New South Wales case study: Mental health and psychosocial risk factor screening

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Safe Start

New South Wales (NSW) Health’s Safe Start model aims to provide universal preventative screening during the perinatal period and delivers psychosocial, domestic violence and mental health screening for women birthing in public maternity services. Perinatal women are screened at least once during the antenatal and postnatal periods, with repeated screening when indicated, using the Safe Start psychosocial assessment tool, the Edinburgh Postnatal Depression Scale (EPDS) and domestic violence routine screening. Clinicians administer the screening tools in the context of a clinical interview and use the patient-reported responses with their own observations and clinical judgement to discuss and determine the woman’s needs. Safe Start screening aims to identify women at higher risk of mental health and psychosocial concerns by screening for the following risk factors:

  • high risk of depression 
  • thoughts of self-harm
  • possible symptoms of anxiety 
  • lack of support (practical support with their baby* and emotional support from being able to talk about feelings and worries)
  • major stressors in the past year (for example, financial stress, loss or grief, trauma)
  • history of mental health problems
  • adverse childhood experiences (physical, emotional or sexual abuse)
  • current or recent domestic violence
  • relationship problems or dysfunction*.

* Data for ‘Lack of practical support’ and ‘Relationship problems or dysfunction’ were not supplied to the AIHW due to confidentiality requirements.

Interpreting risk factors

The presence of one or more Safe Start risk factors does not on its own indicate severity or impact on the woman. Clinical decisions about whether a woman would benefit from additional supports or referral to specialist services are complex, and take into consideration the number, combination, intensity and impact of risk factors on mothers. Data about clinical judgements on risk and referral are captured in clinical notes but are not available for this report. Women with higher levels of risk receive further assessment in triaged processes, such as multidisciplinary meetings, always with the woman’s informed consent and expressed choices.

Initial findings

Counting mothers

In this section, mothers with multiple screening records are counted once for each pregnancy they received screening for. 

For more detail, see Technical notes.

New South Wales supplied de-identified antenatal mental health, psychosocial and domestic violence screening data from public maternity services between July 2019 and June 2022. This included data collected using Safe Start or the EPDS for 207,110 mothers. From 2020 to 2022, 204,880 mothers gave birth in public hospitals (excluding birthing centres) within the supplied local health districts (referred to as Local Hospital Networks nationally). 

Data were supplied for all 6 metropolitan and 9 regional and rural Local Health Districts (LHDs). Data are not available for:

  • mothers who exclusively received antenatal mental health and domestic violence screening in other settings, such as through antenatal care provided by their general practitioner (where this was not subsequently included in their public maternity care record)
  • mothers who were not offered or declined mental health and/or domestic violence screening during their pregnancy
  • mothers who received maternity care through speciality networks (St Vincent’s Health Network, Sydney Children’s Hospitals Network and Justice Health and Forensic Mental Health)
  • mothers who did not access public maternity care – between 2020 and 2022, around 1 in 5 (22%) mothers in New South Wales gave birth in a private hospital (CEE 2024).

Limitations on the supplied data are not a reflection on statewide completion rates for Safe Start antenatal screening. Between January 2018 and June 2022, an internal New South Wales data report found high average completion rates for the EPDS (96%) and Safe Start psychosocial (94%) and domestic violence questions (91%) across 13 LHDs using the eMaternity information management system.

From July 2019 to June 2022, the number of mothers screened remained steady in regional and rural LHDs (Figure 6). While the number of mothers screened declined in metropolitan LHDs, which corresponds to a decline in the number of public hospital births across the supplied LHDs, from a peak of 36,538 in the first half of 2021 down to 32,327 in the second half of 2022. This decline was stronger in metropolitan LHDs, where a 14% reduction in the number of births was observed, compared to 7% in regional and rural LHDs.  Further variation may be explained by public health responses to the COVID‑19 pandemic, such as the drop in the number of mothers screened when New South Wales first implemented statewide COVID‑19 restrictions from 6,071 in March 2020 to 4,644 in April 2020 (Figure 6). 

Figure 6: Number of mothers screened in public maternity services, by metropolitan and regional or rural LHDs and month, New South Wales, July 2019 to June 2022

Source: AIHW analysis of NSW antenatal mental health and domestic violence screening data, July 2019 to June 2022.

