The assessment should mainly investigate PMD response in terms of: pressure variability over the whole active area and for the whole pressure range; pressure accuracy; hysteresis; creep and answer stability over short as well as long periods - the latter being mandatory if the device is going to be used for posturographic purposes -; accuracy and repeatability of center of pressure (COP) estimation.
Testing procedures should be properly designed to assess PMDs intended for use in specific scenarios like running, jumping, sprinting, jogging.
More technical details can be found in two 2010 publications (Giacomozzi, 2010 a; Giacomozzi, 2010 b) and on the above on-line forums[1] -. Briefly, recommended features of testing equipment for pressure platforms to be used for gait analysis in Clinics (i.e. Medical PMDs) are, at minimum: pressure resolution below 10kPa; force resolution below 1N; spatial positioning re-positioning error lower than 2mm, and sinusoidal loading-unloading cycles applied with a frequency in the range 0.5-1.0Hz.
An example of in-factory testing equipment is widely described together with some suggested testing protocols in (Giacomozzi C, 2010 c): essentially it consists in a wide press machine for delivering pressure steps over the entire PMD surface, and a sensorized, ad hoc testing device which applies controlled static or varying pressure – through pneumatic valves and proper circuitry – as well as force over small active areas.
An example of testing equipment thought for on-site periodic checking is instead described and discussed in (Giacomozzi C, 2010 b). Basically, is consists in a light graduated round table placed on three small pylons, to be used with some weights and a positioning mask. When properly used, the testing device may help to periodically check the accuracy of COP estimation as well as local load and mean pressure under the pylons.
Specific for optical pedobarographs, instead, a very interesting testing equipment and methodology has been described in a 1997 paper with applications to the Sheffield optical pedobarograph (Franks CI, 1997).
4. Pressure measurement protocols and parameters
A wide variety of measurement protocols are currently implemented in the field of plantar pressure assessment, obviously according to the scenario and target of each investigation, e.g., the diagnosis of a pathologic condition, the outcome of a treatment, a patient’s monitoring, a footwear/orthosis design and testing, the assessment of a sports performance, a specific study of applied biomechanical research, the identification of reference normative data, and so on. Similarly, there are plenty of pressure-related parameters which are currently considered relevant, some of them directly measured by means of PMDs, some other successively derived or estimated, and, again, the selection of parameters does depend on the final goal of each study. However, there is the need for the identification of some standardisation guidelines -at least to define a few basic parameters and measurement protocols to be taken as reference quantities and reference procedures so as to guarantee the comparability among studies. Moreover, if innovative parameters or measuring conditions were to be compared with some reference parameters and protocols, a better and more correct comprehension would be guaranteed, of new approaches to plantar pressure investigation. The following paragraphs briefly discuss relevant points for both issues.
4.1. Parameters: Traditional and novel ones
With respect to the entire plantar surface of the foot and to the way it is loaded during walking or standing, the following parameters are mostly used and known by the majority of researchers, clinicians and operators in the field:
Peak pressure: For each sensor, it is the highest pressure value experienced during the measurement. It is usually expressed in kPa, even though it is sometimes reported as PSI, N/cm2, bar. Software applications associated to PMDs usually deliver a peak pressure map which contains the maximum pressure value reached by each sensor: this represents a spatial rather than a temporal map, since there is no association with the time frame each peak pressure occurres at. There is no confusion or misunderstanding on this parameter, the only doubt is associated with those devices which only deliver relative data rather than absolute values of pressure.
Mean pressure: For each sensor, it is the pressure value averaged over the measurement period. Measurement units are the same as for peak pressure. Two approaches may be followed to compute this parameter: averaging pressure over the entire measurement time period or only over the time period the specific sensor had been loaded, which may be much shorter than the entire duration of the test. Thus, in order to avoid interpretation mistakes, the computation algorithm should be clearly stated. Mean pressure output is usually delivered in the form of spatial maps.
Peak pressure curve (usually known as PPC): For the entire measurement surface, it represents the time process of the instantaneous maximum pressure value along the entire measurement period. In an x-y Cartesian graph, the horizontal axis x represents the time process expressed in absolute values (usually s or ms) or as percentage of the whole stance phase, while the y axis represents the instantaneous peak pressure expressed in absolute pressure units (kPa is recommended). Unlike the peak pressure map, this plot contains temporal information while it does not associate such information to the different areas of the plantar surface which instantaneously registers the highest pressure. PPC curve smoothing depends on PMD sampling rate and on eventual smoothing algorithms.
Force curve: Similarly to PPC, it represents the time evolution of the instantaneous value of the vertical component of the GRF. Absolute force values are expressed in N; for inter-subject comparisons, force is normalised to each subject’s body weight, and thus expressed as %N or %b.w. This parameter is especially relevant for assessment issues, since the curve can be directly compared with the corresponding curve obtained with a standard force platform.
Pressure-time integral or impulse (usually indicated as PTI): It represents the area under PPC. If peak pressure is expressed in kPa, PTI should be expressed as kPa*s. Great differences might be found in the final PTI value due to the specific computation algorithm and to the PMD sampling rate, which must therefore be clearly stated. Just to explain the concept, if PTI is calculated as the sum of the products of instantaneous pressure by sampling interval, the final value will be much more accurate when using higher sampling rates.
Force-time integral or impulse (usually indicated as FTI): Similarly to PTI, this parameter is obtained by calculating the area under the force curve and is usually expressed as N*s or %N*s. As for PTI, computation procedures should be clearly stated.
Contact area: It is the instantaneous value of loaded PMD area. It is usually expressed in cm2, and a curve similar to PPC is usually plotted to show contact area evolution along the measurement period. Differences in the estimated area are mainly due to PMD spatial resolution, sensor size and pressure threshold. Thus, proper information should be delivered together with this parameter.
COP trajectory: Represented by a two-dimensional array formed by the instantaneous COP coordinates, it is usually expressed in cm or PMD pixel units, for the whole measurement period. Again, differences may be found due to PMD spatial resolution, which must be clearly stated. A clear statement of the reference coordinate system used must be given too. In case of posturographic analyses, when parameters like COP sway or area or frequency content are of great interest, PMD sampling rate and frequency response may significantly affect the final COP values.
Besides the above parameters, other interesting indicators are used in specific pressure-related studies, as is for specific pressure gradients (Mueller MJ et al, 2008) or indicators related to COP velocity or acceleration (Wang Y, Watanabe K, 2008). Novel computational approaches have been tried, validated and used in recent publications dealing with neural networks (Betker AL et al, 2005), fuzzy logics (Senanayake CM, Senanayake SM, 2010 a), cluster analysis (Giacomozzi C., Martelli F, 2006), finite element models (Shiang TY, 1997; Petre M et al, 2008; Gu YD et al, 2010; Chen WM et al, 2010), image processing techniques (Pataky TC et al, 2009; Oliveira FP, Tavares JM, 2010) and so on. Usually, the inputs of such models are represented by the above traditional parameters, their reliability strongly relying on the quality and reliability of raw data. For all these interesting new approaches, proper background knowledge and details should be delivered to readers and potential users so that they may deeply understand the meaning, clinical relevance and applicability, limitations, potential, and proper field of application of each new pressure-related parameter.
Proposals for innovative parameters: pressure-integral map, actual mean pressure map, loading time map.
Pressure-integral map: the computation of PTI as the area under PPC is a useful parameter, but it is not able to discriminate those areas of the plantar surface which undergo higher, prolonged and more dangerous loading, i.e., it does not contain spatial information. Moreover, it is associated with an ideal sensor which is loaded with the instantaneous maximum pressure for the entire measurement period: being this almost impossible in dynamic measurement, the final PTI value almost always represents an overestimation even with respect to the most “stressed” region of the foot (conversely, PTI values represent a good estimation of the true local impulse in the case of a regional analysis, as will be described in the following paragraph). The proposed Pressure-integral maps should rather request the calculation of the ‘local’ PTI for each activated sensor. As for peak pressure maps, pressure-integral maps would contain temporal besides spatial loading information and might indeed have a high clinical relevance.
Actual mean pressure map: while most of the current PMD softwares deliver mean pressure maps which result from averaging pressure values over the whole measurement period, the actual mean pressure map should contain values averaged only over the time frame of each sensor activation. This may render the map more helpful in detecting those areas loaded for a limited amount of time, but with a potentially dangerous mean load.
Loading time map: this is again an attempt to add temporal to spatial information on load distribution. In this case, a previous agreement is needed on the definition of a certain number and duration of contact phases. As a suggestion, the conventional contact phases might be used, i.e. initial contact and loading response (initial 16% of stance), midstance (successive 32% of stance), propulsion (successive 33% of stance) and push-off (remaining 19% of stance) (Vaughan CL et al, 1999). If different colours are associated with the different phases, and with the persistence of loading across several phases, a specific colour – and a specific numeric value - may be associated to each activated sensor on a spatial-temporal map.
4.2. Regional parameters: potentialities of different methodological approaches
Regional analysis of plantar pressure maps and parameters is commonly used, and most of the more recent publications do implement procedures and algorithms to identify specific regions of the plantar surface of the foot. Great potential should be recognised to regional analysis, since it allows to focus on specific areas of interest and to better quantify local alterations of biomechanical parameters. This is particularly important when the effectiveness of a surgical or orthotic treatment has to be exactly quantified. However, what has been discussed in the previous paragraphs with respect to PMD variability of response, lack of standardisation and risk for misleading or missing comparisons, is here amplified, and even greater attention must be paid when designing, implementing and reporting plantar pressure investigations. The increased difficulties, in fact, are essentially due to the variability of the criteria for defining plantar regions, and to the percentual increased weight of computational errors related to smaller areas of interest. While the latter can only be minimised by better characterising PMD technical performance as already pointed out in previous paragraphs, it is interesting here to focus on the criticalities of the regionalisation procedures. Basically, two main approaches are currently followed to identify foot regions: one exploits the geometry of the footprint and the background knowledge of the anatomical structure of the foot; the other uses the information coming straight from the anatomy of the analysed foot.
Geometry-based approach: each and every selection method based on the acquired footprint does start from the longitudinal bisection of the footprint, which is usually computed from: i) the bisecting line of the foot; ii) the line going from the center of the heel to the second toe; iii) the midline of the rectangular box which contains the footprint. As a second step, the transversal selection of the main foot regions with respect to the longitudinal axis of the footprint is usually done by using lines which are perpendicular to it, and roughly located in correspondence with anatomical structures such as the Lisfranc or the Chopart line or the projection of the ankle joint axis, or structures that represent specific percentages of the footprint length. As a successive step in the regionalisation process, toes and individual metatarsal areas are identified on the basis of least square error algorithms, anatomically related assumptions, or other specific criteria. While, as already said, almost all 2010 published studies rely on regional analysis, none of them describe the way regions have been obtained. Sometimes, algorithms are known within a certain community, i.e. groups of researchers who are using the same commercial product. In any case, no procedure for footprint regionalisation has been “standardised” so far. Therefore, in order to avoid misleading conclusions it is mandatory that selection criteria are clearly described in the papers. With discrete sensors the regionalisation phase can be simplified, since they are indeed positioned under well-defined anatomical locations, thus variability in the final outcome of regional analysis will be mainly related to variability in sensor positioning.
Anatomy-based approach: this quite complex approach calls for the simultaneous use of a PMD and a kinematics measurement system to acquire instantaneous positions of foot anatomical landmarks, which are then projected onto the footprint and used for the anatomically-based region selection. This approach greatly improves the reliability of regional analysis in case footprints are not complete or strongly altered by the pathology. Dedicated algorithms must be designed and implemented to properly use the kinematic foot model, superimpose all the involved reference systems, and project the anatomical landmarks. Up to now, the anatomical masking approach has been applied to a prototype pressure platform and dedicated integration software by the Italian National Institute of Health together with a five-segment foot model by Istituti Ortopedici Rizzoli (Giacomozzi C et al, 2000; Stebbins JA et al, 2005), and to Novel platforms and dedicated integration software together with the Oxford Foot Model (Giacomozzi C et al, 2010). A further methodological study based on a Tekscan platform (Miller AL, 2010) only dealt with reference system integration issues.
4.3. Thoughts on protocols
Human walking and standing show intrinsic variability due to the high number of variables which play a role in the gait biomechanical model. In particular, the instantaneous pressure distribution obtained while interacting with the ground suffers from even greater variability due to fast local adjustments of the whole system while bearing and transferring load. The best approach to assess foot biomechanics through reliable and reproducible pressure measurements should therefore be based on the characterisation and control, as complete as possible, of measurement conditions. Here below a limited – certainly not exhaustive - list of concepts and suggestions is given, which should be taken into account to render investigations reliable and reproducible. Most concepts are equally applicable to both platforms and in-shoe systems when performing dynamic gait analysis; system-specific issues, and issues only related to posturographic analysis are identified separately.
