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Access to water immersion for labour and birth during the pandemic: an opinion piece

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the first of five articles in a series. The author of this article preferred to publish anonymously. 

Access to water immersion for labour and birth during the pandemic: an opinion piece

There is no denying that COVID-19 has completely changed the world (United Nations Children’s Fund, 2020). Many populations have been unequally disadvantaged by the global pandemic, including childbearing women (Gausman & Langer, 2020). It has been a period of heightened anxiety as new policies aimed at flattening the curve have limited women’s birth preferences and choices (Australian College of Midwives [ACM], 2020a). This includes the Royal Australian and New Zealand College of Obstetrics and Gynecology (RANZCOG) recommendation to suspend the use of water immersion for all labouring women within COVID-19 hotspots (ACM, 2020a). Whilst staunchly opposed by ACM (2020a), this position statement has been adopted by health services across the nation including the Department of Health and Human Services [DHHS] in Victoria (2020). The topic is controversial as the suspension of access to water immersion is not supported by evidence (Centres for Disease Control [CDC], 2020a) and devalues a woman’s autonomy and right to self-determination.

Midwives have a professional obligation to advocate for evidence-based practices that empower women and promote normal birth. Water immersion during labour is associated with positive outcomes and should be available to all low-risk women who are presumed or confirmed COVID-19 negative.

Arguments for the suspension

Let us consider the evidence for suspending water immersion in the context of a woman with a confirmed positive COVID-19 test result. The rationale behind RANZCOGs recommendation was the protection of healthcare workers (ACM, 2020a; 2020b). Concerns have been raised regarding the level of protection provided by personal protective equipment when immersed in water (DHHS, 2020; Royal College of Midwives [RCM], 2020). It was also believed the moist atmosphere of the birth pool room could increase the risk of droplet transmission (RCM, 2020).

Some evidence contradicts this viewpoint, however, finding the virus is less likely to be transmitted in humid environments (Qi et al., 2020). Given that COVID-19 is not a waterborne virus, it is believed that liquid may dilute contamination and therefore reduce the potential risk of transmission (ACM, 2020a). Another potential benefit from water immersion is that the birth pool aids in physical distancing by providing a barrier between women and care providers (Burns et al., 2020; Ulfsdottir et al., 2018).

Another concern that was raised was faecal-oral transmission of COVID-19 within a birth pool. While some studies suggest the virus can be transmitted through faeces (Wang et al., 2020; Zhang et al., 2020a), there has been no evidence of faecal-oral transmission to date (World Health Organization, 2020). Some argued that if faeces were highly contagious for COVID-19, healthcare workers would be at greater risk during land birth as the particles are not diluted (ACM, 2020a). So while water immersion has been framed as posing a risk to clinical staff, women and babies; there is limited evidence to suggest it is easily spread to humans through birth pools (CDC, 2020a).

Benefits of water immersion

It is important to recognise the known benefits of water immersion during labour and for birth. Water immersion facilitates positive birth experiences (Cooper & Warland, 2019; Lathrop et al., 2018; Neiman et al., 2019). When immersed in water during labour, women have increased feelings of empowerment and experience a greater sense of privacy, safety, control and focus (Fair et al., 2020; Ulfsdottir et al., 2018). It is also an effective pain management method which can help to avoid a cascade of intervention and therefore promotes normal birth practices (Cluett et al., 2018). Women who were prevented from accessing water immersion as a consequence of their COVID-19 status would not access these benefits. The arbitrary decision to suspend water immersion for all labouring women is consistent with historical practices in maternity care that value subjectivity over evidence-based recommendations (Cooper et al., 2017).

What the suspension really represents

It can be assumed that broader socio-cultural factors have influenced RANZCOGs recommendation. RANZCOG is an obstetric organisation that aligns itself with the technocratic model of care and values surveillance, intervention, and hierarchy (Davis-Floyd, 2001). This is demonstrated by their staunch and public opposition to practices such as homebirth – which is discussed in the context of obstetric outcomes and perinatal mortality (Licqurish & Evans, 2015).

