What is known about this topic?
- Magnitude of antenatal psychosocial problem and its adverse outcome.
- Locally validated and standardized tools have already been available for antenatal psychosocial assessment.
- There is internal/external referral system in the health system study area.
What does this article add?
- Applied locally validated and standardized tool for antenatal psychosocial assessment and linkage of antenatal clinic with psychiatric outpatient department using available internal referral paper.
- Identified barriers and facilitators to achieve a compliance with evidence-based criteria regarding antenatal psychosocial assessment in low-income countries.
- Improved knowledge of best practice and outcomes pertinent to antenatal psychosocial assessment among care providers working in the antenatal clinic in the study area.
An umbrella review study indicates that the global burden of antenatal depression ranges from 15 to 65%.1 In the lower-income and middle-income countries, its pooled prevalence was 34.0 and 22.7%, respectively.2 Estimates from East Africa reveal that this figure reaches up to 20%,3,4 whereas in Ethiopia it ranges from 23 to 36%.4,5 These studies also depict that antenatal depression increases over the three trimesters. However, even if its prevalence is very high and dangerous for the well-being of a pregnant woman and to the future child, it is the most neglected aspect of obstetric medicine especially in low-income countries. In developing countries, including Ethiopia, antenatal care focuses entirely on the traditional way of detecting medical or obstetrical problems. Thus, a high-risk pregnancy was traditionally defined as it would get complicated by a serious medical condition that may jeopardize its outcome.6 This care has been deemed effective in improving the physical health of the mother and her child in recent decades but it is not as such effective when compared with the huge resource invested in it.
Among the problems that most women face during pregnancy, depression and significant depressive symptoms result in adverse physical and psychological consequences for both the mother and the child.7 A meta-analysis study showed that untreated maternal depression is linked to higher rates of spontaneous abortion, prolonged labour, and operative deliveries.8,9 Similarly, depression symptoms during pregnancy increase the relative risk of preterm birth by 39%, low birth weight by 49%, and intrauterine growth restriction by 45%.10 Women's decision-making ability to use any care during perinatal period is also affected by mothers’ emotional problems.11,12 Moreover, postpartum depression is commonly preceded by antenatal depression, which has been associated with unfavorable obstetric outcomes and impaired child neurodevelopment,13,14 early cessation of breastfeeding,15–17 and receiving fewer preventive health services like vaccinations.18 The WHO indicates that treating the depression of mothers leads to improved growth and development of the newborn, and reduces the likelihood of diarrhea and malnutrition in children.19 Consequently, this would pose a considerable burden to the women, their families and society.
In this vein, various studies highlight that women who are poor and have more psychological symptoms during pregnancy are more likely to remain depressed several months after giving birth. This indicates the need for developing a mechanism of early detection and suitable interventions to minimize the damaging effects of persistent postnatal depression in poor communities.20 Moreover, recent studies acknowledge that the peripartum onset has been specified as major depressive episodes that emerge during pregnancy, and can last up to 1 year after delivery.21 Pertinent to this, the WHO recommends that primary health care providers should hold a crucial role on detecting, if necessary, providing referrals to mental health care for affected women.22 Similarly, the American College of Obstetricians and Gynecologists and other scholars also recommend that universal screening has to be carried out at least once during the perinatal period for depressive symptoms using a standardized and validated tool.6,23
Moreover, empirical studies indicate that there is no single screening tool for all type of clients and, therefore, the examination instrument should be locally validated.24 On the basis of this evidence, scholars have tried to measure and validate several tools for the assessment of depression in the perinatal population. However, from all available screening tools, Patient Health Questionnaire-9 (PHQ-9) has got high validity and reliability. Measured by Cronbach's alpha scale, the reliability coefficient of this tool was 0.84 whereas the intra-class correlation coefficients for the 1-week test–retest reliability were 0.98, sensitivity 80.8%, and a specificity of 79.5%.25 Therefore, PHQ-9 meets the criteria established by Linacre for rating scale effectiveness, and it is also appropriate for health literacy; it takes less than 10 min to complete.26 The PHQ-9 scoring guideline ranges from 0 (absence of depressive symptoms) to 27 (most severe depressive symptoms), which helps to measure severity of depression. Each of the nine items can be scored from 0 (not at all) to 3 (nearly every day). The score ranges from normal (0–4), mild (5–9), moderate (10–14) to severe depressive symptoms (≥15).27,28 The minimum score for diagnosis of antenatal depression is eight.25 In line with this, shortage of specialized providers, busy clinic, and failure in recognizing depression as a problem were the common identified barriers to antenatal psychosocial assessment.22 These evidence implementation projects were used for promoting evidence-based health care using audit and re-audit by evidence-based criteria. Furthermore, team-based analysis of the organizational barriers, and setting strategies to overcome the barriers were also undertaken. Therefore, the present study aimed at assessing antenatal psychosocial assessment practice by using best evidence-based practice.