Measurement environment: environment conditions should always be controlled and described in order to render measurements reproducible. Any change introduced in a “standard” measurement environment should be well characterised and described: it may have relevant impact on pressure measurements. Barefoot gait analysis focussed on level walking is usually performed in a laboratory environment with good control of light, noise, temperature and humidity; the platform is inserted flush in a comfortable walking pattern, parallel and integral to the ground (patients should not be aware of the exact position of the platform); the walkway is large and long enough to guarantee the performance of a certain number of “at-regimen” steps. Walkways usually consist of quite rigid surfaces; wherever soft carpets are used, even though they do not cover the platform, it must be clearly stated in the study. It may happen that thin portable pressure platforms are placed over soft carpets rather than directly on the floor: this unstable installation should always be avoided and, in any case, it surely entails some alteration in platform performance. When in-shoe systems are used, the measurement scenario may be more varied, and must definitely be described as for: i) the environment itself (a laboratory context, a room or a place into a clinic, outdoors, …); ii) the walkway (a level hard/soft surface, a slope, stairs, a treadmill, …).
Number and kind of steps: owing to gait variability, pressure parameters cannot be calculated over one step only; a certain number of steps are thus necessary to perform stable and reliable averages. A study published in 1996 showed that data averaged over 12 steps have quite an adequate standard deviation, which improved only slightly by increasing the number of steps (Macellari V, Giacomozzi C, 1996); however, this number of steps might be indeed too high to be obtained in a clinical context, especially with compromised patients. Five or six is the usual number of steps to obtain mean values of pressure quantities acquired through a platform; more steps are used in case of in-shoe systems, since they are acquired quite easily and the acquisition process is less time consuming. As for which step is to be included in the analysis, standardised approaches with pressure platforms commonly take into account the first, the second, or the third step: the three approaches may be valid, the choice mainly depending on the measurement environment and the main target of the investigation. With in-shoe systems, it is quite common to discard the initial and last steps and to average data over a fixed number of central steps (usually 5-10 steps for each foot).
Assessment tasks: according to the target of the investigation, patients or volunteers are asked to perform specific locomotor tasks (posturographic tasks are briefly discussed as the last point of this list). With the only reference to platform-based gait analysis during walking, some “requirements” of the measurement protocol are already worldwide agreed upon, i.e.: patients have to be tested barefoot, with arms moving freely along the body; they should become acquainted with the task before acquiring data; artefacts due to sudden noise, light or movements of people should be avoided; patients should look straight ahead, walk naturally and avoid looking at their feet; overtly altered trials must be discarded. As for walking speed, two main approaches are followed: i) the patient has to keep a fixed progression speed– usually with the help of a metronome -; ii) the patient walks at a self-selected speed. Changes in the measurement protocol should be clearly described, as is for example for purposely faster or slower walk, walk on treadmill, dual tasks such as cognitive, acoustic or visual tasks requested during walking. When an in-shoe system is used, changes from the above protocol are frequent: variation in progression speed, true and proper modification of the gait path – i.e. non straight paths, slopes, stairs, treadmill, etc.
Specific in-shoe system assessment requirements: one of the most challenging targets of PMD measurement standardisation is the identification of a reference measurement protocol to be used with in-shoe systems. As a point of fact, these systems are only used in conjunction with an interface between the foot and the floor – i.e. the footwear – which not only modifies and interferes with pressure measurement from a technical point of view, but significantly alters gait as well. For both reasons it is not possible to use barefoot measurement as a reference: rather, it would be useful to standardise the footwear to be used for reference measurements. This is usually done in individual studies, i.e., each research group identifies and uses the measurement conditions and the footwear which are considered the most suitable in terms of feasibility, reproducibility, patient’s wearing and equipment burden, allowed gait pattern. Most common in-shoe reference measurements are performed while wearing special socks (with no shoes on), sandals, or a well defined type of sports shoes.
Posturographic assessment: standard measurement protocols do exist even though they are usually implemented with force, rather than pressure, platforms. These protocols account for several aspects, i.e., foot position, patient’s position and behaviour, platform position and environment, task duration, etc. (Kapteyn TS et al, 1983). Any deviation from the standardised measurement conditions should thus be clearly described and motivated.
4.4. The role of pressure data processing
This issue is of special relevance in the field of plantar pressure measurements, being the third critical factor, together with PMD technical performance and measurement protocols, to be taken into account in the standardisation process. Several controversies are currently open in the scientific world as for the proper way to process pressure raw data. At the same time, the lack of relevant processing details in some PMD commercial softwares and in the scientific literature renders any description of the state of the art quite complex. The issue will be widely discussed in the i-FAB-PG in the next future, and the eventual agreement on standardised proposals will be shared with the scientific community. As for the discussion on the topic in the present document, the author is here only contributing with two very general, but basic, suggestions. The first is the strong recommendation to clearly describe each and every step of the data processing that takes from pressure raw data to derived parameters: this description is mandatory to render researchers aware of whether, and to what extent, some datasets may be compared with those extracted from their own studies. The second is a suggestion to a proper selection and use of statistical analysis: in fact, most investigations strongly rely on parametric statistics, i.e., data are usually reported and analysed in terms of mean values and standard deviations. It is not infrequent, however, that the number of samples used and/or of experiments conducted in the study is too small to guarantee the normal distribution of the measured quantities, as is mandatory for a correct use of parametric statistics. In some cases non-parametric statistics are more suitable to describe and interpret datasets, and to infer on the relevance of differences among populations or treatments.
5. Conclusions
Plantar pressure measurements do have a great potential to support the study of foot biomechanics both in a research context and in the clinic. The literature overview reported hereby, even though it only focusses on the 2010 peer-reviewed publications indexed in PubMed, clearly shows that PMD measurements are increasingly used – alone or in conjunction with other kinetic/kinematic parameters – to deeply investigate clinical outcomes of surgical interventions, rehabilitation treatments, preventive actions, disease evolution, as well as to implement new biomechanical models or validate novel methodological approaches. Even though PMDs have been used for several years now, criticalities are still present, which still prevent the complete exploitation of all their potentialities. In the sequence from the design and construction of a PMD to its use on the field, such criticalities may be identified as: i) lack of standardisation of the procedures to assess and compare PMDs technical performance; ii) lack of comparability of measurement protocols; iii) lack of standardisation of the definition and use of data processing procedures. The scientific community is currently demonstrating increasing interest in the above issues. With respect to the first one, attempts towards consensus agreement have already been started in 2010 and are currently implemented within international scientific communities; basic concepts and preliminary recommendations have been described and discussed in the present document. As for the second issue, a short overview of the main measurement parameters and protocols has been reported, along with some suggestions to parameters which might be relevant and meaningful especially in the clinic. The last issue is still at a preliminary discussion phase, and only two basic suggestions have been briefly given in the document, which mainly point to the importance of a clear description of processing procedures and to the proper identification of statistical analysis tools.
Fast advances in technology as well as in computational mechanics are already showing new promising scenarios for the investigation of foot biomechanics, where pressure measurements might become more reliable and suitable (as might be the case with more flexible, wearable textile sensors), and successfully integrated with local friction and shear measurements -at the foot-floor or the foot-insole interface-, reliable low-cost kinematics systems, and 3D dynamic FE models.
Acknowledgments
The Author gratefully acknowledges Ms. Monica Brocco for the English editing of the manuscript.