RANZCOGs position statement on water immersion is similar. By standardising institutional practices and banning all women from using water immersion, the individual needs of women are deemed unimportant. Consequently, these clinicians retain their position at the top of the organisation’s hierarchy (Davis-Floyd, 2001). The recommendation represents authority and responsibility inherent in the healthcare provider, not the woman –  as the woman’s personal preferences are disregarded by the institution (Davis-Floyd, 2001).

Loss of choice and failing to make decisions in partnership with women may also add to women’s feelings of stress and anxiety (Jago et al., 2020). This further impacts normal birth outcomes as women are passive in decision-making and do not challenge recommended practices (Carolan- Olah et al., 2015). The prohibition of water immersion also fails to demonstrate a holistic approach to care as the social and emotional needs of women are neglected (Jago et al., 2020) during a period in history that has elevated anxiety and depression amongst pregnant women (Lebel et al., 2020).

Medicalisation of childbirth also likely influenced the decision to suspend water immersion. An obstetric approach views water immersion as inherently risky and therefore requires medical management (Licqurish & Evans, 2016; Milosevic et al., 2019). This is demonstrated by RANZCOGs recommendations for water immersion statement (2017) which focuses on rigorous protocols, exclusion criteria, and obstetric emergency drills. Their value of a medicalised approach is also apparent when considering that they have not recommended suspending the use of nitrous oxide for all labouring women (RANZCOG, 2020c), despite posing a higher risk of contracting COVID-19 through droplet or aerosol transmission (ACM, 2020a; CDC, 2020b).

The influence of medicalisation is even more obvious in the recommendation to site an epidural early in labour, in case an emergency caesarean section becomes ‘indicated’ (DHHS, 2020). This practice has been adopted by Barwon Health, along with the recommendation of continuous fetal heart rate monitoring, should a woman be suspected of COVID-19 (2020). Normal birth outcomes then become even more difficult to achieve as interventions such as instrumental birth are increased (Alfirevic et al., 2017).

To affect any sort of change, it is important for midwives to gain confidence in water immersion (Plint & Davis, 2016). Lack of training creates a workplace culture where water immersion is feared (Klein et al., 2011). Consequently, medicalised approaches are promoted as midwives do not feel confident advocating for normal birth practices.

The media also plays a pivotal role in the depiction of childbirth, often shaping public opinion irrespective of evidence (Petrovska et al., 2017). Normal birth practices are vastly underrepresented, with childbirth often portrayed as medicalised and risky (Luce et al., 2016). Commonly associated with fear, pain and intervention, high-impact dramatic stories are more often depicted in the media rather than calm, normal births (Maclean, 2014). Media portrayals will influence women’s perceptions of water immersion given that two out of three women source information from the media instead of their healthcare provider (Carlsson & Ulfsdottir, 2020). Combined with media coverage on COVID-19, it is no wonder water immersion is scarcely supported. As women become fearful of childbirth, they are disempowered to advocate for normal birth practices (Plint & Davis, 2020). It is imperative for midwives to support women in making informed choices to ensure their decisions are not influenced by fear perpetuated by the media
(Jago et al., 2020).

How do we move forward?

Maintaining the health and safety of women, babies, and healthcare workers is paramount.

Measures can be taken to minimise the potential risk of COVID-19 transmission whilst still promoting normal birth practices. Screening women for COVID-19 and fast-track testing will inform care management more accurately (RCM, 2020). Individualised risk assessments should be undertaken and midwives should demonstrate effective clinical decision making (RCM, 2020). Being up-to-date with infection control practices would be supportive (Liang & Archarya, 2020; Public Health England, 2020) along with access to appropriate personal protective equipment (RCM, 2020). Burns et al. (2020) found wearing long gauntlet gloves that are one size too small can improve the seal when immersed in water. Maintaining proper cleaning and hygiene practices reduces the risk of transmission (ACM, 2020a) as well as removing faecal matter should it contaminate the water (Gu et al., 2020).