The objective of this best evidence-based practice implementation project was to promote antenatal psychosocial assessment amongst midwives.
- To determine current compliance with evidence-based criteria in antenatal psychosocial assessment amongst midwives.
- To identify barriers relevant to facilitators in addressing compliance with evidence-based criteria in antenatal psychosocial assessment.
- To develop strategies to address areas of noncompliance in antenatal psychosocial assessment practice amongst midwives.
- To improve the knowledge of best practice amongst care providers working in antenatal clinic.
- To improve compliance with evidence-based criteria in antenatal psychosocial assessment amongst midwives.
The project was of 16 weeks’ duration, from December 2018 to April 2019. From 1 to 15 December 2018 a baseline audit was conducted, and from 01 January 2019 to 30 March 2019 the implementation was carried out, and finally, from 01 April 2019 to 15 April 2019 the follow-up audit was performed at antenatal clinic. This evidence implementation project was conducted using the Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. These tools were employed to promote evidence-based health care using audit and re-audit standard criteria concomitant to team-based analysis of the organizational barriers and identification of strategies to overcome these barriers. Though informed consent was obtained from each midwife, target participants were not informed about the specific procedure for which they were being observed.
Two MSc holder midwives from another health facility collected data through participatory observation. To this effect, the project leader oriented the midwives on the principles of evidence-based antenatal psychosocial assessment, and on how to determine each audit criterion as well. The project activities were described as three distinct but interrelated phases of activities as follows.
Phase 1: design of evidence-based audit criteria, team engagement, and baseline audit
The major activities of phase 1 include identifying audit criteria, setting identification and sample selection, organizing a study team, and conducting a baseline audit. After the study's topic was decided, the project team was organized based on team members’ position, willingness and agreement to participate and implement the project, and provide their support for the successful accomplishment of the project.
The team leader was responsible for coordinating group member access to evidence-based audit criteria and strategy implementation; monitoring data collection and analysis; and supervising the overall implementation of the project
The medical director was responsible for making relevant administrative actions to correct barriers regarding human resources and ensure timely allocation of budget for the sustainability of the project.
Matron of the hospitals
The matron of the hospitals supervised the technical aspect of the project, and would work to fill the skill gaps of the midwives through training.
Maternal and Child Health coordinator of the hospital
The Maternal and Child Health (MCH) coordinator of the hospital organized the technical aspect of the project, supply of materials, and to the point of care, staff assignment at the point of care, and being a role model.
Overall team organizer
This was a team member who was responsible for overseeing the whole project; he/she observed activities with the team leader, managed timelines, scheduled project meetings to review audit result, and coordinated training sessions and ensured feedback was provided at all steps to the organization.
Accordingly, the project team leader gave an orientation to the team members about standard antenatal psychosocial assessment based on the JBI Practical Application of Clinical Evidence System (PACES) criteria. On the basis of the evidence summary, audit criteria for evidence-based antenatal psychosocial assessment were developed and used in the baseline and follow-up audit.
All health professionals involved in providing care to pregnant women had received training in woman-centered communication skills and psychosocial assessment.
Pregnant women upon initial contact with their health professional were asked about past or present mental illness (including family history).
Pregnant women upon initial contact with their health professional were asked specific questions to identify possible depression and assessed by PHQ-9 (Appendix I, https://links.lww.com/IJEBH/A69).
Follow-up was made to all pregnant women who had scored 10 or more on the PHQ-9.