\n',keywords:null,chapterPDFUrl:"https://cdn.intechopen.com/pdfs/19660.pdf",chapterXML:"https://mts.intechopen.com/source/xml/19660.xml",downloadPdfUrl:"/chapter/pdf-download/19660",previewPdfUrl:"/chapter/pdf-preview/19660",totalDownloads:2820,totalViews:435,totalCrossrefCites:3,totalDimensionsCites:9,hasAltmetrics:1,dateSubmitted:"November 26th 2010",dateReviewed:"May 19th 2011",datePrePublished:null,datePublished:"September 9th 2011",readingETA:"0",abstract:null,reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/19660",risUrl:"/chapter/ris/19660",book:{slug:"biomechanics-in-applications"},signatures:"Claudia Giacomozzi",authors:[{id:"52138",title:"Dr.",name:"Claudia",middleName:null,surname:"Giacomozzi",fullName:"Claudia Giacomozzi",slug:"claudia-giacomozzi",email:"c_giacomozzi@yahoo.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Literature overview",level:"1"},{id:"sec_3",title:"3. Pressure measurement devices (PMDs): Technical and performance issues",level:"1"},{id:"sec_3_2",title:"3.1. Basic concepts on PMD sensor technology",level:"2"},{id:"sec_4_2",title:"3.2. Basic concepts on PMD technical assessment",level:"2"},{id:"sec_6",title:"4. Pressure measurement protocols and parameters",level:"1"},{id:"sec_6_2",title:"4.1. Parameters: Traditional and novel ones",level:"2"},{id:"sec_7_2",title:"4.2. Regional parameters: potentialities of different methodological approaches",level:"2"},{id:"sec_8_2",title:"4.3. Thoughts on protocols",level:"2"},{id:"sec_9_2",title:"4.4. The role of pressure data processing",level:"2"},{id:"sec_11",title:"5. Conclusions",level:"1"},{id:"sec_12",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",body:'Abu-FarajZ. O.AkarH. A.AssafE. H.Al-QadiriM. N.YoussefE. G.2010Evaluation of fall and fall recovery in a simulated seismic environment: A pilot study.Conf Proc IEEE Eng Med Biol Soc.\n\t\t\t\t\t139547'},{id:"B2",body:'AlibertiS.CostaM. S.PassaroA. C.ArnoneA. C.SaccoI. C.2010Medial contact and smaller plantar loads characterize individuals with Patellofemoral Pain Syndrome during stair descentPhys Ther Sport.\n\t\t\t\t\t111304'},{id:"B3",body:'Barberài.GuillemR.GómezSendra. F.BermejoBosch. I.GarcésPérez. L.2010Reducing the pressure on heel and foot-sole areas by means of Allevyn Gentle, Gentle Border and Gentle Border Heel dressings. Rev Enferm. 333516'},{id:"B4",body:'BattagliaG.BellafioreM.BiancoA.PaoliA.PalmaA.2010Effects of a dynamic balance training protocol on podalic support in older women. Pilot Study.Aging Clin Exp Res. 22(5-6):406 EOF11 EOF\n\t\t\t'},{id:"B5",body:'BayomyA. F.AubinP. M.SangeorzanB. J.LedouxW. R.2010Arthrodesis of the first metatarsophalangeal joint: a robotic cadaver study of the dorsiflexion angleJ Bone Joint Surg Am. 928175464'},{id:"B6",body:'BekN.KinikliG. I.CallaghanM. J.AtayO. A.2010Foot biomechanics and initial effects of infrapatellar strap on gait parameters in patients with unilateral patellofemoral pain syndromeFoot (Edinb). Dec 9. [Epub ahead of print]'},{id:"B7",body:'BetkerA. L.MoussaviZ. M.SzturmT.2005On modeling center of foot pressure distortion through a medium.IEEE Trans Biomed Eng. 52334552'},{id:"B8",body:'BoschK.RosenbaumD.2010Gait symmetry improves in childhood--a 4-year follow-up of foot loading data. Gait Posture.\n\t\t\t\t\t3244648'},{id:"B9",body:'BoschK.GerssJ.RosenbaumD.2010Development of healthy children’s feet--nine-year results of a longitudinal investigation of plantar loading patterns. Gait Posture.\n\t\t\t\t\t32456471'},{id:"B10",body:'BrazR. G.CarvalhoG. A.2010Relationship between quadriceps angle (Q) and plantar pressure distribution in football players.Rev Bras Fisioter.\n\t\t\t\t\t144296302'},{id:"B11",body:'ChenW. M.LeeT.LeeP. V.LeeJ. W.LeeS. J.2010Effects of internal stress concentrations in plantar soft-tissue-A preliminary three-dimensional finite element analysisMed Eng Phys.\n\t\t\t\t\t32432431'},{id:"B12",body:'ChesninK. J.Selby-SilversteinL.BesserM. P.2000Comparison of an in-shoe pressure measurement device to a force plate: concurrent validity of center of pressure measurements.Gait and Posture 12128133'},{id:"B13",body:'ChevalierT. L.HodginsH.ChockalingamN.2010Plantar pressure measurements using an in-shoe system and a pressure platform: a comparisonGait Posture.\n\t\t\t\t\t3133979'},{id:"B14",body:'CisnerosLde. L.FonsecaT. H.AbreuV. C.2010Inter- and intra-examiner reliability of footprint pattern analysis obtained from diabetics using the Harris mat.Rev Bras Fisioter.\n\t\t\t\t\t1432005'},{id:"B15",body:'CobbJ.ClaremontD. J.1995Transducers for foot pressure measurement: survey of recent developments.Med Biol Eng Comput. 33452532'},{id:"B16",body:'CramR. H.1953A sign of sciatic nerve foot pressure J Bone Joint Surg Br. 35B(2):192-5.'},{id:"B17",body:'D’AmicoM.D’AmicoG.PanicciaM.RoncolettaP.VallascianiM.2010An integrated procedure for spine and full skeleton multi-sensor biomechanical analysis & averaging in posture gait and cyclic movement tasks.Stud Health Technol Inform. 15811826'},{id:"B18",body:'DeleuP. A.LeemrijseT.VandeleeneB.MaldagueP.DevosBevernage. B.2010Plantar pressure relief using a forefoot offloading shoeFoot Ankle Surg.\n\t\t\t\t\t16417882'},{id:"B19",body:'doCarmoDos.ReisM.SoaresF. A.daRocha. A. F.CarvalhoJ. L.RodriguesS. S.2010Insole with pressure control and tissue neoformation induction systems for diabetic foot.Conf Proc IEEE Eng Med Biol Soc.\n\t\t\t\t\t1574851'},{id:"B20",body:'DuckworthT.BettsR. P.FranksC. I.BurkeJ.1982The measurement of pressures under the foot.Foot Ankle 3313041'},{id:"B21",body:'DuckworthT.BoultonA. J. M.BettsR. P.FranksC. I.WardJ. D.1985Plantar pressure measurements and the prevention of ulceration in the Diabetic foot.The Journal of Bone and Joint Surgery67B (1): 79-85.'},{id:"B22",body:'EllisS. J.YuJ. C.JohnsonA. H.ElliottA.O’MalleyM.DelandJ.2010Plantar pressures in patients with and without lateral foot pain after lateral column lengtheningJ Bone Joint Surg Am.\n\t\t\t\t\t9218191'},{id:"B23",body:'FariaA.GabrielR.AbrantesJ.BrásR.MoreiraH.2010The relationship of body mass index, age and triceps-surae musculotendinous stiffness with the foot arch structure of postmenopausal womenClin Biomech (Bristol, Avon).\n\t\t\t\t\t25658893'},{id:"B24",body:'FranksC. I.1997Calibration of optical foot pressure systems.Med. & Biol. Eng. & Comput. 356972'},{id:"B25",body:'GiacomozziC.2010Performance of plantar pressure measurement devices (PMDs): update on consensus activitiesAnn Ist Super Sanita.\n\t\t\t\t\t4643435a'},{id:"B26",body:'GiacomozziC.2010Hardware performance assessment recommendations and tools for baropodometric sensor systemsAnn Ist Super Sanita.\n\t\t\t\t\t46215867b'},{id:"B27",body:'GiacomozziC.2010Appropriateness of plantar pressure measurement devices: a comparative technical assessmentGait Posture.\n\t\t\t\t\t3211414c'},{id:"B28",body:'GiacomozziC.MartelliF.2006Peak Pressure Curve: an effective parameter for early detection of foot functional impairments in diabetic patientsGait & Posture23464470'},{id:"B29",body:'GiacomozziC.MacellariV.LeardiniA.BenedettiM. G.2000Integrated pressure-force-kinematics measuring system for the characterisation of plantar foot loading during locomotion.Med Biol Eng Comput. 38215663'},{id:"B30",body:'GiacomozziC.StebbinsJ.KalpenA.2010Footprint masks: reproducibility of the Oxford anatomically-based selection by means of novel geometrical masks. Procs of Scientific Meeting ESM2010, Providence, RI, USA, August 1417'},{id:"B31",body:'GirardO.EicherF.MicallefJ. P.MilletG.2010Plantar pressures in the tennis serveJ Sports Sci.\n\t\t\t\t\t28887380'},{id:"B32",body:'GoffarS. L.NaylorJ.ReberR. J.RodriguezB. M.ChristiansenB. C.WalkerM. J.MillerR. B.TeyhenD. S.2010Dynamic plantar pressure changes dUS Army Med Dep ring loaded gaitUS Army Med Dep J. Jul-Sep:77.'},{id:"B33",body:'GordonV.1976Treatment of the patient with calcaneal and plantar pressure ulcers of neurogenic etiology.J Am Osteopath Assoc. 7555256'},{id:"B34",body:'GuY.LiJ.RenX.LakeM. J.ZengY.2010Heel skin stiffness effect on the hind foot biomechanics during heel strikeSkin Res Technol.\n\t\t\t\t\t1632916'},{id:"B35",body:'HastingsM. K.GelberJ. R.IsaacE. J.BohnertK. L.StrubeM. J.SinacoreD. R.2010Foot progression angle and medial loading in individuals with diabetes mellitus, peripheral neuropathy, and a foot ulcerGait Posture.\n\t\t\t\t\t32223741'},{id:"B36",body:'HetsroniI.NyskaM.Ben-SiraD.MannG.SegalO.MaozG.AyalonM.2010Analysis of foot structure in athletes sustaining proximal fifth metatarsal stress fractureFoot Ankle Int.\n\t\t\t\t\t31320311'},{id:"B37",body:'HillsA. P.HennigE. M.Mc DonaldM.Bar-OrO.2001Plantar pressure differences between obese and non-obese adults: a biomechanical analysisInternational Journal of Obesity2516741679\n\t\t\t'},{id:"B38",body:'HirasakiE.HigurashiY.KumakuraH.2010Brief communication: Dynamic plantar pressure distribution during locomotion in Japanese macaques (Macaca fuscata)Am J Phys Anthropol.\n\t\t\t\t\t142114956'},{id:"B39",body:'HirataR. P.Arendt-NielsenL.Graven-NielsenT.2010Experimental calf muscle pain attenuates the postural stability during quiet stance and perturbationClin Biomech (Bristol, Avon).\n\t\t\t\t\t2599317'},{id:"B40",body:'HirschmüllerA.KonstantinidisL.BaurH.MüllerS.MehlhornA.KontermannJ.GrosseU.SüdkampN. P.HelwigP.2010Do changes in dynamic plantar pressure distribution, strength capacity and postural control after intra-articular calcaneal fracture correlate with clinical and radiological outcome?InjuryNov 12. [Epub ahead of print]'},{id:"B41",body:'HongY.WangL.LiJ. X.ZhouJ. H.2010Changes in running mechanics using conventional shoelace versus elastic shoe cover.J Sports Sci. Dec 2017Epub ahead of print]'},{id:"B42",body:'HyslopE.WoodburnJ.Mc InnesI. B.SempleR.NewcombeL.HendryG.RaffertyD.De MitsS.TurnerD. E.2010A reliability study of biomechanical foot function in psoriatic arthritis based on a novel multi-segmented foot modelGait Posture.\n\t\t\t\t\t32461926'},{id:"B43",body:'JeansK. A.KarolL. A.2010Plantar pressures following Ponseti and French physiotherapy methods for clubfootJ Pediatr Orthop.\n\t\t\t\t\t301829'},{id:"B44",body:'KaipelM.KrapfD.WyssC.2010Metatarsal Length does not Correlate with Maximal Peak Pressure and Maximal ForceClin Orthop Relat Res. Oct 13. [Epub ahead of print]'},{id:"B45",body:'KapteynT. S.BlesW.NjiokiktjienC. J.KoddeL.MassenC. H.MolJ. M. F.1983Standardization in Platform Stabilometry being a Part of Posturography.Agressologie 24, 7: 321 EOF6 EOF'},{id:"B46",body:'Karadag-SaygiE.Unlu-OzkanF.BasgulA.2010Plantar pressure and foot pain in the last trimester of pregnancyFoot Ankle Int.\n\t\t\t\t\t3121537'},{id:"B47",body:'KeijsersN. L.StolwijkN. M.PatakyT. C.2010Linear dependence of peak, mean, and pressure-time integral values in plantar pressure images. Gait Posture. 3111402'},{id:"B48",body:'KendellC.LemaireE. D.DudekN. L.KofmanJ.2010Indicators of dynamic stability in transtibial prosthesis usersGait Posture.\n\t\t\t\t\t3133759'},{id:"B49",body:'KellyL. A.RacinaisS.TannerC. M.GranthamJ.ChalabiH.2010Augmented low dye taping changes muscle activation patterns and plantar pressure during treadmill runningJ Orthop Sports Phys Ther.\n\t\t\t\t\t401064855'},{id:"B50",body:'LeeK. M.ChungC. Y.ParkM. S.LeeS. H.ChoJ. H.ChoiI. H.2010Reliability and validity of radiographic measurements in hindfoot varus and valgusJ Bone Joint Surg Am.\n\t\t\t\t\t9213231927'},{id:"B51",body:'LidtkeR. H.MuehlemanC.KwasnyM.BlockJ. A.2010Foot center of pressure and medial knee osteoarthritisJ Am Podiatr Med Assoc.\n\t\t\t\t\t100317884'},{id:"B52",body:'LordM.1981Foot pressure measurement: a review of methodology.J Biomed Eng 391'},{id:"B53",body:'MacellariV.GiacomozziC.1996Multistep pressure platform as a standalone system for gait assessment. Med & Biol. Eng. & Comput., 34 (4), 299304'},{id:"B54",body:'MackeyR. B.ThomsonA. B.KwonO.MuellerM. J.JohnsonJ. E.2010The modified oblique keller capsular interpositional arthroplasty for hallux rigidusJ Bone Joint Surg Am.\n\t\t\t\t\t9210193846'},{id:"B55",body:'Martínez-NovaA.Sánchez-RodríguezR.Pérez-SorianoP.Llana-BellochS.Leal-MuroA.Pedrera-ZamoranoJ. D.2010Plantar pressures determinants in mild Hallux ValgusGait Posture.\n\t\t\t\t\t3234257'},{id:"B56",body:'Martínez-NovaA.Sánchez-RodríguezR.Leal-MuroA.Sánchez-BarradoE.Pedrera-ZamoranoJ. D.2008Percutaneous distal soft tissue release-akin procedure, clinical and podobarometric assessment with the BioFoot in-shoe system: a preliminary report.Foot Ankle Spec. 1422230'},{id:"B57",body:'MenzH. B.MunteanuS. E.ZammitG. V.LandorfK. B.2010Foot structure and function in older people with radiographic osteoarthritis of the medial midfootOsteoarthritis Cartilage.\n\t\t\t\t\t18331722'},{id:"B58",body:'MickleK. J.MunroB. J.LordS. R.MenzH. B.SteeleJ. R.2010Foot pain, plantar pressures, and falls in older people: a prospective study.J Am Geriatr Soc.\n\t\t\t\t\t5810193640'},{id:"B59",body:'MillerA. L.2010A new method for synchronization of motion capture and plantar pressure dataGait Posture.\n\t\t\t\t\t32227981'},{id:"B60",body:'MonteiroM. A.GabrielR. C.SousaM. F.CastroM. N.MoreiraM. H.2010Temporal parameters of the foot roll-over during walking: influence of obesity and sarcopenic obesity on postmenopausal womenMaturitas67217885a'},{id:"B61",body:'MonteiroM. A.GabrielR. E.Nevese.CastroM.SousaM. F.AbrantesJ. M.MoreiraM. H.2010Exercise effects in plantar pressure of postmenopausal womenMenopause175101725b'},{id:"B62",body:'MonteiroM.GabrielR.AranhaJ.Nevese.CastroM.SousaM.MoreiraM.2010Influence of obesity and sarcopenic obesity on plantar pressure of postmenopausal womenClin Biomech (Bristol, Avon). 