Empowering women to guide their babies into the world while immersed in water facilitates physical distancing practices (RCM, 2020). This would be supported by antenatal education as it  instills confidence and allows women to engage in their care (ACM, 2020a; Milosevic et al., 2019; Plint & Davis, 2016). Arguably the most important factor, is that midwives must be trained in water immersion. This will ensure competence and develop a workplace culture that supports normal birth practices (Nicholls et al., 2016). Midwives should also engage in respectful conversations that promote midwifery care by challenging practices that are deemed unnecessary or not based on evidence.

In summary

Midwives have a professional obligation to protect choices for women and promote normal birth practices (ACM, 2020b). Water immersion should be available to all women. RANZCOGs recommendation is not based on evidence and has been influenced by technocratic ideologies. As gatekeepers to normal birth, midwives are in a powerful position to influence maternity reform and must continually advocate for evidence-based practices to ensure women are supported throughout their childbearing journey (McIntyre et al., 2012).

References

Alfirevic, Z., Gyte, G., Cuthbert, A., & Devane, D. (2017). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, (5), 1-141. https://dx.doi.org/10.1002/14651858.CD006066.pub3

Australian College of Midwives. (2020a). ACM’s updated position on use of water in labour. https://www.midwives.org.au/news/acm-s-updated-position-use-water-labour

Australian College of Midwives. (2020b). Midwifery philosophy and values. https://www.midwives.org.au/midwifery-philosophy-values

Barwon Health. (2020). COVID-19 (coronavirus) and pregnancy.
https://www.barwonhealth.org.au/maternity-services/component/zoo/item/covid-19- coronavirus-and-pregnancy

Burns, E., Cooper, M., Feeley, C., Hall, P., Roehr, C., & Venderlaan. (2020). Coronavirus COVID-19: Supporting healthy pregnant women to safely give birth. https://www.brookes.ac.uk/WorkArea/DownloadAsset.aspx?id=2147622699

Carlsson, T., & Ulfsdottir, H. (2020). Waterbirth in low‐risk pregnancy: An exploration of women’s experiences. Journal of Advanced Nursing, 76(5), 1221-1231. https://dx.doi.org/10.1111/jan.14336

Carolan-Olah, M., Kruger, G., & Garvey-Graham, A. (2015). Midwives׳ experiences of the factors that facilitate normal birth among low risk women at a public hospital in Australia. Midwifery, 31(1), 112-121. https://dx.doi.org/10.1016/j.midw.2014.07.003

Center for Disease Control. (2020a). Coronavirus Disease 2019 (COVID-19) [Topic: Pools, Hot Tubs, and Water Playgrounds]. https://www.cdc.gov/coronavirus/2019- ncov/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2 019-ncov%2Fphp%2Fwater.html#COVID-19-and-Water

Center for Disease Control. (2020b). How COVID-19 Spreads. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid- spreads.html

Cluett, E., Burns, E., & Cuthbert, A. (2018). Immersion in water during labour and birth. Cochrane Database of Systematic Reviews, (6), 1-171. https://dx.doi.org/10.1002/14651858.cd000111.pub4

Cooper, M., McCutcheon, H., & Warland, J. (2017). A critical analysis of Australian policies and guidelines for water immersion during labour and birth. Women and Birth, 30(5), 431-441. https://dx.doi.org/10.1016/j.wombi.2017.04.001

Cooper, M., & Warland, J. (2019). What are the benefits? Are they concerned? Women’s experiences of water immersion for labor and birth. Midwifery, 79, 102541-102551. https://dx.doi.org/10.1016/j.midw.2019.102541

Davis-Floyd, R. (2001). The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynecology and Obstetrics, 75(1), 5-23. https://dx.doi.org/10.1016/S0020-7292(01)00510-0

