What is perinatal mental health and psychosocial screening and why is it important?

Screening for perinatal mental health and psychosocial risk and protective factors

Perinatal mental health and psychosocial screening involves asking women a series of questions about their current and past emotional and social wellbeing, to detect signs, symptoms and risk factors for having or developing a mental health condition. This can be done as part of routine pregnancy (antenatal or prenatal) and postnatal care by midwives, obstetricians, and other health care providers.

The iCOPE screening platform, developed by the Centre of Perinatal Excellent (COPE), includes the questions from the EPDS and ANRQ and enables automated clinical scoring; it delivers timely reports to clinicians and patient record systems.

Perinatal mental health screening is an important tool to identify at-risk women who may benefit from further support and formal mental health assessment. Perinatal mental health conditions are underdiagnosed during routine pregnancy care without routine screening (Willey et al. 2020). 

Screening may take the form of a questionnaire with defined response options or may comprise of open-ended questions discussed with a health care provider. Screening is usually undertaken using pen and paper and more recently through digital tools such as the iCOPE digital perinatal mental health screening platform. 

Mental health and psychosocial screening tools that have been validated are perceived as credible by health professionals, provide a framework for initiating conversations with mothers about sensitive topics and improve diagnosis and timely access to care (Willey et al. 2020). There are several established and validated screening tools that are recommended by the Australian clinical practice guidelines for mental health care in the perinatal period (National guideline) (Highet et al. 2023), which are routinely offered to women during pregnancy and in the postnatal period in Australia and aim to detect different aspects of mental health and psychosocial risk: 

  • Depression risk is most commonly screened for using the Edinburgh Postnatal Depression Scale (EPDS) but may also be screened for using other tools such as the depression module of the Patient Health Questionnaire (PHQ-9), the Whooley Questions, the Kessler Psychological Distress Scale (K-10) and the Depression, Anxiety and Stress Scale (DASS). Perinatal mental health screening tools specific for First Nations women have also been developed including Part 1 of the Kimberley Mum's Mood Scale (KMMS), Baby Coming You Ready? (BCYR) and the Mount Isa Depression Scale.  
  • Psychosocial risk factor screening is commonly conducted using the Antenatal/Postnatal Risk Questionnaire (ANRQ/PNRQ) or SAFESTART psychosocial questions. Other tools include the ANRQ-Revised (ANRQ-R) (Reilly et al. 2021), Part 2 of the KMMS and BCYR. These screening tools ask about a range of psychosocial risk factors, including the mother’s mental health history, social support system and if they are experiencing or have ever experienced abuse or family violence. Note – Family violence is a psychosocial risk factor that is not specifically asked by the ANRQ. To bridge this gap, the iCOPE screening platform, which includes the ANRQ, asks additional questions relating to perceptions of safety, and problems with drugs and alcohol within the relationship.
  • Anxiety risk is commonly determined through the anxiety-related items in the depression and psychosocial risk factor screening tool used. The Generalised Anxiety Disorder 7-Item Scale (GAD-7) may also be used.
  • Protective factors: Exploring and amplifying strengths and protective factors raised by a person may be a more effective way to promote mental health, rather than trying to reduce risk factors (KMMS 2023). For example, social support has been found to play a role in protecting against perinatal depression (Milgrom et al. 2019) and childbirth-related PTSD (Ayers et al. 2016). Current research in Queensland is exploring the role of protective factors and potential benefits of their inclusion in perinatal mental health screening tools such as the iCOPE screening platform. 

It should be noted that scoring high on a perinatal mental health screening tool does not represent a diagnosis.

Clinical screening tools allow health care providers to gather information about a patient to identify potential risk factors, and enable clinical decision-making to provide support, formal mental health assessment and referral. 

Risk factors may be identified:

  • by specific item(s) in the tool — for example, answering ‘Yes’ to the ANRQ question ‘Have you ever been sexually or physically abused?’ identifies a history of abuse.
  • by a combination of items in the tool — for example, responses to items in the EPDS are scored from zero to 3, and a combined score of 5 or higher for the items ‘I have blamed myself unnecessarily when things went wrong,’ ‘I have been anxious or worried for no good reason,’ and ‘I have felt scared or panicky for no very good reason,’ identifies a risk of anxiety.
  • by overall score — for example, a total score for all items in the EPDS of 13 or higher identifies a risk of depression.
  • by more than one tool — for example, both the ANRQ and EPDS have items that may identify a risk of anxiety.