In light of this, the third activity in phase 1 involved a baseline audit to assess the gaps between routine antenatal psychosocial assessment practice and evidence-based antenatal psychosocial assessment practice. It was conducted from 1 December 1 to 15 December 2018 using the four evidence-based antenatal psychosocial assessment audit criteria. For the first criterion, all registered midwives (14 midwives) who were working at maternal and child health care services (antenatal, delivery, postnatal, expanded program on immunization, and family planning) were audited. As they would give the antenatal care service by rotation of every 6 months, it was decided to include all midwives by considering its effect in sustaining the project. This criterion does not specify the range of time within which the staff midwives were trained. For the purpose of report, we considered it as ‘Staff have ever received woman-centered communication skills and psychosocial assessment’.
For the rest of the three audit criteria, only four midwives who were working at the antenatal clinics were observed. The sample size was calculated using Epi-info software with hypothesized percentage frequency of outcome factor in the population (P) of 50% (no previous study in Ethiopia's context on practice of psychosocial assessment), 95% confidence interval (CI), and a margin of error of 5% with a 2-week antenatal clinic client flow of 80 new ANC visits. The final sample size was 66 opportunities. The data collectors observed 66 first visit antenatal care assessment opportunities using the JBI-PACES software whereas the four midwives gave care for pregnant mothers.
Apparently, in order to implement this project, there should be an enabling environment. Therefore, in addition to the above assessment criteria, some important factors that would hinder practice rates, such as staff training, client load, functionality of referral linkage system with psychiatric outpatient department, private room for client screening, and availability of a locally validated tool for assessment of depression, were assessed.
Phase 2: implementation of best practice
At the implementation phase, guided by the PACES Getting Research into Practice (GRiP) framework tool, the project team discussed the results of the baseline data. Then, the possible barriers to the practice of antenatal psychosocial assessment were explored. On the basis of the identified barriers, key strategies and subsequent actions were developed and set by the team and other stakeholders. The barriers, strategies, and resources identified by the team are presented in the results. In general, all registered midwives (14 midwives) were also involved so as to guarantee the sustainability issue of the project. Finally, the strategies were implemented over 12 weeks (from 01 January 2019 to 30 March 2019) so as to solve the gaps identified in the baseline audit.
Phase 3: postimplementation audit
In the follow-up audit, the same tool (JBI PACES) was employed for data collection. Data were collected from 66 first visit antenatal care assessment opportunities using the same method as the baseline audit while the four midwives gave care for pregnant women who came for antenatal care service from 01 April 2019 to 15 April 2019.
Phase 1: baseline audit
The baseline audit result indicates a 0% compliance rate for all evidence-based antenatal psychosocial assessment audit criteria. Results from audit criterion 1 revealed that care providers had taken a general maternal mental health course during their preservice training as one course called ‘Psychiatry for Midwifery’. However, they had not received specific in-service training on women-centered communication skill and psychosocial assessment using validated screening tools like PHQ-9 and other tools used at antenatal clinic. For the second audit criterion, pregnant women upon initial contact with their health professionals were asked about past or present mental illness including family history, and apparently a big knowledge gap among providers was found. As they responded, they usually ask these questions only if the women have severe mental disturbance like agitation or violence as providers consider mental illness only if the client displays such symptoms but they do not think of it as routine assessment. During the baseline audit that kind of result was not observed, and therefore, it was reported zero for baseline audit criterion 2. On the other hand, audit criteria 3 and 4, which was asking the woman specific questions to identify possible depression using screening tools and giving follow-up to all pregnant women who score 10 or more on the PHQ-9, were not performed for all 66 cases (100% not done) (Table 1).
Table 1 -
The results of baseline audit on antenatal psychosocial assessment, at antenatal clinic, 2018
||All health professionals involved in providing care to pregnant women have received training in woman-centered communication skills and psychosocial assessment
||Pregnant women upon initial contact with their health professional are asked about past or present mental illness (including family history)
||Pregnant women upon initial contact with their health professional are asked specific questions to identify possible depression
||Follow-up is given to all pregnant women who score 10 or more on the PHQ-9
PHQ-9, Patient Health Questionnaire-9.
Generally, the baseline audit identified the most potential barriers to not performing antenatal psychosocial assessment that include: weak internal referral system or weak linkage between antenatal clinic and medical or behavioral treatment services, lack of private or separate room for screening, lack of locally validated and standardized tool, and poor staff knowledge and attitude towards maternal mental health.