Notes: 

  1. Regional/rural LHDs include Central Coast, Far West, Hunter New England, Illawarra Shoalhaven, Mid North Coast, Murrumbidgee, Northern NSW, Southern NSW and Western NSW LHDs. Metropolitan LHDs include Nepean Blue Mountains, Northern Sydney, South Eastern, South Western Sydney, Sydney and Western Sydney LHDs.
  2. Mothers are counted for each separate pregnancy. Where multiple screening events occurred during the same pregnancy, mothers are reported as having a risk factor if it was recorded during any screening event for their pregnancy.

Representativeness and comparability

Care should be taken when interpreting the following data as there are notable demographic differences between mothers who gave birth in New South Wales public hospitals and those in other sectors or jurisdictions.

Between 2020 and 2022, mothers who gave birth in New South Wales public hospitals (Figure 7):

  • were more likely to be younger, to live in more disadvantaged socio-economic areas or to be First Nations mothers, and less likely to live in major cities compared to mothers giving birth in New South Wales private hospitals
  • were more likely to live in areas with higher socio-economic disadvantage compared to all mothers in Australia
  • were more likely to be First Nations mothers compared to all mothers in Australia.

While these data may not be nationally representative, there is still value in exploring the differences between different cohorts within the available data.

Figure 7: Demographic differences between mothers giving birth in New South Wales public and private hospitals, public hospitals in other jurisdictions and all mothers nationally, 2020–2022

Source: AIHW analysis of NPDC data 2020 to 2022.

Mental health and psychosocial risk factors

In the supplied public antenatal screening data collected from July 2019 to June 2022 (Figure 8):

  • a third of women reported major stressors in the past year (33%)
  • possible symptoms of anxiety were identified for around 1 in 5 women (19%)
  • 1 in 5 women (20%) reported a history of mental health problems
  • 1 in 9 women (11%) reported a history of childhood abuse (physical, emotional or sexual)
  • 5.8% of women screened with the EPDS scored 13 or above, indicating a high risk of depression.

Figure 8: Percentage of screened mothers with Safe Start and EPDS assessed risk factors in the antenatal period, available LHDs, New South Wales, July 2019 to June 2022

Source: AIHW analysis of NSW antenatal mental health and domestic violence screening data, July 2019 to June 2022.

Notes: 

  1. Mothers are counted for each separate pregnancy. Where multiple screening events occurred during the same pregnancy, mothers are reported as having a risk factor if it was recorded during any screening event for their pregnancy.
  2. Metropolitan includes hospitals in Nepean Blue Mountains, Northern Sydney, South Eastern Sydney, South Western Sydney, Sydney and Western Sydney LHDs.
    Regional or rural includes hospitals in Central Coast, Hunter New England, Illawarra Shoalhaven, Far West, Mid North Coast, Murrumbidgee, Northern NSW, Southern NSW and Western NSW LHDs.
    Excludes records with unknown screening location.
  3. Records with missing responses for items used to indicate specific risk factors are excluded when calculating the percentage of mothers with that risk factor.
  4. See Technical notes for risk factor definitions.

Maternal age

From July 2019 to June 2022, mothers aged under 20 were the most likely to be identified at risk for each individual Safe Start or EPDS risk factor (Figure 9), including having:

  • major stressors in the past year (47% of women aged under 20 compared to 37% of women aged 20–24)
  • a history of mental health problems (34% of women aged under 20 compared to 25% of women aged 20–24)
  • experienced emotional, physical or sexual abuse in childhood (31% of women aged under 20 compared to 18% of women aged 20–24)
  • possible symptoms of anxiety (36% of women aged under 20 compared to 28% of women aged 20–24)
  • a high risk of depression (16% of mothers aged under 20 compared to 10% of mothers aged 20–24)

One in 12 mothers aged under 20 reported thoughts of self-harm (8.7%), proportionally more than for mothers aged 20–24 (4.2%) or over 25 (1.6%).

Meanwhile, mothers aged 35 and over were more likely to report having experienced major stressors in the past 12 months (35%) compared with mothers aged 25–29 or 30–34 (both 31%).

Figure 9: Percentage of screened mothers with Safe Start and EPDS assessed risk factors in the antenatal period, by maternal age at screening, available LHDs, New South Wales, July 2019 to June 2022

Source: AIHW analysis of NSW antenatal mental health and domestic violence screening data, July 2019 to June 2022.

Notes:

  1. Mothers are counted for each separate pregnancy. Where multiple screening events occurred during the same pregnancy, mothers are reported as having a risk factor if it was recorded during any screening event for their pregnancy.
  2. Excludes mothers with unknown age at screening, or whose calculated age at screening was less then 10 or greater than 60.
  3. Records with missing responses for items used to indicate specific risk factors are excluded when calculating the percentage of mothers with that risk factor.
  4. See Technical notes for risk factor definitions.