Refer to the Glossary for more information about terms and clinical tools. This report focuses on mental health and psychosocial risk factor screening, which can also include screening for family violence. For more information about family violence data see Family, domestic and sexual violence: National data landscape 2022.

Perinatal mental health screening and identifying risk of suicide and intentional self-harm

Where to find help and support

The AIHW respectfully acknowledges those who have died or have been affected by suicide or intentional self-harm. We are committed to ensuring our work continues to inform improvements in both community awareness and prevention of suicide and self-harm. This page discusses suicide and presents material that some people may find distressing. If this report raises any issues for you, support services can help. Crisis support services can be reached 24 hours a day.

Mindframe is a national program supporting safe media coverage and communication about suicide, mental ill health and alcohol and other drugs. Resources to support reporting and professional communication are available on the Mindframe website. 

Visit Suicide & self-harm monitoring for information on suicide and self-harm data.

 Suicide and intentional self-harm are complex issues and can have multiple contributing factors. Screening for mental and psychosocial risk factors plays an important role in providing timely support, further assessment and follow-up for women. In a study of women giving birth in Western Sydney between 2006 and 2016, women reporting intimate partner violence at their first antenatal care visit were more likely to have an EPDS score above 13, to have had a history of anxiety and depression, or to have had thoughts of self-harm (Dahlen et al. 2018). Further assessment is recommended for any women who report thoughts of self-harm on the EPDS, regardless of total EPDS score (Highet et al. 2023). Experiencing one or more psychosocial risk factors does not mean a person will experience suicidal behaviours, and most people experiencing psychosocial risk factors will not experience suicidal behaviours (AIHW 2023).

While most individuals with a mental health condition do not report suicidal behaviours, suicidality is more prevalent for people with a mental health condition compared to those without (AIHW 2022d). In the 2007 National Survey of Mental Health and Wellbeing, almost 3 in 4 people exhibiting suicidality (72%) reported a mental health condition in the preceding 12 months (ABS 2008). Research indicates that individuals with a diagnosed mental illness such as borderline personality disorder, psychotic disorders and severe perinatal depression are at increased risk of suicidality and intentional self-harm (Cantwell et al. 2011; Kroger et al. 2011).

Death by suicide was the leading cause of death for women in Australia aged 15-44 between 2011 and 2020 (ABS 2013, 2014, 2015, 2016a, 2016b, 2017, 2018b, 2019, 2020, 2021) and was one of the leading causes of maternal death in Australia, accounting for 10% of maternal deaths (20 women) between 2011 and 2020 (AIHW 2022c). Maternal death is defined as the death of a woman while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and outcome of the pregnancy.

Research indicates the risk of death by suicide may be even higher between 43 and 365 days after the end of pregnancy. In Queensland between 2014 and 2019, 31 of the 130 deaths during pregnancy and up to 1 year postpartum (24%) were by suicide of which 27 (87%) occurred after 42 days postpartum (Queensland Health 2018, 2020, 2022). 

Mental health screening is a critical tool for the early identification of women at risk of suicide, and can reduce the risk of perinatal suicide if supported by strong referral pathways that connect at-risk mothers to accessible mental health care and support (Chin et al. 2022).

For further information see: Australia’s mothers and babies: Maternal deaths and Suicide & self-harm monitoring, and refer to the Glossary for more information about terms used.

If you or someone you know needs help, contact: 

When are women screened?

National guidelines recommend all women are routinely screened for depression and psychosocial risk factors at least twice during pregnancy and twice during the first year after birth (Highet et al. 2023).

In practice, women may not be routinely screened, or may be screened multiple times across a range antenatal and postnatal mental health settings (Figure 1). Health care is provided in many ways during and after pregnancy, depending on the woman’s health care needs, personal preference, individual circumstances and where they live. Settings include public hospitals, private hospitals, antenatal clinics, maternal and child health services, local primary health care services, Aboriginal Community Controlled Health Services and outreach home visits. While there are national guidelines, there are differences across state and territories and health settings in how, when and if women are screened for perinatal mental health and psychosocial risk factors.

Although perinatal mental health screening has increased over time, research indicates that some groups have historically been under-represented including First Nations women, women born overseas, single or separated women, private patients and older mothers (Moss et al. 2020; San Martin Porter et al. 2019).