Department of Health and Human Services. (2020). Maternity and neonatal care during coronavirus (COVID-19). https://www.dhhs.vic.gov.au/covid-19-maternity-and-neonatal- care-during-coronavirus

Fair, C., Crawford, A., Houpt, B., & Latham, V. (2020). “After having a waterbirth, I feel like it’s the only way people should deliver babies”: The decision-making process of women who plan a waterbirth. Midwifery, 82, 102622-102628. https://dx.doi.org/10.1016/j.midw.2019.102622

Gausman, J., & Langer, A. (2020). Sex and gender disparities in the COVID-19 pandemic. Journal of Women’s Health, 29(4), 465–466. https://dx.doi.org/10.1089/jwh.2020.8472

Gu, J., Han, B., & Wang, J. (2020). COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology, 158(6), 518-519. https://dx.doi.org/10.1053/j.gastro.2020.02.054

Jago, C., Singh, S., & Moretti, F. (2020). Coronavirus disease 2019 (COVID-19) and pregnancy: Combating isolation to improve outcomes. Obstetrics and Gynecology, 136(1), 33-36. https://dx.doi.org/10.1097/AOG.0000000000003946

Klein, M., Liston, R., Fraser, W., Baradaran, N., Hearps, S., Tomkinson, J., Kaczorowski, J., & Brant, R. (2011). Attitudes of the new generation of Canadian obstetricians: How do they differ from their predecessors? Birth, 38(2), 129-139. https://dx.doi.org/10.1111/j.1523- 536x.2010.00462.x

Lathrop, A., Bonsack, C., & Haas, D. (2018). Women’s experiences with water birth: A matched groups prospective study. Birth, 45(4), 416-423. https://dx.doi.org/10.1111/birt.12362

Lebel, C., MacKinnon, A., Bagshawe, M., Tomfohr-Madsen, L., & Giesbrecht, G. (2020). Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic. Journal of Affective Disorders, 277, 5-13. https://dx.doi.org/10.1016/j.jad.2020.07.126

Liang, H., & Acharya, G. (2020). Novel coronavirus disease (COVID‐19) in pregnancy: What clinical recommendations to follow? Acta Obstetricia et Gynecologica Scandinavica, 99(4), 439-442. https://dx.doi.org/10.1111/aogs.13836

Licqurish, S., & Evans, A. (2016). ‘Risk or Right’: A discourse analysis of midwifery and obstetric colleges’ homebirth position statements. Nursing Inquiry, 23(1), 86-94. https://dx.doi.org/10.1111/nin.12111

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. https://dx.doi.org/10.1186/s12884-016-0827-x

Maclean, E. (2014). What to expect when you’re expecting? Representations of birth in British newspapers. British Journal of Midwifery, 22(8), 580-588. https://dx.doi.org/10.12968/bjom.2014.22.8.580

McIntyre, M., Francis, K., & Chapsman, Y. (2012). Primary maternity care reform: Whose influence is driving the change?. Midwifery, 28(5), 705-711. https://dx.doi.org/10.1016/j.midw.2011.08.004

Milosevic, S., Channon, S., Hunter, B., Nolan, M., Hughes, J., Barlow, C., Milton, R., & Sanders, J. (2019). Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff. Midwifery, 79, 102554-102561. https://dx.doi.org/10.1016/j.midw.2019.102554

Neiman, E., Austin, E., Tan, A., Anderson, C., & Chipps, E. (2019). Outcomes of waterbirth in a US hospital‐based midwifery practice: A retrospective cohort study of water immersion during labor and birth. Journal of Midwifery & Women’s Health, 65(2), 216-223. https://dx.doi.org/10.1111/jmwh.13033

Nicholls, S., Hauck, Y., Bayes, S., & Butt, J. (2016). Exploring midwives’ perception of confidence around facilitating water birth in Western Australia: A qualitative descriptive study. Midwifery, 33, 73-81. https://dx.doi.org/10.1016/j.midw.2015.10.010