2554617c'},{id:"B63",body:'MorrisonK. E.HudsonD. J.DavisI. S.RichardsJ. G.RoyerT. D.DierksT. A.KaminskiT. W.2010Plantar pressure during running in subjects with chronic ankle instabilityFoot Ankle Int.\n\t\t\t\t\t31119941000'},{id:"B64",body:'MuellerM. J.ZouD.BohnertK. L.TuttleL. J.SinacoreD. R.2008Plantar stresses on the neuropathic foot during barefoot walkingPhys Ther. 8811137584'},{id:"B65",body:'NajafiB.CrewsR. T.ArmstrongD. G.RogersL. C.AminianK.WrobelJ.2010Can we predict outcome of surgical reconstruction of Charcot neuroarthropathy by dynamic plantar pressure assessment?--A proof of concept study. Gait Posture.\n\t\t\t\t\t3118792'},{id:"B66",body:'NataliA. N.ForestieroA.CarnielE. L.PavanP. G.DalZovo. C.2010Investigation of foot plantar pressure: experimental and numerical analysisMed Biol Eng Comput.\n\t\t\t\t\t4812116774'},{id:"B67",body:'NavarroL. A.GarciaD. O.VillavicencioE. A.TorresM. A.NakamuraO. K.HuamaniR.YabarL. F.2010Opto-electronic system for detection of flat foot by using estimation techniques: Study and approach of design.Conf Proc IEEE Eng Med Biol Soc.\n\t\t\t\t\t1576871'},{id:"B68",body:'(No authors listed)2010Monitoring of Posture Allocations and Activities by a Shoe-Based Wearable Sensor. IEEE Trans Biomed Eng. Apr 15. [Epub ahead of print]'},{id:"B69",body:'NordsidenL.Van LunenB. L.WalkerM. L.CortesN.PasqualeM.OnateJ. A.2010The effect of 3 foot pads on plantar pressure of pes planus foot typeJ Sport Rehabil.\n\t\t\t\t\t1917185'},{id:"B70",body:'OliveiraF. P.TavaresJ. M.2010Novel framework for registration of pedobarographic image dataMed Biol Eng Comput. Nov 3. [Epub ahead of print]'},{id:"B71",body:'OrlinM. N.Mc PoilT. G.2000Plantar pressure assessment.Phys Ther. 80399409'},{id:"B72",body:'PatakyT. C.KeijsersN. L.GoulermasJ. Y.CromptonR. H.2009Nonlinear spatial warping for between-subjects pedobarographic image registrationGait Posture. 29347782'},{id:"B73",body:'PatakyZ.de LeónRodriguez. D.AlletL.GolayA.AssalM.AssalJ. P.HauertC. A.2010Biofeedback for foot offloading in diabetic patients with peripheral neuropathyDiabet Med. 271614'},{id:"B74",body:'PauM.CoronaF.LebanB.PauM.2010Effects of backpack carriage on foot-ground relationship in children during upright stanceGait Posture. Nov 25. [Epub ahead of print]'},{id:"B75",body:'PaukJ.DaunoravicieneK.IhnatouskiM.GriskeviciusJ.RasoJ. V.2010Analysis of the plantar pressure distribution in children with foot deformitiesActa Bioeng Biomech.\n\t\t\t\t\t1212934'},{id:"B76",body:'PetreM.ErdemirA.CavanaghP. R.2008An MRI-compatible foot-loading device for assessment of internal tissue deformationJ Biomech. 4124704'},{id:"B77",body:'PuttiA. B.ArnoldG. P.AbboudR. J.2010Differences in foot pressures between Caucasians and IndiansFoot Ankle Surg.\n\t\t\t\t\t1641958a'},{id:"B78",body:'PuttiA. B.ArnoldG. P.AbboudR. J.2010Foot pressure differences in men and womenFoot Ankle Surg.\n\t\t\t\t\t161214b'},{id:"B79",body:'QueenR. M.AbbeyA. N.WiegerinckJ. I.YoderJ. C.NunleyJ. A.2010Effect of shoe type on plantar pressure: a gender comparisonGait Posture.\n\t\t\t\t\t3111822'},{id:"B80",body:'RamanathanA. K.HerdF.MacnicolM.AbboudR. J.2009A new scoring system for the evaluation of clubfoot: the IMAR-ClubFoot scaleFoot (Edinb). 19315660'},{id:"B81",body:'RamanathanA. K.KiranP.ArnoldG. P.WangW.AbboudR. J.2010Repeatability of the Pedar-X in-shoe pressure measuring system.Foot Ankle Surg.\n\t\t\t\t\t162703'},{id:"B82",body:'RaoS.SaltzmanC. L.YackH. J.2010Relationships between segmental foot mobility and plantar loading in individuals with and without diabetes and neuropathyGait Posture. 3122515'},{id:"B83",body:'RibeiroA. P.Trombini-SouzaF.TessuttiV. D.LimaF. R.JoãoS. M.SaccoI. C.2010The effects of plantar fasciitis and pain on plantar pressure distribution of recreational runnersClin Biomech (Bristol, Avon). Sep 13. [Epub ahead of print]'},{id:"B84",body:'RouhaniH.CrevoisierX.FavreJ.AminianK.2010Outcome evaluation of ankle osteoarthritis treatments: Plantar pressure analysis during relatively long-distance walkingClin Biomech (Bristol, Avon). Dec 16. [Epub ahead of print] a'},{id:"B85",body:'RouhaniH.FavreJ.CrevoisierX.AminianK.2010Ambulatory assessment of 3D ground reaction force using plantar pressure distributionGait Posture.\n\t\t\t\t\t3233116b'},{id:"B86",body:'SchepersT.KieboomB.van DiggeleP.PatkaP.Van LieshoutE. M.2010Pedobarographic analysis and quality of life after Lisfranc fracture dislocationFoot Ankle Int.\n\t\t\t\t\t311085764'},{id:"B87",body:'SchuhR.AdamsS.HofstaetterS. G.KrismerM.TrnkaH. J.2010Plantar loading after Chevron osteotomy combined with postoperative physical therapyFoot Ankle Int.\n\t\t\t\t\t31119806a'},{id:"B88",body:'SeeC. K.AcharyaU. R.ZhuK.LimT. C.YuW. W.SubramaniamT.LawC.2010Automated identification of diabetes type-2 subjects with and without neuropathy using eigenvaluesProc Inst Mech Eng H. 22414352'},{id:"B89",body:'SenanayakeC. M.SenanayakeS. M.2010A computational method for reliable gait event detection and abnormality detection for feedback in rehabilitation.Comput Methods Biomech Biomed Engin. Sep 30:1. [Epub ahead of print] a'},{id:"B90",body:'SenanayakeC. M.SenanayakeS. M.2010Computational intelligent gait-phase detection system to identify pathological gaitIEEE Trans Inf Technol Biomed.\n\t\t\t\t\t14511739b'},{id:"B91",body:'SchuhR.TrnkaH. J.SaboA.ReichelM.KristenK. H.2010Biomechanics of postoperative shoes: plantar pressure distribution, wearing characteristics and design criteria: a preliminary studyArch Orthop Trauma Surg. Jun 12. [Epub ahead of print] b'},{id:"B92",body:'ShiangT. Y.1997The nonlinear finite element analysis and plantar pressure measurement for various shoe soles in heel region.Proc Natl Sci Counc Repub China B. 21416874'},{id:"B93",body:'ShuL.HuaT.WangY.QiaoLi. Q.FengD. D.TaoX.2010In-shoe plantar pressure measurement and analysis system based on fabric pressure sensing arrayIEEE Trans Inf Technol Biomed.\n\t\t\t\t\t14376775'},{id:"B94",body:'StebbinsJ. A.HarringtonM. E.GiacomozziC.ThompsonN.ZavatskyA.TheologisT. N.2005Assessment of sub-division of plantar pressure measurement in children.Gait Posture 2243726'},{id:"B95",body:'StögglT.HaudumA.BirklbauerJ.MurrerM.MüllerE.2010Short and long term adaptation of variability during walking using unstable (Mbt) shoesClin Biomech (Bristol, Avon).\n\t\t\t\t\t25881622'},{id:"B96",body:'StolwijkN. M.DuysensJ.LouwerensJ. W.KeijsersN. L.2010Plantar pressure changes after long-distance walkingMed Sci Sports Exerc.\n\t\t\t\t\t4212226472'},{id:"B97",body:'TessuttiV.Trombini-SouzaF.RibeiroA. P.NunesA. L.SaccoI. C.2010In-shoe plantar pressure distribution during running on natural grass and asphalt in recreational runnersJ Sci Med Sport.\n\t\t\t\t\t1311515'},{id:"B98",body:'TeyhenD. S.StoltenbergB. E.EckardT. G.DoyleP. M.BolandD. M.FeldtmannJ. J.Mc PoilT. G.Christie IiiD. S.MolloyJ. M.GoffarS. L.2010Static Foot Pressure Associated With Dynamic Plantar Pressure ParametersJ Orthop Sports Phys Ther. Oct 22. [Epub ahead of print]'},{id:"B99",body:'TongJ. W.NgE. Y.2010Preliminary investigation on the reduction of plantar loading pressure with different insole materials (SRP--Slow Recovery Poron, P--Poron, PPF--Poron +Plastazote, firm and PPS--Poron+Plastazote, soft). Foot (Edinb).\n\t\t\t\t\t20116'},{id:"B100",body:'TuraA.RaggiM.RocchiL.CuttiA. G.ChiariL.2010Gait symmetry and regularity in transfemoral amputees assessed by trunk accelerationsJ Neuroeng Rehabil. 19;7:4.'},{id:"B101",body:'VaughanC. L.DavisC. L.O’ConnorJ. C.1999Dynamics of human gaitnd Edition. Kiboho Publishers, Cape Town, South Africa. 0-62023-558-6'},{id:"B102",body:'VuillermeN.BoisgontierM.2010Changes in the relative contribution of each leg to the control of quiet two-legged stance following unilateral plantar-flexor muscles fatigueEur J Appl Physiol.\n\t\t\t\t\t110120713'},{id:"B103",body:'WagenmannB.SchuhR.TrnkaH. J.2010Functional Outcome of Cheilectomy for the Treatment of Hallux RigidusZ Orthop Unfall. Mar 8. [Epub ahead of print]'},{id:"B104",body:'WangC. H.LiF.ZhangR.ShiY. Z.2010Application study of gait analysis on different syndrome types based on musculature zones of the knee osteoarthritis Zhongguo Zhen Jiu.\n\t\t\t\t\t3031837'},{id:"B105",body:'WangY.WatanabeK.2008The relationship between obstacle height and center of pressure velocity during obstacle crossing. Gait Posture 2711725'},{id:"B106",body:'YalçinN.EsenE.KanatliU.YetkinH.2010Evaluation of the medial longitudinal arch: a comparison between the dynamic plantar pressure measurement system and radiographic analysis. Acta Orthop Traumatol Turc.\n\t\t\t\t\t4432415'},{id:"B107",body:'YavuzM.DavisB. L.2010Plantar shear stress distribution in athletic individuals with frictional foot blisters. J Am Podiatr Med Assoc. 100211620'},{id:"B108",body:'YavuzM.HusniE.BotekG.DavisB. L.2010Plantar shear stress distribution in patients with rheumatoid arthritis: relevance to foot pain. J Am Podiatr Med Assoc.\n\t\t\t\t\t10042659'},{id:"B109",body:'YoonH. K.ParkK. B.RohJ. Y.ParkH. W.ChiH. J.KimH. W.2010Extraarticular subtalar arthrodesis for pes planovalgus: an interim result of 50 feet in patients with spastic diplegia. Clin Orthop Surg.\n\t\t\t\t\t211321'},{id:"B110",body:'ZammitG. V.MenzH. B.MunteanuS. 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1. Introduction
This chapter presents a discussion pertaining to psychosocial care for women during pregnancy. Pregnancy as a developmental phase involves both physiological and psychological adaptations that are acceptable to a certain extent, but if excessive, may lead to pathological changes. Psychosocial stressors experienced during pregnancy encompass life experiences that include changes in personal life, job status, family makeup, housing and the possibility of domestic violence [1]. While risks cannot be totally eliminated once pregnancy is established, they can be reduced through effective, accessible and affordable maternity health care. Numerous studies reveal significant depressive symptoms in pregnant women that are associated with sociodemographic and economic status and that depression during pregnancy may negatively influence psychosocial adjustment [2, 3]. Research findings also recommend an integrated approach to antenatal care that focuses on both the physiological and psychosocial dimensions.
2. Antenatal care as a process
Antenatal care has been described as one of the effective forms of preventative care. It involves screening symptomatic and asymptomatic pregnant women, with the aim of detecting and thereby preventing both maternal and neonatal adverse events. The introduction of antenatal care in 1910 in the Royal Adelaide Hospital in Australia has played an important role in preventing high maternal and perinatal mortality rates. Antenatal care should ideally be geared towards the promotion of health and the prevention of physical and psychosocial problems [16].
The psychopathology of pregnancy needs to be understood in terms of the adjustment that all women have to make when they conceive, as pregnancy is also an adaptive process. A pregnant woman should carry the baby safely through to delivery and adjust to the sacrifices that motherhood demands. The challenges that face her, include the acceptance of the pregnancy by the family; development of an attachment to the baby and preparation for birth; and adjustment to the changes in her physical appearance, and to development and maintenance of a positive relationship with the father of the baby. Many women respond to this complex process with grief and anger, especially when the pregnancy is unplanned and unaccepted. Unmanaged grief or anger might ultimately lead to maternal depression [17].