Phase 2: implementation of best practice
The strategies and resources were identified by the project team and key stakeholders to solve the identified barriers. First, midwives were encouraged to actively participate in this project. Thus, all midwives providing maternal and child health care services were given a brief introduction to evidence-based practice and best practice of maternal psychosocial problem assessment. This was done based on the assumption that conducting this project without midwives’ understanding of evidence-based practice and best practice for maternal psychosocial problem assessment would not be sustainable for their practice. In addition, the baseline audit shows all of them had knowledge gaps on maternal psychosocial problem assessment and they had no awareness about current available best practice on maternal psychosocial problems, and the steps to perform antenatal psychosocial assessment in the antenatal clinic. Therefore, the following implementation strategies were developed.
- (1) Introducing evidence-based practice (EBP) and best practice for maternal psychosocial problem assessment.
- (2) Distribution and presentation of evidence summary to all staff and key stakeholders.
- (3) Discussions with midwives and other responsible staff to explore barriers.
- (4) Training on the risk of psychosocial problems on pregnancy outcomes, mother, family, and society as a whole.
- (5) Training on women-centered communication skill and psychosocial problem assessment. Introducing the validated PHQ-9 and helping midwives to assess mothers. Inserting PHQ-9 tool in the antenatal card.
- (6) Inviting and having discussion with experts and clinicians (local opinion leaders) on current evidence on maternal mental health.
- (7) Strengthening the link between antenatal clinics with psychiatric outpatient department (OPD) with available internal referral paper.
- (8) Monitoring of team members and champion recognition strategy.
The GRiP strategies and outcomes are described further in Table 2.
Table 2 -
Identified barriers to best practice and strategies to overcome them, 2018/2019
||Giving on-the-job training by including local opinion leadersDisseminating educational materials
||There is significant change in providers’ knowledge, practice and attitude
|Lack of locally validated tool
||Searching for locally validated and standardized tool for pregnant women
||Inserting PHQ-9 in the ANC card
||Discussing guidelines and agreeing to offer psychosocial assessment only for first visit mothers. And repeat if it is important.
||Providers accepted to work with available challenges.Follow-up by head of MCH
|Lack of private room
||Discussion about the importance of privacy on the quality of services client received specially for psychosocial assessment
||Reduced number of people move here and there in the roomClosing the ANC door during client screeningTaking women to an other private room during screening
ANC, Antenatal Care; MCH, Maternal and Child Health; PHQ-9, Patient Health Questionnaire-9.
Phase 3: postimplementation audit
In the follow-up audit, all midwives involved in providing care to pregnant women had received training in woman-centered communication skills and psychosocial assessment (100% fulfilled for criterion 1). The majority, 55 (83.3%), of pregnant women were asked about past or present mental illness (including family history) upon initial contact with their health professional, and they were assessed for the presence of possible depression by PHQ-9. Follow-up was made with those who have scored 10 or more on the PHQ-9. The changes in implementation of best practice were recognized and marked following the training strategies to overcome the identified barriers (Fig. 1).
The baseline audit uncovered that antenatal psychosocial assessment was not practiced at antenatal clinics. Antenatal care providers considered severe mental disturbances like psychosis, agitation, and other severe cases as the only psychosocial problems. They referred patients to mental health clinics if they came across such mothers only. It was not based on screening results that they did so; it was simply done by severe clinical clues that the mothers had shown.
The evidence implementation project was successful in that improvements were observed in all the evidence-based audit criteria. The postimplementation audit showed 100% achievement for criteria 1 and 4, and 83.3% for criteria 2 and 3.
On-the-job training was given for all staff working on maternal health care units, on maternal psychosocial problem, such as women-centered communication skill and assessment of psychosocial problems, magnitude of maternal psychosocial problems and its effect on pregnancy outcomes, mothers’ health, child development, family, and community as a whole. Reading materials, a well-validated tool (PHQ-9) in the local context and a follow-up chart were availed at the antenatal clinics by the project team. Its effectiveness was supported by a systematic review done on the effectiveness and efficiency of guideline dissemination and implementation strategies to improve health care services.21 Furthermore, midwives felt happy with the given training and materials.