First Nations mothers

Supplied public antenatal data from July 2019 to June 2022 included 14,085 First Nations mothers, 6.8% of all mothers in the supplied data. From 2020 to 2022 there were 13,168 (6.4%) First Nations mothers who gave birth in public hospitals within the supplied LHDs.

From July 2019 and June 2022:

  • almost half of the First Nations mothers reported major stressors in the past year (crude proportion 47%, 6,084 mothers) (Figure 10)
  • almost 1 in 8 First Nations mothers had an EPDS score indicating a high risk of depression (crude proportion 12%, 1,535 mothers), while 3 in 10 (crude proportion 29%, 3,377 mothers) reported possible symptoms of anxiety
  • the number of First Nations mothers who reported having experienced physical, emotional or sexual abuse during childhood was 3,265, with a crude proportion of 27%
  • the number of First Nations mothers who reported thoughts of self-harm was 707, with a crude proportion of 5.6%
  • the number of First Nations mothers who reported experiencing domestic violence was 1,565, at a crude proportion of 12%.

After adjusting for differences in the age structure, First Nations women were twice as likely to report experiencing physical, emotional or sexual abuse during childhood (rate ratio of 2.1), and more than two and a half times as likely to report having experienced domestic violence (rate ratio of 2.8).

Figure 10: Percentage of screened First Nations and non-Indigenous mothers with Safe Start and EPDS assessed risk factors in the antenatal period, available LHDs, New South Wales, July 2019 to June 2022

Source: AIHW analysis of NSW antenatal mental health and domestic violence screening data, July 2019 to June 2022.

Notes:

  1. Age-standardised proportions calculated using direct age-standardisation with the June 2001 Australian female estimated resident population aged 15–44 years as the standard population.
  2. Mothers are counted for each separate pregnancy. Where multiple screening events occurred during the same pregnancy, mothers are reported as having a risk factor if it was recorded during any screening event for their pregnancy.
  3. First Nations mothers are counted as those who ever indicated being of Aboriginal or Torres Strait Islander origin. Remaining mothers were counted as non-Indigenous if they indicated not being of Aboriginal or Torres Strait Islander origin, otherwise were excluded.
  4. Records with missing responses for items used to indicate specific risk factors are excluded when calculating the percentage of mothers with that risk factor.
  5. See Technical notes for risk factor definitions.

Regional and rural local health districts

Data were supplied for all regional and rural LHDs and all metropolitan LHDs. In the supplied data, 81,282 mothers (39%) were screened in regional or rural public hospitals, while births in regional and rural hospitals accounted for 39% of mothers giving birth in New South Wales public hospitals from 2020 to 2022.

Compared to mothers screened in regional or rural public hospitals, between July 2019 and June 2022, mothers screened in metropolitan public hospitals were less likely to report a high risk of depression (5.0% vs 7.0%), possible symptoms of anxiety (16% vs 21%) and were almost half as likely to report thoughts of self-harm (1.6% vs 2.9%) (Figure 11).

Mothers screened in metropolitan public hospitals were also less likely to report a history of mental health problems (16% vs 25%) or having experienced abuse during childhood (9.0% vs 15%) compared with mothers screened in regional or rural public hospitals.

Figure 11: Percentage of screened mothers with Safe Start and EPDS assessed risk factors in the antenatal period, metropolitan and regional or rural public hospitals, available LHDs, New South Wales, July 2019 to June 2022

Source: AIHW analysis of NSW antenatal mental health and domestic violence screening data, July 2019 to June 2022.

Notes:

  1. Mothers are counted for each separate pregnancy. Where multiple screening events occurred during the same pregnancy, mothers are reported as having a risk factor if it was recorded during any screening event for their pregnancy.
  2. Metropolitan includes hospitals in Nepean Blue Mountains, Northern Sydney, South Eastern Sydney, South Western Sydney, Sydney and Western Sydney LHDs.
    Regional or rural includes hospitals in Central Coast, Hunter New England, Illawarra Shoalhaven, Far West, Mid North Coast, Murrumbidgee, Northern NSW, Southern NSW and Western NSW LHDs.
    Excludes records with unknown screening location.
  3. Records with missing responses for items used to indicate specific risk factors are excluded when calculating the percentage of mothers with that risk factor.
  4. See Technical notes for risk factor definitions.

References

Centre for Epidemiology and Evidence (CEE) (2024) Place of birth, NSW Ministry of Health, Sydney, accessed 25 October 2024.

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