Pregnancy can be enhanced through a coordinated antenatal care programme, which includes both medical and psychosocial care. As such, pregnant women’s mental health should be a primary concern for all midwives due to a reported high prevalence of depressive and anxiety disorders in women. Hollander and Langer [18, 19] reported a 21% incidence of depression and 34% anxiety disorders in women, which may be exacerbated by pregnancy. Pregnancy-specific anxiety may occur as the woman worries about her pregnancy, physical changes and delivery.
Antenatal preparation should be offered to all women during pregnancy as a national policy. Screening during pregnancy is crucial, with the aim of detecting and preventing both maternal and neonatal adverse events and instituting early intervention. During screening, midwives should actively listen to the concerns and needs of pregnant women to be able to assess them comprehensively.
The findings of a cross-cultural survey by Namagembe [20] on the extent of physical and emotional abuse on African American, White American and Hispanic women during pregnancy indicated that one in four women gave a history of battering and physical abuse. The implication for this was that many women’s community subsystems of safety and physical environment are not in harmony and that battering and physical abuse during pregnancy might lead to a significant delay in obtaining antenatal care by 6.5 weeks as compared to non-abused women.
During childbirth, women may look upon their midwives as their advocates despite the existing medically inclined maternity care context. The challenge faced by midwives is the provision of comprehensive and holistic maternity care. This challenge can be achieved through the maintenance of a woman-centred, individualised and caring approach, which needs a caring and responsive midwife. Midwifery care should involve the physical, emotional, social, spiritual and psychological elements for it to be regarded as comprehensive [14].
3. The importance of psychosocial care during pregnancy
Psychosocial morbidity is not given enough recognition, it is not thought to be self-limiting as it is the care that is attributed to normal emotionality of pregnancy, and it is less frequently identified, especially if there is no continuity of care by the same midwife or clinician. Pereira et al. [4] reported that antenatal depression affects 4–16% of women, domestic violence during pregnancy rates at 16% and postnatal depression affects 15–20% of postpartum women.
Historically and contemporarily [4], much of what constitutes antenatal care throughout the world remains strongly rooted in the medical model within which it developed. Widespread, institutionalised routine antenatal care began around 80 years ago, focusing on mass screening with the aim of reducing maternal and perinatal morbidity and mortality under medical supervision [5] What is of concern within the context of antenatal care are the beliefs and assumptions that continue to underpin the structure and content of antenatal care.
Traditionally, antenatal care consists of a prescribed set of acts with a focus on the clinical physiological monitoring and screening of pregnant women. This approach was based on the notion by Oakley (1984) that pregnancy is a state of pathology rather than a normal physiological and developmental stage [5]. As further stated by Chitra and Gnanadurai [1], “antenatal care is usually offered in a form of routine physical assessment and care with limited or no psychosocial assessment and care”.
Inadequate psychosocial risk assessment may lead to lack of psychosocial support afforded to the pregnant women. Pregnant women who lack psychosocial support may experience stress during their pregnancy and childbirth. These changes may increase the woman’s vulnerability to depression, which may in turn have adverse effects on both maternal and foetal well-being [6]. Unrelieved stress can also increase vulnerability to physical and emotional problems, for example, insomnia, fatigue, development of ulcers and heart problems [7].
Supportive care during childbirth may have long-term positive effects and may protect some women from a long-lasting negative birth experience. The latter was found in a longitudinal cohort study on “why some women change their opinions about childbirth over time” [8]. Mixed feelings were elicited from women regarding their attitude towards childbirth, changing from positive to less-positive opinions based on, for instance, dissatisfaction with intra-partum care and lack of support for psychosocial problems such as single marital status or the presence of depressive symptoms. Changing from negative to less-negative feelings was associated with less worry about birth in early pregnancy and a more positive experience of support by the midwife.
According to O’Keane and Marsh [9], psychosocial support not only lowers prematurity and low birth weight rates but also inspires healthier behaviours and lifestyle among pregnant women and discourages behaviours like smoking, substance abuse and poor nutritional intake, which can have other detrimental effects on the mother and baby. Psychosocial support calls for a multi-level approach, consisting of strengthening partners and families and enhancing system capacity by ensuring the availability of resources. Interventions need to bolster the support provided within the woman’s existing social network in order to maintain the woman’s cultural beliefs and values.
Dodd et al. [10] tested a hypothesis on the relationship between psychosocial stress, social support, self-efficacy and circulating pro- and anti-inflammatory cytokines in women throughout pregnancy. Pregnant women within the study completed the Denver Maternal Health Assessment. The conclusion was that high social support was associated with low stress scores. Elevated stress scores positively correlated with higher levels of pro-inflammatory cytokine interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α).
A longitudinal community-based study conducted by Gelder et al. [11] through the use of the Edinburgh Postnatal Depression Scale (EPDS) revealed that women who lacked social support showed more symptoms of depressed mood. The maternal depressive mood had a negative impact on breastfeeding, the experiences of motherhood and the relationship with partners.
Appropriate psychosocial assessment is important for designing relevant intervention strategies and for public health policy formulation [12]. Ethically, psychosocial risk assessment should be linked to a plan of care through the provision of appropriate psychosocial support. The plan of care should ensure that the maternal referral arrangements are in place at the participating facilities. The plan of care should be coordinated with all appropriate disciplines.
Irrespective of how maternity care providers perceive antenatal care, the important issue to be taken into consideration is the woman. From a psychosocial point of view, for midwives using a midwifery model, antenatal care is a time of building a relationship with each woman and her family. It is a time when a partnership is developed and negotiated; expectations, roles and responsibilities are identified; options are discussed and choices are made by women and supported by midwives.
While not neglecting physical safety, antenatal care should be emotionally, socially, culturally and religiously acceptable to the woman. Physical care alone is not sufficient for the woman, as her needs and expectations are unique. The effectiveness of antenatal care as a central focus is still being discussed by midwives, obstetricians, medical anthropologists, sociologists and women’s organisations. Handley [13] cited Oakley (1984) in her book “Captured Womb” and wrote extensively on pregnancy, antenatal care and childbirth. She argues the importance of antenatal care but also believes that antenatal care is something that is done in an attempt to control the behaviour of women’s bodies, an intervention offered to women that does not benefit all women, but probably a few who do not know what to expect from an antenatal care service.
Purdy (2001) as cited by Woodward [14] defines medicalisation as the process that transpires when health practitioners treat natural bodily functions as if they were diseased. Purdy further stated that it is essential that conventional medicine re-evaluates its health care model towards the needs of patients and not its own.
Conventional medicine must also accept other health care practices such as midwifery-led maternity care as a valid source of healthcare, especially to address psychosocial risk factors. Women’s health problems, including pregnancy, should cease to be medicalised.
Parry [15] in a study exploring whether Canadian women’s choice of midwifery care identifies a resistance to the medicalisation of pregnancy and childbirth came to the conclusion that women have a desire for personal control of their pregnancy as reflected in this comment:
“I just wanted to be in control of what was going on with my body, It scares me that they will push you when you are in your most vulnerable state, because it is more convenient for their schedule”. Participants further related how midwifery care met their needs for control over their bodies, their pregnancies and their experiences with childbirth, notwithstanding a sentiment that medical interventions also have a place in pregnancy and childbirth.
An ideal option for effective antenatal care is the incorporation of psychosocial care as a component of antenatal care, acknowledging the women’s own experiences of pregnancy [2]. Midwifery, which means “to be with women”, is based upon a philosophy of care in which the management of pregnancy is shared between the midwife and the woman, with a focus on informed choice, shared responsibility, mutual decision making and women articulating their health needs.
4. Maternal risks during pregnancy
According to Baldo [7], maternal risk is defined as the probability of experiencing various levels of injuries or even dying as a result of pregnancy or childbirth. Physiological and psychosocial risk screening should therefore be conducted during the first and subsequent visits of antenatal care as part of a comprehensive assessment during antenatal care.
The opinions of Handwerker (1994), Lupton (1999) and Saxell (2000) as cited by Refs. [1, 21] were that risk assessment during childbirth is made more complex by the differences in the perceptions of risks between midwives and pregnant women, as risk from a midwife’s perspective is based on her specialised knowledge and training, epidemiology, personal values and experience, whereas a woman’s understanding of risk is far more contextual, individualised and embedded in her social environment and everyday life experience.
Historically, the definition of maternal risk emphasises mainly medical factors and includes few psychological and socioeconomic factors. To add to this, the interest of midwives seems to be directed towards foetal well-being and the newborn child, ignoring the psychosocial needs of the mother. Furthermore, when a woman reports for delivery, her family member’s concern is mostly on the well-being of the newborn rather than on the maternal well-being.
Psychosocial factors are an important area to assess during pregnancy. Various studies, for example, those of [12, 22, 23, 24] demonstrate that stress, depression, alcohol abuse and lack of social support during pregnancy are commonly associated with low birth weight and perinatal morbidity and mortality. Furthermore, in this era of HIV/AIDS, psychosocial problems are common among affected populations. These issues may have an indirect influence by affecting antenatal care attendance, the woman’s coping capacity and the physiology of pregnancy.
Most of the risk assessment systems in midwifery care focuses on physical characteristics such as age, parity and education; however, these assessment systems are not exclusively suggestive of a risk for maternal morbidity and mortality as they mostly exclude psychosocial factors. A review of several studies by Hamid et al. [25] on the perceptions of antenatal care by women suggests that there are several psychosocial risk factors that need to be taken into consideration in order to ensure a safe pregnancy and delivery. Psychosocial interventions have proved to be beneficial in providing comprehensive antenatal care.
Furthermore, a systematic review of 16 studies on antenatal screening for postnatal depression by Hamid et al. [25], which involved 23,000 participants, revealed that the proportion of women who are at risk for postnatal depression was between 10 and 67%. The authors further commented that the preliminary evidence suggested that the introduction of screening tools to aid early detection and diagnosis of depression has helped to raise awareness among health care providers regarding social and psychological maternal risk factors.
5. Possible psychosocial risk factors during pregnancy
Psychosocial risks are described as the demands or challenges that are psychological or social in origin, having the potential to directly or indirectly alter homeostasis during pregnancy and childbirth [21]. They relate to a combination of the affective states and cognitive factors of anxiety, depression, self-esteem mastery and perceived stress as measured by the scale of Gunn et al. [30].
According to Glazier et al. [28], a psychosocial problem may occur in response to an exposure to a stressful life event, for example, unemployment. The psychosocial response will, however, be determined by the effect it has on an individual, for example, loss of self-esteem and feelings of worthlessness.
Fawole et al. [29] have identified the following as some of the psychosocial risk factors that a woman may have experienced or may experience during pregnancy: woman battering; family violence or intimate partner abuse; sexual abuse and harassment; discrimination; gender inequality; past history of depressive disorders; absent/abusive or non-supportive spouse; marital difficulties; pregnancy occurring below 18 years of age, which antedates social development; unintended, unplanned or unwanted pregnancy; maternal or paternal unemployment; adverse life events, for example, loss of spouse; socio-economic factors, for example, poverty; barriers to accessing health care services, for example, distance travelled and transport unavailability; medical disorders, for example, hypertension and HIV/AIDS and poor quality of interaction with health care providers that may lead to non-compliance to planned interventions and defaulting treatment.
6. The impact of pregnancy on maternal well-being
6.1. The physiological effect of pregnancy
Pregnancy may have an enormous psychological and physiological effect on a woman’s body and mind. This is due to suppression of the hypothalamic-pituitary-adrenal axis, which leads to dramatic changes in oestrogen and progesterone levels. Changes in these hormone levels may alter a pregnant woman’s coping mechanisms. The physical discomfort of pregnancy, accompanied by anticipation of childbirth and the responsibility of parenthood, often causes anxiety and emotional changes [27].
6.2. Stress alters physiology
There is a growing body of data suggesting that psychosocial factors such as high stress and low social support negatively affect the success of pregnancy. The findings of a survey by Shamim ul Moula [26] to address relationships between psychosocial variables and serum inflammatory markers during pregnancy support the notion that prenatal stress alters maternal physiology and immune function in a manner that is consistent with an increased risk of pregnancy complications such as preterm delivery and pregnancy-induced hypertension. The conclusion based on the findings of the above survey was a need for the development of strategies for supporting maternal mental health.
6.3. The impact of psychosocial stress on maternal and foetal well-being
It is clear that birth and infant development are affected by prenatal events that could lead to maternal stress. Maternal psychosocial stress has been recently identified as a factor in early foetal development. There is growing evidence that perinatal psychological and environmental stressors are detrimental to pregnancy success and infant outcomes. Stress is often defined as events, situations, emotions and interactions that are perceived as negatively affecting the well-being of an individual or that cause responses that are perceived as harmful [10].