Petrovska, K., Sheehan, A., & Homer, C. (2017). Media representations of breech birth: A prospective analysis of web‐based news reports. Journal of Midwifery & Women’s Health, 62(4), 434-441. https://dx.doi.org/10.1111/jmwh.12609

Plint, E., & Davis, D. (2016). Sink or Swim: Water immersion for labor and birth in a tertiary maternity unit in Australia. International Journal of Childbirth, 6(4), 206-222. https://dx.doi.org/10.1891/2156-5287.6.4.206

Public Health England. (2020). COVID-19: infection prevention control guidance. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection- prevention-and-control

Qi, H., Xiao, S., Shi, R., Ward, M., Chen, Y., Tu, W., Su, Q., Wang, W., Wang, X., & Zhang, Z. (2020). COVID-19 transmission in Mainland China is associated with temperature and humidity: A time-series analysis. Science of the Total Environment, 728, 138778. https://dx.doi.org/10.1016/j.scitotenv.2020.138778

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2017). Warm water immersion during labour and birth. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG- MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical- Obstetrics/Warm-water-immersion-during-labour-and-birth-(C-Obs-24)-Review-July- 2017.pdf?ext=.pdf

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020a). COVID-19: Protection of midwives and doctors in the birth unit. https://ranzcog.edu.au/news/covid-19-protection-of-midwives-and-doctors-in-th

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020b). RANZCOG statement. https://ranzcog.edu.au/news/ranzcog-statement

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020c). A message for pregnant women and their families. https://ranzcog.edu.au/statements- guidelines/covid-19-statement/information-for-pregnant-women

Royal College of Midwives. (2020). RCM Professional briefing on waterbirths for women without symptoms during the COVID-19 pandemic. https://www.rcm.org.uk/media/4034/rcm-professional-briefing-on-waterbirth-in-the- time-of-covid-v-3-7-may-2020.pdf

Ulfsdottir, H., Saltvedt, S., Ekborn, M., & Georgsson, S. (2018). Like an empowering micro- home: A qualitative study of women’s experience of giving birth in water. Midwifery, 67, 26-31. https://dx.doi.org/10.1016/j.midw.2018.09.004

United Nations Children’s Fund. (2020). How COVID-19 is changing the world. https://data.unicef.org/resources/how-covid-19-is-changing-the-world-a-statistical-perspective/#

Wang, J., Tang, K., Feng, K.,; Li, X., Lv, W., Chen, K., & Wang, F. (2020). High temperature and high humidity reduce the transmission of COVID-19. Centre for Evidence- Based Medicine. https://www.cebm.net/study/covid-19-high-temperature-and-high- humidity-reduce-the-transmission-of-covid-19/

World Health Organization. (2020). Modes of transmission of virus causing COVID-19: Implications for IPC precautions and recommendations. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus- causing-covid-19-implications-for-ipc-precaution-recommendations

Zhang, Y., Chen,C., Zhu, S., Shu, C., Wang, D., Song, J., Song, Y., Zhen, W., Feng, Z., Wu, G., Xu, J., & Xu, W. (2020). Isolation of 2019-nCoV from a stool specimen of a laboratory- confirmed case of the coronavirus disease 2019 (COVID-19). China CDC Weekly, 2(8), 123-124. http://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2020.033

Midwives’ mental health during the COVID19 pandemic

Identifying as a midwife is a source of joy and purpose for most midwives, but many midwives describe their midwifery work as challenging. Researchers from the Transforming Maternity Care Collaborative have been co-ordinating the Work, Health, and Emotional Lives of Midwives (WHELM) project. The project has identified high levels of burnout, depression, anxiety, and stress in Australian midwives (Creedy, et al., 2017) and also internationally (Cull, et al., 2020; Dixon, et al., 2017, Pezaro, et al., 2016, Stoll & Gallagher, 2019). Many midwives with high levels of burnout planned to leave midwifery practice, creating the potential for a significant shortfall in the number of qualified midwives available to provide safe maternity care.