Consequently, the important barriers were lack of a system to link the mother to behavioral or medical care and facility infrastructure [there was separate room for antenatal care but it is almost mixed with other services like expanded program of immunization (EPI) and family planning]. The facility plan aimed to deliver different services and address many clients with limited number of health care providers. But in our case, it severely affects the client privacy.6
To solve these barriers, discussion was made with the audit team on the importance of client privacy for psychosocial problem assessment, and improvement was noticed. Even if the room was small, privacy was ensured by reducing the number of people moving here and there and by closing the antenatal care (ANC) door during client screening. Finally, a link was established between antenatal care and psychiatric OPD by using the already available hospital internal referral paper to make the referral system smooth.
Client load was also the other main barrier raised by the staff but before the training, providers had thought that women would have been checked in each visit when they come to the clinic. But after the training, based on the recommended guidelines on antenatal psychosocial assessment, a discussion was held on the recommendations and agreed that each mother should be assessed for the psychosocial problems at least once during antenatal period and postnatal care.6,23,29
Finally, facilitators like hospital mentors and MCH coordinators maintained regular contact with antenatal clinic midwives to assist them in problem-solving and working through challenges for the sustainability of antenatal psychosocial assessment practice. It is supported by a study done to improve the quality of health care.15 Finally, the result of this best practice implementation project was communicated to the team members, who had a say regarding decision-making in the hospital affairs.
This project provided an insight on the power of evidence-based audit and feedback as a tool for implementing best practices in the health care setting. Even in the context of low resources, scaling up providers’ knowledge and attitude through presentation and discussion on evidence summary, on-the-job training, using local leaders’ opinion, involving relevant stakeholders, and people who are directly connected to the project were very important for implementing the evidence into practice. It was recommended for all prenatal care providers, hospital higher officials, and ministry of health representatives to change the culture of health facility. In other words, rather than focusing on only screening and disease prevention packages (physical health), interventions packages that can improve both the physical and emotional condition of women should be given attention. To sustain the gains achieved, continued training, audit and feedback cycles are deemed necessary. Moreover, frequent facility assessments are found important in order to update the provider's knowledge and fill the gaps in the enabling environment.
We would like to thank Jimma University for giving us this chance and conduct a study on this interesting area, and for funding the project as well. We also extend our appreciation to prenatal clinic staff (midwives) in the target hospital for devoting their time and for their motivation to sustain the project. Finally, we are indebted to thank all project team members for their cooperation and successful accomplishment of this project.
Funding: this study was not funded by any grant. Jimma University covered the fees of data collectors but had no role in the design of the study and data collection, analysis, interpretation of data and in writing up the manuscript. There was no reimbursement, fees, funding, nor salary from any organization that depends on and/or influences the results and publication of this study.
Declarations: ethics approval and consent to participate: the project team got an ethical clearance from Jimma University institutional review board, and a formal letter of permission was obtained from the facility. Verbal and written informed consents were obtained from each participant mother and from all providers respectively.
Consent for publication: not applicable.
Availability of data and materials: the datasets used during the current project are available from the corresponding author on request.
Author's contributions: M.T. conceptualized, designed the project and set audit criteria, organized the audit team, implemented the strategy, analyzed and interpreted the data, and also drafted the manuscript. D.B. designed the project and set audit criteria, analyzed and interpreted the data, and implemented the strategy.
B.A.M. designed the project and set audit criteria, analyzed and interpreted the data, and also drafted the manuscript. A.B. designed the project and set audit criteria, and implemented the strategy. G.T. supervised the overall implementation of the project. G.T.F. designed the project and set audit criteria, implemented the strategy and supervised the overall implementation of the project. M.A. supervised the overall implementation of the project. Z.B. supervised the overall implementation of the project. All the authors have read and approved the manuscript.
Authors’ information: M.T. is a PhD Fellow, D.B. is Assistant Professor at Department of Nursing, Debre Berhan University, A.B. is Assistant Professor at School of Nursing, B.A.M. is Assistant Professor at School of Midwifery, G.T.F. is Associate Professor at Department of Health, Behavior and Society, G.T. is Associate Professor at Department of Population and Family Health, M.A. is Associate Professor at Department of Population and Family Health and Z.B. is Associate Professor at Department of Health, Behavior and Society, Jimma University.
Conflicts of interest
The authors report no conflicts of interest.
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