A direct relationship is said to exist between maternal psychological stress and low birth weight, prematurity and intra-uterine growth retention. This is related to the release of catecholamines that results in placental hypo-perfusion and consequent restriction of oxygen and inhibition of nutrients to the foetus, leading to foetal growth impairment [27].
6.4. The relationship between antenatal depression and postnatal depression
There is considerable evidence that postnatal depression is a public health care challenge as it can become chronic, can damage the relationship between the woman and her partner and might have adverse consequences for the emotional and cognitive development of the newborn. Regular assessment of mood during pregnancy should be routine for all women to establish the risk for depression, as postnatal depression can recur. Antenatal mood assessment is one of the most robust predictors of postnatal depression, as 50% of postnatal depression is reported to have begun during pregnancy [27].
There is evidence from research that women with antenatal psychosocial risk factors are more likely to have a postnatal mood disorder, and as such, antenatal assessment can be beneficial for these women. The early identification and management of psychosocial risk factors have been shown to be beneficial in various studies. For example, in the study by Ref. [29], regarding the review of existing tools that are used to assess psychosocial morbidity in pregnant women, and a study by Gunn et al. [30] on anxiety and depression during pregnancy, outcomes were improved by minimising the occurrence of postpartum depression.
Recommendations from a survey by Namagembe [20] were that a search for battering and abuse should be carried out during the antenatal assessment of pregnant women and midwives should have knowledge of the appropriate interventions and be familiar with the resources for referral. The increased cost and complications that may arise as a result of any delays should be a concern for maternal-child health professionals. Routine antenatal and postnatal screening for psychosocial distress has been supported by investigators as a preventive measure for postnatal depression [28].
7. Psychosocial assessment
Psychosocial assessment is defined by Chitra and Gnanadurai [1] as an evaluation of an individual’s mental health, social status and functional capacity. The individual’s physical status, appearance and modes of behaviour are observed for factors that may indicate or contribute to emotional distress or mental illness. Observation includes posture, facial expressions, manner of dress, speech and thought patterns, degree of motor activity and level of consciousness. The individual is questioned concerning patterns of daily living, including work schedule and social and leisure activities. Data should include the individual’s response to and methods of coping with stress, relationships, cultural orientation, unemployment or change of employment, change of residence, marriage, divorce or death of a loved one [30].
The above-listed risk factors can directly or indirectly affect the outcome of pregnancy in a negative way [7]. A meta-analysis of perinatal depression identified depression as a major complication of pregnancy affecting 14.5% of pregnant women [19].
8. Psychosocial care as a missing piece of the antenatal care puzzle
Traditionally and in many contemporary contexts, including in South Africa, antenatal care consists of a prescribed set of acts based around the clinical monitoring and screening of all pregnant women. This establishment of routine care was based on the notion that pregnancy is a state of pathology rather than normal physiology. There is evidence of a focus on technological dominance and a focus on the detection of obstetric and medical conditions occurring during pregnancy. This is based on a review of seven guidelines for antenatal care from the USA, Canada, Australia and Germany and mostly reflects expert opinion rather than scientific evidence [21].
For example, antenatal care in South Africa is provided at the primary, secondary and tertiary levels of care in both the public and private health care systems. Basic antenatal care services include physical examination, weight measurement, urinalysis, blood pressure monitoring, blood investigations and health information and are supposedly provided at all levels of antenatal care as routine practice.
The ongoing debate on antenatal care regarding its frequency, content, continuity, quality and effectiveness in reducing maternal and neonatal morbidity and mortality led to a new evidence-based protocol on the frequency of antenatal care. This is the result of randomised trials carried out in the United Kingdom and Zimbabwe and of the World Health Organisation trials in Thailand, Argentina, Cuba and Saudi Arabia during 1996 [31].
The new schedule, as recommended by WHO [30], consists of four visits during pregnancy, the first one being early in pregnancy, with subsequent visits at 26, 32 and 36 weeks. This schedule is designed for the pregnant woman at low risk. These fewer antenatal visits led to poorer psychosocial outcomes and drew attention to greater maternal satisfaction with the routine care that was previously provided. The question is whether there would be an opportunity for the midwives to address psychosocial care within this regime.
Baldo [7] in a review of the antenatal care debate quoted Mcllwaine (1980) highlighting that he was amazed that pregnant women came for antenatal care and waited in the clinic for 2 hours, only to be seen for 2 minutes by someone laying his or her hands on them, and then leave. The reason for this is the traditional focus on the biophysiology of pregnancy. The author recommended that antenatal care appointments should be structured, focused and advocated for longer first appointments to allow comprehensive assessment in order to address both physiological and psychosocial risk factors.
The Changing Childbirth report explicitly confirmed that women should be the focus of antenatal care to enable a woman to make informed decisions based on her needs, having discussed her matters with the midwife involved. Key aspects of care valued by women are reported to be respect, competence, communication, support and convenience [32].
The above are supported by the researcher’s findings from a phenomenological study on the expectations of antenatal care by pregnant women. Most women were happy with the physical health care but were dissatisfied with interpersonal aspects, for example, involvement, guidance and communication from the health care providers [33].
As a midwifery lecturer, the researcher often accompanied students for clinical facilitation. On guiding students on psychosocial care of women in the antenatal care clinic, women frequently verbalised social and emotional concerns. The researcher’s further experience is that if psychosocial assessment is indeed conducted on a pregnant woman, it usually elicits the woman’s current active and significant psychosocial challenges.
The following are common remarks that were expressed by women during their antenatal visits while the researcher was engaged in student accompaniment.
A woman carrying her first pregnancy at age 25, gravida 1 para 0, from one of Gauteng’s provincial hospital’s antenatal clinic remarked:
“No one ever asked me this. Why don’t everyone do like this? I think I am lucky today, I had so much to ask or discuss previously but there was just no one to listen to me. I moved from a black hospital to a one for whites thinking things will be better but it’s the same. We come here, they quickly check the baby, and within 30 minutes you are gone with so much to share, as if the baby is the only one important”. She then asked for the lecturer’s and the student’s contact numbers for further consultation.
A pregnant woman, 42 years old, was asked if the pregnancy was planned at this vulnerable age as her first child was 20 years old. Her response was that she had lost a husband 5 years ago and had recently remarried. She was coping but her challenge was that the first child was rejecting both the new husband and the pregnancy. This was a reflection of another need for psychosocial support that could have been achieved through a proper psychosocial assessment by a midwife and appropriate referral offered.
9. Why should psychosocial risks be screened during antenatal care?
The concept of psychosocial stressors during pregnancy encompasses life experiences, including among others, changes in personal life, job status, family makeup, housing and domestic violence [1]. All these require adaptive coping mechanisms on the part of the pregnant woman, which can be achieved through the support of the midwife.
Risk screening, according to Refs. [1, 7], involves using a list of risk factors and some form of scoring system to classify pregnant women into specific risk categories, typically high risk or low risk, using cutoff points or thresholds. The focus of risk screening is to detect early symptoms and to predict the likelihood of complications. The intention of risk assessment is to predict problems before they occur and, as such, take appropriate action by providing optimal maternal care.
Bibring (1959) as cited by Stahl and Hundley [16] was among the first psychoanalytic writers to claim that “pregnancy is a psychobiological crisis affecting all expectant mothers, no matter what their state of psychic health is. As [with] every normal crisis that constitutes a turning point in life, it precipitates an acute disequilibrium…may lead to a new level of psychological maturity and integration. The outcome of this crisis might have a profound effect not only on the woman herself but also on the mother-child relationship”.
A cross-sectional study to identify a relationship between life stress, perceived social support and symptoms of depression and anxiety was conducted by Waldenstrom [34]. Based on her findings, it was recommended that psychosocial assessment of pregnant women and their partners may facilitate interventions to augment support networks and as such reduce the risk of psychosocial stress.
The New Antenatal Care Model proposed by WHO [35] recommends a set of activities during each visit for those women who are identified to be at low risk by screening for conditions likely to increase adverse outcomes of pregnancy, providing therapeutic intervention known to be beneficial and educating women about safe birth. However, the model does not emphasise psychosocial issues but proposes that some time should be set aside during each visit to discuss the pregnancy and related issues. Emphasis was put on the importance of communication.
As a measure to promote psychosocial risk assessment, a new approach to psychosocial risk assessment during pregnancy (ANEW) was implemented in Australia during 2000, in a form of a project to provide an alternative way to psychological risk screening in pregnancy. A training programme in advanced communication skills and common psychosocial aspects of childbirth was offered to midwives and doctors at the Mercy Hospital for women, with the aim of improving the identification and support of women with psychosocial needs in pregnancy [36]. The outcome of the programme was that it improved the ability of the health care professionals to identify and care for women with psychosocial needs.
A randomised controlled trial examining the effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial risk factors in pregnant women revealed that 72.7% of the women in the ALPHA group showed interest in discussing psychosocial issues The experimental group was twice as likely to declare psychosocial problems as the control group (based on odds ratio 1.8, 95% confidence interval and 1.1–3.0, ρ = 0.02).
Two-thirds of health care providers in the ALPHA group found the form easy to use, and 86% said they would use it if it were recommended as standard practice. The conclusion of the trial showed that the assessment of psychosocial well-being during antenatal care was acceptable to both women and health care professionals [4, 31] in a project on antenatal psychosocial risk assessment in Australia, stating that antenatal depression, domestic violence and postnatal depression occurred more frequently than gestational diabetes, placenta praevia, pre-eclampsia and other obstetric and medical conditions, but most midwifery care settings still do not routinely screen for psychosocial problems.
As stated in Ref. [5] and other literature, for example, Hall (2001) as cited in Ref. [5], the procedures that are commonly undertaken to monitor pregnancy are aimed at reducing morbidity and mortality, but have been found to often cause physical, social and emotional harm. The physiological care that is routinely offered during antenatal care clearly illustrates that the scope of antenatal care is primarily derived from a medical perspective. The implication is that routine antenatal care fails to meet reasonable expectations and the needs of women.
Midwives are urged to overcome the perception in literature and media that health care providers are unkind, rude, unsympathetic and uncaring, as negative emotions such as anger may arise when a woman receives insensitive care. Delwo [37] concluded her study of Swedish women’s satisfaction with medical and emotional aspects of antenatal care by urging midwives working in antenatal care to support pregnant women and their partners in a professional and friendly way in order to increase their satisfaction with care. They also advised that identifying and responding to women who are dissatisfied with their antenatal care could help to improve their satisfaction.
10. A study on psychosocial risk assessment and support during pregnancy conducted in Gauteng Province, South Africa
The aim of this study was to develop guidelines for the enhancement of psychosocial risk assessment of pregnant women, with a focus on the provision of psychosocial support.
It was hoped that the results of the study would provide evidence that could motivate interventions aimed at closing the gap between the routine assessment of physiological risks factors and the assessment of psychosocial risk factors during antenatal care. This would provide a basis for midwives to implement an appropriate action should any psychosocial risk be identified. Once formally tested, such guidelines could be incorporated into national guidelines for best practice.
10.1. Ethical considerations
Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee, protocol number M081013. Participation was voluntary. Anonymity and confidentiality were maintained throughout the research process. The ethical principles of autonomy, beneficence, non-maleficence and justice were observed accordingly.
10.2. Research context and methods
A mixed-method research was used for this study. A sequential explanatory design was employed, whereby quantitative data were first collected and analysed, followed by qualitative data collection and analysis in two consecutive phases [38]. The investigation was conducted within the following contexts:
10.3. Sampling and data collection
Sampling was purposive for all data sources, which were midwifery education and training regulations from the South African Nursing Council; midwifery education and training records of the three nursing colleges providing basic nurse education in Gauteng Province in South Africa; records of antenatal care for women attending government antenatal facilities in Gauteng Province were reviewed to establish the inclusion of psychosocial care; the administration of questionnaires to pregnant women attending antenatal care in Gauteng Province clinics; focus group discussions with both midwives and pregnant women at the antenatal care clinics; a survey to establish the extent of psychosocial assessment and psychosocial care by midwives during pregnancy, through a self-administered questionnaire; and in-depth interviews conducted with midwifery experts from various settings at which midwifery was offered, for example, universities, nursing colleges and midwifery obstetric units (MOUs).
10.4. Data analysis
10.4.1. Quantitative data analysis
Quantitative data were analysed using Stata Release 10 statistical software. Data analysis generally included summary statistics (mean, standard deviation for continuous variables, frequencies and percentages for discrete variables) and Cronbach’s alpha for internal consistency. Confidence intervals of 95% were used to report for discrete variable.