This research was conducted prior to the arrival of the novel coronavirus pandemic that has transformed the maternity care workplace. Concerns have been raised regarding the potential for the pandemic to have a significant impact on the mental wellbeing of health professionals (Pfefferbaum & North, 2020). Recent research has shown high levels of anxiety among doctors, midwives, and nurses working in maternity services (Uzun, et al., 2020). Rapid and significant changes to the workplace have been required, particularly in places with large numbers of cases. Whether there will be further waves of infection is unpredictable. It is therefore highly likely that midwives’ emotional coping resources are under pressure.

It is important that we continue to measure the emotional health of midwives. To do that we need tools which are fit for purpose and have been used previously so there is a secure baseline to measure against. The WHELM team have developed, tested, and deployed such tools for a number of years (Pallant, et al., 2015; 2016), and are therefore well placed to provide advice this area.

Previous research from the WHELM consortium has demonstrated that a key protector of midwives’ mental wellbeing is working in a midwifery continuity of carer model (Sidhu, et al., 2020). Prioritising a shift away from traditional, fragmented models of maternity care to midwifery continuity of care is likely to enhance the sustainability of maternity care services through this and any future significant external challenges.

You can access the most recent paper from the WHELM consortium for free for a limited time – here.

References

Creedy, D. K., Sidebotham, M., Gamble, J., Pallant, J., & Fenwick, J. (2017). Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey. BMC Pregnancy and Childbirth, 17, 13.

Cull, Hunter, Henley, Fenwick, Sidebotham. (2020). “Overwhelmed and out of my depth”: Responses from early career midwives in the United Kingdom to the Work, Health and Emotional Lives of Midwives study. Women and Birth, 33(6), e549-557.

Dixon,L., Guilliland,K., Pallant,J., Gilkison,A., Sidebotham,M., Fenwick,J.,McAra-Couper,J. (2017).The emotional wellbeing of New Zealand midwives: comparing responses between employed, self-employed (case loading) and midwives who do both. New Zealand College of Midwives Journal, 53, 5-14

Pallant, J. F., Dixon, L., Sidebotham, M., & Fenwick, J. (2015). Further validation of the Perceptions of Empowerment in Midwifery Scale. Midwifery, 31(10), 941– 945.

Pallant, J. F., Dixon, L., Sidebotham, M., & Fenwick, J. (2016). Adaptation and psychometric testing of the Practice Environment Scale for use with midwives. Women and Birth, 29(1), 24– 29.

Pezaro, S., Clyne, W., Turner, A., Fulton, E. A., & Gerada, C. (2016). ‘Midwives Overboard!’ Inside their hearts are breaking, their makeup may be flaking but their smile still stays on. Women and Birth, 29(3), e59– 66.

Pfefferbaum, B., & North, C.S. (2020). Mental health and the Covid-19 pandemic. New England Journal of Medicine, in press. https://doi.org/10.1056/NEJMp2008017

Sidhu R, Su B, Shapiro K & Stoll K. (2020). Exploring prevalence of and factors associated with Burnout in Midwifery: A Scoping Review. European Journal of Midwifery, 4(February), 4.

Stoll K & Gallagher J. (2019). A survey of burnout and intentions to leave the profession among Western Canadian midwives. Women and Birth, 32(4): e441-e449.

Uzun, N, Teki̇n, M, Sertel, E, Tuncar, A. (2020). Psychological and social effects of COVID-19 pandemic on obstetrics and gynecology employees. Journal of Surgery and Medicine, 4(5), 355-358. DOI: 10.28982/josam.735384

Mental health screening during pregnancy and after birth is even more important right now

Professor Debra Creedy 

Up to 15% of pregnant women in Australia, and 21% of mothers of infants up to four months of age will experience depression. The presence of anxiety, which frequently co-exists with depression, is estimated to also be as high as 20%. Depression during pregnancy and/or the postpartum period can have profound effects on not only a woman’s long-term health and well-being but can also adversely affect her relationship with the baby and her partner.

