Review of perinatal mental health screening approaches

Pregnancy and the first couple of years following birth can be a challenging time for parents, carers and families, with an increased prevalence of mental ill health. The Royal Commission into Victoria’s Mental Health System identified a need to review approaches to perinatal mental health screening to address inclusivity, cultural appropriateness and the therapeutic context of screening (recommendation 18.2). To respond to that recommendation the Victorian Department of Heath commissioned KPMG and Monash University to review the evidence and develop recommendations.

The review was informed by:

• A literature review that examined peer reviewed research and relevant grey literature published from 2012 to 2022.
• A workforce screening practice survey with 276 respondents, including 71 midwives, 109 MCH nurses and 96 other clinicians and service representatives.
• Screening data from 81 MCH services and 19 maternity services across a five-year period from 2017 to 2022.
• Consultations with 94 stakeholders, including midwives, MCH nurses, people with lived experience of mental ill health and sector organisations.

Key findings

Most pregnant people miss out on screening and only half are screened postnatally using the Edinburgh Postnatal Depression Scale (EPDS).

• One in four people experience mental ill health throughout the perinatal period.
• 70 per cent of people who experience mental ill health before the birth of their child also experience mental ill health after birth.
• There is inconsistent perinatal mental health screening practice across Victoria in terms of frequency, timing and tools used. This is particularly the case for maternity services.
• Data from 19 health services indicates that one in three people are screened at least once during pregnancy using the EPDS.
• Data from 81 MCH services indicates that one in two people are screened at least once after birth using the EPDS (note the EPDS is a secondary screen postnatally).
• There are currently no state guidelines for screening during pregnancy, and MCH guidelines do not fully align with the national guidelines.

Screening is effective but tools and approaches do not meet the needs of some communities.

• The EPDS is the most common screening tool used across maternity and MCH services in Victoria.
• The literature and consultations with workforce and community representatives identified the EPDS is not appropriate for Aboriginal people, multicultural communities and some mental health conditions.
• People experiencing vulnerability and Aboriginal people are less likely to take part in screening.
• Literature shows some MCH nurses are less likely to screen people with low English proficiency.
• Some maternity and MCH teams are trialling the iCOPE digital screening tool, with most reporting it has increased the time available to discuss screening results.
• Existing service models provide limited opportunities for non-birthing parents to be screened.

Workforce capacity and capability affects screening.

• There is varied capability and confidence to undertake screening across maternity and MCH workforces, which is largely driven by lack of training opportunities.
• The workforce told us there isn’t enough time within the existing appointments to undertake screening well.
• There are missed opportunities for other workforces (for example, neonatal intensive care nurses and Aboriginal health workers) engaging with new and prospective parents to undertake screening.
• Mental health services consulted say they often receive inappropriate and/or unnecessary referrals from maternity and MCH services.

Continuity of care and access to timely services affects screening.

• A trusted relationship with clinicians is important for people to participate in screening and answer questions truthfully.
• Limited information sharing between maternity and MCH services, means people often need to retell their story.
• Workforce told us they are hesitant to screen when timely access to the right services is not available.
• Workforces are sometimes unable to identify the right referral pathway, especially for people with mild or moderate mental ill health.
• The workforce and people with lived experience say it can be difficult to find the right information about perinatal mental health and available services.
• Improved data collection is necessary to provide a greater understanding of screening practice and its impact.

Recommendations

Ten recommendations outline the key actions for change to improve the way mental health screening is undertaken across perinatal services in Victoria.

Strengthening screening practice across our systems of care.

1. Develop Victorian perinatal mental health screening guidelines.
2. Co-design an approach to screening with Aboriginal people.
3. Co-design an approach to screening with multicultural communities.
4. Monitor and support increased access to digital screening.

Building workforce capability and confidence across our services.

5. Deliver a workforce training program in line with new Victorian guidelines.
6. Improve access to online perinatal mental health resources for community and workforces.
7. Strengthen opportunities for workforces to share knowledge and best practice in perinatal mental health.

Improving experiences and continuity of care for people.

8. Review maternity and MCH data and information systems for better alignment to perinatal mental health screening guidelines.
9. Ensure models of care allow sufficient, dedicated time for screening, considering any workforce capacity impacts of new Victorian guidelines.
10. Improve timely local access to targeted support / services for people following screening.