10.4.2. Qualitative data analysis
Qualitative data analysis occurred concurrently with data collection. To enhance the depth of qualitative analysis, multiple approaches to data analysis were used (e.g., constant comparison, thematic analysis and framework analysis) comparing themes and categories as a form of across-case analysis technique [38]. The stages that were involved in reducing data were examining, categorising and tabulating data [39].
Data analysis was systematic, sequential, verifiable and continuous in order to minimise potential bias. A “Framework Analysis” was mostly used in qualitative data analysis.
10.5. An overview of study findings and discussion
10.5.1. Quantitative results
The findings confirmed that women experience stressful life events during pregnancy as illustrated in Table 1.
Pregnancy stressful life events
Women’s responses n (%)
Yes
No
1.1. Have you experienced death of a spouse or family member?
82(27)
218(73)
1.2. Have you gone through a divorce or marital separation?
26(9)
274(91)
1.3. Were you retrenched or fired from work?
37(12)
264(88)
1.4. Have you been a victim of rape or sexual assault?
15(5)
286(95)
1.5. Have you ever experienced any pregnancy loss?
60(20)
242(80)
2. Was the pregnancy planned?
140(46)
162(54)
3. Have you been sick during this pregnancy?
141(47)
160(53)
If yes, what was the illness?
Note response to the questions below
4. Have you ever attempted suicide?
15(5)
285(95)
5. Have you ever been diagnosed with a mental health condition?
14(5)
286(95)
6. Have you been hospitalised for a mental health problem?
16(5)
284(95)
7. Did you attend any mental health counselling session?
27(9)
274(91)
Table 1.
Stressful life events experienced by respondents during the current.
The response from 300 participants was that 184 (61.3%) were experiencing stressful life events during the current pregnancy, whereas 116 (38.6%) did not experience any stressful life events. Among those who experienced stressful life events, 72 (24%) experienced two events and 44 (14%) experienced three or more stressful life events. This provides evidence of the importance of assessing women psychosocially as almost all women present with psychosocial problems.
The SANC Regulations, the curriculum and learning guides display a broad approach to psychosocial care as the focus is on holistic care. Written tests, examinations and clinical tools implemented at the colleges address psychosocial care to a minimal level. The Gauteng antenatal care guideline policy, the Guidelines for Maternity Care in South Africa (2015) and the midwifery competency register do not reflect psychosocial content in their guidelines or psychosocial criteria to be met during antenatal care. The antenatal card does not reflect guidelines on psychosocial care, as midwives recorded what they perceived as relevant to be assessed psychosocially.
10.5.2. Qualitative findings
The findings from the focus group discussions within this study also indicated that psychosocial assessment and care were important during pregnancy. The respondents further highlighted the importance of an appropriate guideline and a record for psychosocial assessment and care as reflected within the following responses:
Respondent 1:“If you look now the state of affairs of our antenatal card it just says social…(emphasizing), and you can ask anything… there is nowhere psychosocial issues are recorded”.
Respondent 2:“Yes, something like TICK, TICK, will help maybe something like a checklist to ask relevant questions, with a checklist I think we would be made aware of the things that we normally don’t ask”.
“Yes, (All participants) the checklist will remind us to go deeper, you know beyond the surface, to go deeper than the care that we normally give because it’s useless to pretend as if everything is fine whereas the patient has a big problem that can lead to complications, but once we have something that will guide us to ask something, even if you don’t ask all the questions, but you know maybe you can highlight, and maybe you pick up something, that will be very helpful”.
Respondent 3:“There must be a tool because on the green card is just a small line, where we ask for example, it is not written clear, just says “social”… therefore if there was a guideline regarding what should be done it will be appropriate for the pregnant women”.
The concern about the need for training and support for midwives and other health professionals undertaking care to pregnant women [40] led to the development of a psychosocial risk assessment tool that was also based on the findings of the study. Furthermore, there are few studies worldwide reporting the development, evaluation and implementation of screening tools for psychosocial risk factors in pregnant women and subsequent intervention and prevention programs [45]. The assessment tool developed from the findings of this study is currently being piloted in 21 Community Health Centers in Gauteng Province as a 3-year project (2017–2019). The aim of the pilot study is to evaluate the tool, modify it and incorporate it as part of routine antenatal care. The long-term plan is to have a policy developed that integrates psychosocial risk assessment and support with routine physical care.
Based on the increasing international move to standardise as routine the psychosocial assessment and depression screening of all pregnant women and offer relevant support [40, 41, 42], different options need to be considered in order to enhance psychosocial care. Some of the interventions that are applied in certain countries globally are reflected in Table 2.
Type of intervention
Description
Group antenatal care (Centering Pregnancy, USA)
Consist of a group facilitated by the clinician that lasts approximately 90–120 minutes. This allows a discussion of a wide range of pregnancy-related issues that include psychosocial issues [43].
Hawaiian-style “Talkstory”
The talk-story is integrated into the woman’s antenatal and postnatal assessment and care and involves an exchange of thoughts between the woman and midwife. It is based on the woman’s values, beliefs and experiences, acknowledging custom and culture.
A psychosocial risk assessment model (PRAM) Australia
Offers a conceptual framework, measures and methods suitable for a brief psychosocial assessment of pregnant and postpartum women [44].
ALPHA tool (Canada)
35 items used to detect 15 risk factors for postnatal adverse psychosocial outcomes [31].
KINDEX (University of Konstanz, Germany)
Assess 11 risk arears during pregnancy, the presence of psychosocial factors and the experience of adversities by women [45]. Has been applied in European countries.
Antenatal risk questionnaire (ANQR)
Composed of 12 items retrieved from the original 23 pregnancy risks [46].
Table 2.
Interventions to enhance psychosocial care.
10.6. Group antenatal care
Based on the shortage of midwives or clinicians reported in this and other studies, and coupled with a limitation in psychosocial care, group antenatal care might be another option.
Group antenatal care originated a decade ago in Minnesota, USA, during the early 1970s. It was introduced in Denmark in 1998, followed by Sweden in 2000. It is offered concurrently with traditional antenatal care. Antenatal visits are carried out in groups of 6–8. There is evidence that this approach increases networking between pregnant women, women are able to validate and sort information within the group and it also allows a midwife to devote more time to pregnant women by saving about 3 hours per woman [47]. Groups may address common psychosocial problems, and those who need further individual consultation can be offered the same, which will probably not be often, with routine individualised care.
The Schindler-Rising model of “centering pregnancy”, one of the recommended models for antenatal care, is presented in Figure 1.
Figure 1.
“Centering pregnancy”.
A “centering pregnancy” model is an innovative model for prenatal care. It focuses on “woman-centred care” by integrating antenatal care, health information and group support. It acknowledges a woman as an expert regarding her needs. The approach is practised, for example, in Canada, where women are involved in their basic assessment by weighing one another, checking one’s own urine sample, and intragroup checking of blood pressure. Each woman also records results in her own antenatal card [47].
Although the “centering pregnancy” model might free midwives or clinicians from routine investigations and as such allow them more time to address issues like psychosocial care, it carries a limitation in a sense that women should be literate, and the process should still be supervised by a midwife or a clinician until women are familiar with all aspects.
10.7. The Hawaiian-style “talkstory”
A Hawaiian-style “talkstory” originated from a needs-assessment project undertaken in Hawaii during 2000, where women indicated that their psychosocial needs were largely unmet.
A Hawaiian-style “talkstory” could offer an ideal approach in offering culturally focused antenatal care as it is a culturally based interactive communication approach, aimed at addressing the pregnant woman’s psychosocial needs. It could be mostly effective during the initial antenatal care booking as the woman is taking the lead in sharing her childbirth experiences. Figure 2 explains the talkstory process as a guideline for midwives who might be interested in its implementation.
Figure 2.
The “talkstory” process.
10.8. The success of the “talkstory” approach
The “talkstory” approach, as illustrated in Figure 3, served as an ideal way of assessing women psychosocially. It offers an opportunity to provide the woman with relevant health information and to validate myths or misconceptions about childbirth that the woman might be having, while also addressing her expectations. This is a type of psychosocial assessment and care that is women-centred, through placing an emphasis on a woman’s own beliefs, offering her autonomy and a right to informed choice [48].
Figure 3.
Outcomes achieved through the “talkstory process”.
A “talkstory” is an ideal approach during the initial contact of the woman and the midwife or a clinician, and as such it might promote communication between the two; it needs some time and requires a midwife or clinician who is skilled in listening and who has an ability to convey compassion, acceptance and encouragement to the woman. This approach might be a challenge in institutions experiencing the shortage of staff.
The implementation of psychosocial care incorporates adherence to the following principles: human rights and equality, justice and confidentiality. Measures to be put in place as part of psychosocial support are availability of referral resources (social, mental, economic and judicial); the assessor should be well informed about the options of referral and to consider the possibility of the accompaniment of the woman throughout the process as a form of continuity of care and as stated by the United Nations Entity for Gender Equality and the Empowerment of Women.
11. Conclusion
The issue of psychosocial risk assessment and support seems to be a concern both nationally and internationally. The process of adapting to pregnancy and the resulting life changes are often difficult, even if the pregnancy is planned as pregnancy involves intense emotional, spiritual, psychological and social factors that need a midwife’s caring awareness and responsiveness. A pregnant woman should be assisted to recognise and incorporate these changes into her self-image, her social network and her lifestyle. When the pregnancy is unplanned, the psychosocial changes may be more profound and lead to uncertainty, anxiety and depression [19].
There is a growing need for understanding the place and significance of maternal psychology and other psychosocial factors in the management of pregnant women by midwives or clinicians. Strategies for supporting maternal and foetal mental health need to be developed, as the importance of a good-quality pregnancy extends beyond antenatal care. Psychosocial risk assessment during pregnancy is further considered as the first strategy to support maternal well-being as this will allow the pregnant woman to cope with her pregnancy [26].
In theory, risk assessment is a logical tool for rationalising service delivery to ensure that those in greater need receive special attention and care. However, it is becoming increasingly clear that with incorrect and inadequate psychosocial risk assessment, scarce resources may be diverted away from pregnant women who are in real need. However, in the absence of evidence of an effective risk screening process, risk assessment cannot be relied on as a basis for matching needs and care in maternity services [7]. Ideally, psychosocial risk assessment should be included within the overall risk assessment or could be administered as a separate tool in the form of a checklist.