We currently don’t know the impact of life changes and restrictions related to COVID 19 on the emotional wellbeing of childbearing women. A systematic review of clinical outcomes of 3559 hospitalised patients (in 72 different studies) was published in the Lancet (18th May, 2020). Rogers and colleagues concluded that if the pattern for COVID 19 follows that of similar pandemics (such as SARS in 2002) many admitted patients will experience confusion, acute depression, anxiety, and sleep difficulties. After the illness, 32.2% patients from these combined studies reported post-traumatic stress, and around 15% reported symptoms of depression and anxiety. This data highlights the importance of assessing the emotional wellbeing of not only people with COVID19 but for members of the community who may be at risk, such as pregnant women. However, the approach to screening for depression and/or anxiety during pregnancy and the postpartum varies a great deal.

In an effort to promote common approaches to assessment and measurement of patient outcomes and experiences, core outcome sets are being developed for a range of conditions and used in practice. A core outcome set is an agreed set of outcomes that should be measured and reported. In 2016 the International Consortium for Health Outcomes Measurement (ICHOM) published a core outcome set to evaluate value in maternity care. Acknowledging mental health as an outcome important to women, the ICHOM Working Party included the Patient Health Questionnaire (PHQ-2) and the Edinburgh Postnatal Depression Scale (EPDS) to measure symptoms of perinatal depression.

Currently in Australia, United States, and Canada clinical guidelines recommend that all women should be screened during pregnancy and at least once in the postpartum using the Edinburgh Depression Scale (EPDS). Whereas in the United Kingdom, health professionals undertake selective screening using two brief questions similar to the PHQ-2 – During the past 2 weeks, have you been bothered by (1) ‘feeling down, depressed or hopeless’; and (2) ‘little interest or pleasure in doing things’. If a woman says ‘yes’ (been bothered for several days =1; more than half the days = 2; or nearly every day =3) to one or both questions, then she is asked to complete the EPDS (10 questions). Subsequently, ICHOM recommended using the 2-item PHQ-2 to screen all women, followed by the EPDS if a woman obtains a score of 3 or more (known as a ‘positive’ screen). But the extent to which the PHQ-2 could correctly identify and not miss childbearing women at risk of depressive symptoms had not been tested and further research was needed.

We aimed to compare the screening accuracy of the PHQ-2 to identify women at risk of probable depression during pregnancy and the postpartum. We recruited 309 pregnant women who completed the PHQ-2 and EPDS (at their booking-in appointment around 36-weeks) and postpartum (at 6 and 26-weeks) 4.

The accuracy of the PHQ-2 was tested using two methods (1) scored cut-points >2 and >3, and (2) dichotomous yes/no (positive response to either question) against EPDS cut-points for probable major and probable minor depression. We were interested in the ‘sensitivity’ of the tool – that is, the ability of the PHQ-2 to correctly identify women with depression (known as the true positive rate), and ‘specificity’ – the ability of the PHQ-2 to correctly identify those women who do not have depression (true negative rate).

Our analysis revealed that the dichotomous yes/no (positive response to either question) had the highest sensitivity (81 – 100%). While specificity was low (60 – 74%) we felt that this shortcoming was outweighed by the ability of the PHQ-2 to correctly identify those women at risk for depression.

COVID19 will challenge the mental health of many people in our community, so we shouldn’t stop mental health screening. Our research highlights the importance of supporting women’s mental health through pregnancy and the first year post birth, and why having screening tools that are simple, easy to use tools, and ‘fit for purpose’ in the face of changes to care provision are important. Women receiving continuity of care from a known midwife throughout pregnancy and up to 6 weeks postpartum are more likely to be screened for depression and are more likely to confide in their midwife about concerns and worries.