Figure 1: Services where women may be offered perinatal mental health screening, noting potential data sources and funding sources

Perinatal mental health screening settings

Perinatal mental health screening settings include:

  • Public hospital admitted patient(a)
  • Public hospital outpatient services, including antenatal clinics and maternity, child and family health services
  • Private hospital admitted patient(a)
  • Out-of-hospital care by allied health workers, including psychologists and other allied mental health workers
  • Out-of-hospital care by medical practitioners, including general practitioners, obstetricians, and other specialists. Includes some maternity and family practices, Aboriginal Health Services and endorsed midwives and nurses working in private practices in a collaborative arrangement with a medical practitioner 

Funding

  • State funding covers public admitted patient and outpatient services. 
  • Medicare subsidised services include out-of-hospital care by medical practitioners, and some public outpatient services, private hospital services and out-of-hospital care provided by allied health workers(b).
  • Private health insurance funds some private hospital care, and out-of-hospital care provided by allied health workers.
  • Some private hospital care, and out-of-hospital care provided by allied health workers is funded by the patient.

Data sources

Potential data sources include:

  • the NPDC for public hospital settings.
  • State and territory perinatal data holdings for state funded services.
  • The Medicare Benefits Schedule (MBS) for MBS subsidised services.
  • Private health insurance data for services funded by private health insurance.
  • And local hospital network/hospital/practice level health information management systems (HIMS).

Notes:
(a) Hospital admission includes admissions related to pregnancy and childbirth, as well as specialised mental health inpatient services. Local referral pathways may exist to ensure the mother receives appropriate care including screening at the right time. Screening for mental health risk factors, for example with the EPDS, may not be needed in these circumstances due to other processes being in place to assess the patient’s mental health.

(b) In 2021–22, 11% of all outpatient (non-admitted) service events in public hospitals were covered by the MBS.

What treatment and support services are available?

Data and discussion about the availability and efficacy of treatment and support services are out of scope for this report but a useful report to refer to is the AIHW’s Resources for supporting psychosocial health in pregnancy for details of clinical guidelines, screening tools and information about services for supporting psychosocial health during pregnancy. There are also a range of treatment and support services provided by private providers like General Practitioners (GPs), as well as Primary Health Networks (PHNs), state and territory government agencies, and non-government organisations. Mothers may also receive support for mental health and psychosocial issues through more general crisis and support services.

Why is national collection of perinatal mental health screening data important and what data are available?

Consistent, nationally collected perinatal mental health screening data helps build the evidence about women’s exposure to risk and protective factors, presentation patterns (before, during and after pregnancy), and health outcomes for mothers and babies across Australia. It enables targeted initiatives, service coordination and delivery, and further research and evaluation to ensure that women and families receive the care they need when they need it, particularly for priority population groups. 

Mental health and family violence Perinatal NBEDS items

The AIHW started investigating the feasibility of including antenatal mental health and family violence screening data in the NPDC in 2010. The NPDC includes the Perinatal National Minimum Data Set (NMDS), a collection of mandatory data items that state and territory health authorities have agreed to supply, and the Perinatal National Best Endeavours Data Set (NBEDS), a collection of data items that are not mandated for national collection but for which there is a commitment to provide data nationally on a best endeavours basis. Several antenatal mental health and family violence data items were developed and refined in consultation with subject matter and data experts between 2013 and 2019. Voluntary implementation of the following four mental health and family violence data items commenced July 2020 through the Perinatal NBEDS 2020–21:

  1. Antenatal mental health risk screening status (METEOR identifier 733468)
  2. Indication of possible symptoms of depression at an antenatal care visit, Edinburgh Postnatal Depression Scale (EPDS) score (METEOR identifier 704384) 
  3. Presence or history of mental health condition indicator (METEOR identifier 622450) 
  4. Family violence screening status (METEOR identifier 733542).

State and territory health authorities are working to implement the four voluntary mental health and family violence Perinatal NBEDS items into their perinatal data collections, and the AIHW is working with them to refine specifications (where required) and progress the items to the mandatory Perinatal NMDS. Data about the postnatal period after discharge are out of scope for the NPDC. 

Perinatal Mental Health pilot

The AIHW is working with state and territory health authorities to develop the Perinatal Mental Health pilot (PMHp), a novel collection of de-identified screening data from public antenatal and postnatal maternity health services. This project is piloting the collection of de-identified clinical data for research purposes in a faster way, compared to traditional data flow pathways, by collecting data through a range of sources:

  • the Centre of Perinatal Excellence’s (COPE) implementation of the iCOPE screening platform to Australian public maternity hospitals and other settings 
  • existing perinatal mental health data supplied directly from state and territory health authorities. 

The PMHp is being established as Local Hospital Networks (LHNs) and state and territory health authorities confirm their interest to participate. The PMHp aims to complement and potentially support the refinement of the NPDC, by collecting data that is currently out of scope for the NPDC. 

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