\n',keywords:"antenatal care screening, pregnancy, psychosocial care, psychosocial support, women",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/63345.pdf",chapterXML:"https://mts.intechopen.com/source/xml/63345.xml",downloadPdfUrl:"/chapter/pdf-download/63345",previewPdfUrl:"/chapter/pdf-preview/63345",totalDownloads:501,totalViews:1059,totalCrossrefCites:0,dateSubmitted:"February 1st 2018",dateReviewed:"July 19th 2018",datePrePublished:"November 5th 2018",datePublished:"February 8th 2019",readingETA:"0",abstract:"The rationale of any national screening programme is to recognise the benefits for public health, to assess a predominantly healthy population including pregnant women and to detect risk factors for morbidity in order to provide timely care interventions. The focus of antenatal care screening is to identify wider determinants of health that may have an impact on a pregnant woman’s well-being that includes the physical, psychological, social and religious factors. Psychosocial risks, among others, include poor socioeconomic conditions such as poverty, lack of social support, general health inequalities, domestic violence and a history of either personal or familial mental illness, all of which have the capacity to influence a pregnant woman’s decision to utilise health care services. This chapter highlights the antenatal care process, the importance of psychosocial care during pregnancy, maternal risks during pregnancy, the impact of pregnancy on maternal well-being, the possible psychosocial risk factors during pregnancy, psychosocial assessment, psychosocial care as a missing piece of the antenatal care puzzle, the presentation of the results of a study on psychosocial risk assessment and support and further outlining various antenatal care approaches that could be adopted to offer pregnant women holistic care.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/63345",risUrl:"/chapter/ris/63345",signatures:"Johanna Mmabojalwa Mathibe-Neke and Seipati Suzan\nMasitenyane",book:{id:"7259",title:"Selected Topics in Midwifery Care",subtitle:null,fullTitle:"Selected Topics in Midwifery Care",slug:"selected-topics-in-midwifery-care",publishedDate:"February 8th 2019",bookSignature:"Ana Polona Mivšek",coverURL:"https://cdn.intechopen.com/books/images_new/7259.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"85109",title:"Dr.",name:"Ana Polona",middleName:null,surname:"Mivšek",slug:"ana-polona-mivsek",fullName:"Ana Polona Mivšek"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"243661",title:"Prof.",name:"Johanna",middleName:null,surname:"Mathibe-Neke",fullName:"Johanna Mathibe-Neke",slug:"johanna-mathibe-neke",email:"mathijm@unisa.ac.za",position:null,institution:null},{id:"255954",title:"Mrs.",name:"Suzan",middleName:null,surname:"Masitenyane",fullName:"Suzan Masitenyane",slug:"suzan-masitenyane",email:"seipatimasite@gmail.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Antenatal care as a process",level:"1"},{id:"sec_3",title:"3. The importance of psychosocial care during pregnancy",level:"1"},{id:"sec_4",title:"4. Maternal risks during pregnancy",level:"1"},{id:"sec_5",title:"5. Possible psychosocial risk factors during pregnancy",level:"1"},{id:"sec_6",title:"6. The impact of pregnancy on maternal well-being",level:"1"},{id:"sec_6_2",title:"6.1. The physiological effect of pregnancy",level:"2"},{id:"sec_7_2",title:"6.2. Stress alters physiology",level:"2"},{id:"sec_8_2",title:"6.3. The impact of psychosocial stress on maternal and foetal well-being",level:"2"},{id:"sec_9_2",title:"6.4. The relationship between antenatal depression and postnatal depression",level:"2"},{id:"sec_11",title:"7. Psychosocial assessment",level:"1"},{id:"sec_12",title:"8. Psychosocial care as a missing piece of the antenatal care puzzle",level:"1"},{id:"sec_13",title:"9. Why should psychosocial risks be screened during antenatal care?",level:"1"},{id:"sec_14",title:"10. A study on psychosocial risk assessment and support during pregnancy conducted in Gauteng Province, South Africa",level:"1"},{id:"sec_14_2",title:"10.1. Ethical considerations",level:"2"},{id:"sec_15_2",title:"10.2. Research context and methods",level:"2"},{id:"sec_16_2",title:"10.3. Sampling and data collection",level:"2"},{id:"sec_17_2",title:"10.4. Data analysis",level:"2"},{id:"sec_17_3",title:"10.4.1. Quantitative data analysis",level:"3"},{id:"sec_18_3",title:"10.4.2. Qualitative data analysis",level:"3"},{id:"sec_20_2",title:"10.5. An overview of study findings and discussion",level:"2"},{id:"sec_20_3",title:"Table 1.",level:"3"},{id:"sec_21_3",title:"Table 2.",level:"3"},{id:"sec_23_2",title:"10.6. Group antenatal care",level:"2"},{id:"sec_24_2",title:"10.7. The Hawaiian-style “talkstory”",level:"2"},{id:"sec_25_2",title:"10.8. The success of the “talkstory” approach",level:"2"},{id:"sec_27",title:"11. Conclusion",level:"1"}],chapterReferences:[{id:"B1",body:'Chitra L, Gnanadurai A. Psychosocial outcomes of pregnancy in women living with HIV in Coimbatore district of Tamil Nadu. Journal of Dental and Medical Sciences. 2015;14(1):120-125'},{id:"B2",body:'World Health Organisation. Safe Motherhood: Every Pregnancy Faces a risk. Geneva: Switzerland; 1998'},{id:"B3",body:'Kaaya SF, Mbwambo JK, Kilonzo GP, Van Den Borne H, Leshabari MT, Smith Fawzi MC, et al. Socio-economic and partner relationship factors associated with antenatal depressive morbidity among pregnant women in Dar es Salaam, Tanzania. Tanzania Journal of Health Research. 2010;12(1):1-15'},{id:"B4",body:'Pereira PK, Lovisi GM, Pilowsky DL, Lima LA, Legay LF. Depression during pregnancy: Prevalence and risk factors among women attending a public health clinic in Rio de Janeiro, Brazil. Cadernos de Saúde Pública. 2009;25(12):2725-2736'},{id:"B5",body:'Willinck L, Schubert R. Antenatal psychosocial risk assessment project. Australian College of Midwives Incorporated. 2000:7-12'},{id:"B6",body:'Clinical Guideline 2003. Antenatal Care Routine Care for the Healthy Pregnant Woman. London: National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Clinical Excellence: Royal College of Obstetricians and Gynecologists Press; 2003. pp. 26-40'},{id:"B7",body:'Baldo MH. The antenatal care debate. Review. Eastern Mediterranean Health Journal. 2001;7(6):1046-1055'},{id:"B8",body:'Mehdizadeh A, Roosta F, Chaichian S, Alaghehbandan R. Evaluation of the impact of birth preparation courses on the health of the mother and the newborn. American Journal of Perinatology. 2005;22(1):7-9'},{id:"B9",body:'O’Keane V, Marsh MS. Depression during pregnancy. British Medical Journal. 2007;334(7601):1003-1005'},{id:"B10",body:'Dodd JM, Robinson SJ, Crowther AC. Guiding antenatal care. The Medical Journal of Australia. 2002;176(6):253-254'},{id:"B11",body:'Gelder MG, Lo’pez-Ibor J, Anderson NC. New Oxford Textbook of Psychiatry. Vol. 2. Oxford: Oxford University Press; 2003. 2131 p'},{id:"B12",body:'Goodman JH. Womens’ mental health. Journal of Obstetric Gynecology and Neonatal Nursing. 2005;34:245 Medline'},{id:"B13",body:'Handley MC. Emotional responses to pregnancy based on geographical classification of residence. Online Journal of Rural Nursing and Health Care. 2006;6(2):7-1'},{id:"B14",body:'Woodward V. Caring for women: The potential contribution of formal theory to midwifery practice. Midwifery. 2000;16:68-75'},{id:"B15",body:'Parry DC. We wanted a birth experience, not a medical experience: Exploring Canadian women’s use of midwifery. Health Care for Women International. 2008;29(8):784-806'},{id:"B16",body:'Stahl K, Hundley V. Risk and risk assessment in pregnancy: Do we scare because we care? Midwifery. 2003;19(4):298-309'},{id:"B17",body:'Dejin-Karlsson E, Ostergon PO. Psychosocial factors, lifestyle and foetal growth: the added value of of both pre- and post-natal. The European Journal of Public Health. 2003;13(3):210-217'},{id:"B18",body:'Hollander D. Poor psychosocial support raises the odds of having an underweight infant. Guttmacher Digest: Family Planning Perspectives. 2000;32(3):1-3'},{id:"B19",body:'Langer A. Support During Pregnancy for Women at an Increased Risk of Low Birthweight Babies: RHL Commentary. The WHO Reproductive Library; Geneva: World Health Organisation; 2003. pp. 1-2'},{id:"B20",body:'Namagembe I. Prevalence of Stress, Depression, Alcohol Use, and Social Support among HIV Infected and Uninfected Pregnant Women in Uganda. Washington, DC: APHA Annual Meeting and Expo; 2007'},{id:"B21",body:'Coussons-Read ME, Okun ML, Nettles CD. Psychosocial stress increases inflammatory markers and alters cytokine production across pregnancy. Brain Behavior and Immunty. 2007;21(3):343-350'},{id:"B22",body:'Rondo PHC, Ferreira RF, Nogueira F, Lobert H, Artes R. Marternal psychological stress and distress as predictors of low birth weight, prematurity and intrauterine growth retardation. European Journal of Clinical Nutrition. 2002;57:266-272'},{id:"B23",body:'Raynor M, Sullivan A, Oates M. Why mothers die: A public health concern. British Journal of Midwifery. 2003;11(6):393-395'},{id:"B24",body:'Matthey S. Assessing for psychosocial morbidity in pregnant women. Canadian Medical Association Journal. 2005;173(3):267-269'},{id:"B25",body:'Hamid F, Asif A, Haider II. Study of anxiety and depression during pregnancy. Pakistan Journal of Medical Sciences. 2008;24(6):861-864'},{id:"B26",body:'Shamim ul Moula SM. Health care behaviour: Factors influencing health care behaviour of a person [PhD thesis]. Blog Archive. 2009. Available from: http://ealthcarebehaviorshamim.blogspot.com/2009/06/psychosocial-factors-related-t [Accessed: May 12, 2011]'},{id:"B27",body:'Smith MV, Brunetto WL, Yonkers KA. Identifying perinatal depression-sooner is better. Contemporary Obstetric and Gynecology. 2004;49:58'},{id:"B28",body:'Glazier RH, Elgar FJ, Goel V, Holzapfel S. Stress, social support and emotional distress in a community sample of pregnant women. Journal of Psychosomatic Obstetrics and Gynaecology. 2004;25(3-4):247-255'},{id:"B29",body:'Fawole AO, Okunlola MA, Adekunle AO. Client’s perceptions of the quality of antenatal care. Journal of the National Medical Association. 2008;100(9):1052-1057'},{id:"B30",body:'Gunn J, Hegarty K, Nagle C, Forster D, Brown S, Lumley J. Putting women-centered care into practice: A new approach to psychosocial risk assessment during pregnancy (ANEW). Birth. 2006;33(1):46-55'},{id:"B31",body:'Carroll JC, Reid AJ, Biringer A, Midmer D, Glazier RH, Wilson L, et al. Effectiveness of the antenatal psychosocial health assessment (ALPHA) form in detecting psychosocial concerns: Arandomised controlled trial. Canadian Medical Association Journal. 2005;73(3):253-259. DOI: 10.1503/cmaj.1040610'},{id:"B32",body:'Hildingsson I, Radestad I. Sweddish women’s satisfaction with medical and emotional aspects of antenatal care. Journal of Advanced Nursing. 2005;52(3):239-249'},{id:"B33",body:'Suppaseemanont W. Depression in pregnancy: Drug safety and nursing management. The American Journal of Maternal Child Nursing. 2006;31(1):10-15'},{id:"B34",body:'Waldenstrom U. Why do some women change their opinion about childbirth over time? Birth. 2004;31(2):102-107'},{id:"B35",body:'Feldman P. Social support during pregnancy can affect foetal growth and birthweight. Psychosomatic Medicine. Journal of the American Psychosomatic Society. 2000. Available from: http://www.cfah.org/hbns/newsrelease/social9-22-00.cfm [Accessed: Jul 7, 2007]'},{id:"B36",body:'Seimyr L, Edhborg M, Lundh W, Sjogren B. In the shadow of maternal depression mood: Experiences of parenthood during the first year after birth. Journal of Psychosomatic Obstetrics and Gynaecology. 2004;25(1):23-34'},{id:"B37",body:'Delwo K. Women’s Health Issues—Feminist Medicine. 2010. Available from: http://www.suite101.com/content/womens-health-issues---feminist-medicine-a320107'},{id:"B38",body:'Christensen LB, Johnson RB, Turner LA. Research Methods, Design, and Analysis. 12th ed. Edingburg Gate, England: Pearson Education limited; 2015. p. 542'},{id:"B39",body:'Rabiee F. Focus group interview and data analysis. Proceedings of the Nutrition Society. 2004;63:655-660'},{id:"B40",body:'Rollans M, Schmied V, Meade T. We just ask some questions… the process of antenatal psychosocialassessment by midwives. Midwifery. 2013;29:935-942'},{id:"B41",body:'Kalra H, Reilly N, Austin M. An evaluation of routine antenatal depression screening and psychosocial assessment in a regional private maternity setting in Australia. Journal of Obstetric and Gynaecology. 2018:1-14'},{id:"B42",body:'Castillo-Torralba M. Psychosocial and Psychological Interventions for Preventing Postpartum Depression: RHL Commentary. The WHO Reproductive Health Library, Geneva: World Health Organisation; 2008. pp. 1-5'},{id:"B43",body:'Novick G, Reid AE, Lewis J, Kershaw TS, Schindler Rising S, Ickovics JR. Group prenatal care: model fidelity and outcomes. American Journal of Obstetric and Gynecology. 2013;112:1-6'},{id:"B44",body:'Priest SR, Austin MP, Barnett BB, Buist A. A psychosocial risk assessment model (PRAM) for use with pregnant and postpartum women in primary care settings. Archives of Women’s Mental Health. 2008;11:307-317'},{id:"B45",body:'Spyridou A, Schauer M, Ruf-Leushner M. Obstetric care providers assessing psychosocial risk factors during pregnancy: Validation of a short screening tool—KINDEX Spanish Version. Child and Adolescent Psychiatry and Mental Health. 2014;8(30):1-15'},{id:"B46",body:'Austin M, Colton J, Priest S, Reilly N, Hadzi-Pavlovic D. The antenatal risk questionnaire (ANRQ): Acceptability and use for psychosocial risk assessment in the maternity setting. Women and Birth. 2013;26(1):17-25'},{id:"B47",body:'Wedin K, Molin J, Crang Svalenius EL. Group antenatal care: New pedagogic method for antenatal care—A pilot study. 2010'},{id:"B48",body:'Poat A, McElligott M, Fleming V. How midwives attitudes can affect the research process. British Journal of Midwifery. 2003;11(6):396-400'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Johanna Mmabojalwa Mathibe-Neke",address:"mathijm@unisa.ac.za",affiliation:'
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