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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.

Towards value-based maternity care: Validation of the ICHOM Standard Set for Pregnancy and Childbirth

Valerie Slavin, PhD candidate, Midwife, Transforming Maternity Care Collaborative, Griffith University & Gold Coast University Hospital

Professor Jenny Gamble, Transforming Maternity Care Collaborative, Griffith University

Professor Debra Creedy, Transforming Maternity Care Collaborative, Griffith University

Maternity services aim to provide high quality and high value care that women want to access. A challenge lies in how to measure the quality and value of maternity care. In Australia, evidence of widespread variation in maternity care, costs, and outcomes suggests over-use of services for some women and under-use for others. Unexplained variation raises concerns regarding the equity, effectiveness, and efficiency of care.

Traditional maternity measures used to report on the quality of maternity care are limited and generally focus on outcomes such as mortality, mode of birth, post-partum haemorrhage, and severe perineal trauma; or processes such as induction of labour, postnatal readmission, or length of stay. Although these are important outcomes, in isolation they reveal little about performance, quality, or value of maternity care.

Having tools that can reliably report on a range of outcomes over time, and that are important to childbearing women, care providers, and healthcare funding bodies, provides a means to inform real-time clinical decision-making, monitor and benchmark performance, and drive quality improvement activities.

PROMs and PREMs

Person-reported outcome/experience measures (PROMs/PREMs) can supplement traditional measures by assessing the efficacy of maternity care and interventions from the woman’s perspective. Without consistent use of the same questions however, data generated from PROMs and PREMs are of limited value.

Standardised outcome measures

Standard Sets are collections of standardised outcomes and instruments. They represent the missing link to measure the quality and value of care but must be developed using rigorous methods. Since 2012 the International Consortium for Health Outcomes Measurement (ICHOM) has been developing global Standard Sets including outcomes, measurement tools, time-points, and risk adjustment factors to improve value-based healthcare. In 2016 ICHOM developed a Standard Set to measure the value of maternity care which included measures of health-related quality of life, incontinence, emotional wellbeing, pain during sex, birth experience, breastfeeding experience and self-efficacy, and mother infant bonding. To be implemented in practice, maternity services must have confidence that the outcomes and measures included in the Set were developed using rigorous methods and that the measures are valid and reliable in childbearing women. Until recently, the quality of the set had not been evaluated.

Ensuring the validity of PROMs in maternity care

As a group of researchers from the Transforming Maternity Care Collaborative we evaluated the quality and feasibility of the ICHOM Standard Set for Pregnancy and Childbirth. Firstly, we conducted two systematic reviews to assess the quality of the Standard Set development process (manuscript currently under review), and the quality and suitability of the PROMs included in the Set. While the Set was developed using rigorous methods, five included PROMs had not been previously been validated in childbearing women.

We conducted a program of work to evaluate the psychometric performance of these unvalidated PROMs in childbearing women. We conducted a study with 309 consecutive women from one large tertiary hospital in Queensland and collected survey data at five time-points as prescribed by ICHOM (at booking, and 36 weeks of pregnancy and one, six and 26 weeks after birth). We also collected electronic hospital data at six weeks following birth. We provided women with the option of using a tablet device while attending an antenatal care visit, electronic survey completion on their own device, or to complete the survey by phone with the research midwife. The ICHOM Standard Set was acceptable to women. Almost all women invited agreed to participate (95%), and response rates were high at all time-points; being highest at booking (92%) and lowest at 26-weeks post birth (71%).

We conducted psychometric analysis on five PROMs and developed recommendations and/or refinement of the tools to measure health related quality of life (Slavin, Gamble, Creedy, Fenwick, & Pallant, 2019), urinary and anal incontinence (Slavin, Gamble, Creedy, & Fenwick 2019; Slavin, Creedy, & Gamble, 2019), depression symptoms (Slavin, Creedy & Gamble, 2020a), and social support (Slavin, Creedy and Gamble, 2020b).

Our findings support the implementation of the revised Standard Set for Pregnancy and Childbirth to measure value of maternity care. If your health service is interested in using the ICHOM Standard Set and you would like assistance designing methods for women to report their experiences, our study team can assist you.

References
Slavin, V., Gamble, J., Creedy, D. K., Fenwick, J., & Pallant J. (2019). Measuring physical and mental health during pregnancy and postpartum in an Australian childbearing population – validation of the PROMIS Global Short Form. BMC Pregnancy and Childbirth, 19, 370.

Slavin, V., Gamble, J., Creedy, D. K., & Fenwick, J. (2019). Perinatal incontinence: Psychometric evaluation of the International Consultation on Incontinence Questionnaire –Urinary Incontinence Short Form and Wexner Scale. Neurology and Urodynamics, 38(8), 2209-2223.

Slavin, V., Creedy, D. K., & Gamble, J. (2019). Benchmarking outcomes in maternity care: Perinatal incontinence–a framework for standardised reporting. Midwifery, 102628, 1-11.

Slavin, V., Creedy, D. K., & Gamble, J. (2020a). Comparison of screening accuracy of the Patient Health Questionnaire–2 using two case-identification methods during pregnancy and childbirth. BMC Pregnancy and Childbirth, 20, 211.

Slavin, V., Creedy, D. K., & Gamble, J. (2020b). Single Item Measure of Social Supports: Evaluation of construct validity during pregnancy. Journal of Affective Disorders, 272, 91-97.