Elsevier

Women and Birth

Volume 32, Issue 3, June 2019, Pages e351-e358
Women and Birth

A brief survey to identify pregnant women experiencing increased psychosocial and socioeconomic risk

https://doi.org/10.1016/j.wombi.2018.08.162Get rights and content

Abstract

Problem

Identifying pregnant women whose children are at risk of poorer development in a rapid, acceptable and feasible way.

Background

A range of antenatal psychosocial and socioeconomic risk factors adversely impact children’s health, behaviour and cognition.

Aim

Investigate whether a brief, waiting room survey of risk factors identifies women experiencing increased antenatal psychosocial and socioeconomic risk when asked in a private, in-home interview.

Methods

Brief 10-item survey (including age, social support, health, smoking, stress/anxious mood, education, household income, employment) collected from pregnant women attending 10 Australian public birthing hospitals, used to determine eligibility (at least 2 adverse items) for the “right@home” trial. 735 eligible women completed a private, in-home interview (including mental health, wellbeing, substance use, domestic violence, housing problems). Regression models tested for dose-response trends between the survey risk factor count and interview measures.

Findings

38%, 31%, 15% and 16% of women reported a survey count of 2, 3, 4 and 5 or more adverse risk factors, respectively. Dose-response relationships were evident between the survey count and interview measures, e.g. of women with a survey count of 2, 8% reported ever having a drug problem, 4% experienced domestic violence in the last year and 10% experienced housing problems, contrasting with 31%, 31% and 26%, respectively, for women reporting a survey count of 5 or more.

Discussion/Conclusions

A brief, waiting room survey of psychosocial and socioeconomic risk factors concurs with a private antenatal risk factor interview, and could help health professionals quickly identify which women would benefit from more support.

Introduction

A range of psychosocial and socioeconomic parental risk factors, such as low socioeconomic status, single parenthood, low educational attainment and poor mental health, have been associated with poorer cognitive, language and socioemotional outcomes in Australian children.1, 2 Similar relationships have been found in cohorts from the United Kingdom, Canada and New Zealand.3, 4, 5 Parental psychosocial and socioeconomic risk factors commonly co-occur and the severity of children’s later problems increases as the number of risk factors increases. For example, a survey of 53,000 Australian children starting school in the state of Victoria found that, compared with children raised in families reporting zero of five risk factors for comorbid speech-language and socioemotional problems, the risk of problems doubled for children raised in families reporting two risk factors; trebled for those reporting three; and was more than six times as likely for those reporting four or five risks.1 Over time, such disparities increase and become more difficult to divert,6 translating to poorer health and wellbeing, and lower education and income across adulthood.7

Families experiencing adversity are the least likely to access services they need, despite having the greatest need for support.8 In considering what is known about prevention, early intervention and return on investment,6, 9 pregnancy is an opportune time to assess women’s levels of psychosocial and socioeconomic risk and intervene, because almost all Australian women obtain professional antenatal healthcare, i.e. more than 99% receive at least one antenatal health appointment, and 95% receive five or more.10 While Australia’s health platforms have universal coverage, antenatal risk assessments differ between states, regions and clinics, likely due to the challenges inherent in assessment. There are many, varied risks that can impact on women’s and children’s health, meaning that health professionals must choose which ones to assess in limited consultation times. This range is reflected in the Australian government’s clinical practice guidelines for antenatal care11, which recommend assessing factors such as medical history, lifestyle factors (e.g. smoking, alcohol use) and psychosocial factors (e.g. mental health problems, domestic violence); yet, do not mention other known risk factors for children’s outcomes such as poverty, low income or education. Additionally, the sensitive nature of antenatal assessments may deter women from disclosing some risks. Questions about psychosocial risks like substance use and domestic violence have been shown to cause distress, with women perceiving the items as unexpected, intrusive and uncomfortable, regardless of whether they reported risk factors.12

These challenges suggest that other ways of assessing antenatal psychosocial and socioeconomic risk in Australian women could be more comprehensive, acceptable and less intrusive. Given the common concurrence of risk factors,3 assessing a broader and less sensitive range of risks factors could help clinicians quickly identify women and families who would benefit from more support. In an earlier pilot study (n = 186), we demonstrated that a brief risk factor survey (referred to hereafter as BRF survey), which assesses a broad range of 10 known adverse risk factors – and is also the focus of this investigation – is acceptable to pregnant women and feasible to collect in the waiting rooms of antenatal clinics.13 While the survey design attempted to capture the most important antenatal psychosocial and socioeconomic risks predictive of poorer child development outcomes, some were not included in the survey (e.g. antenatal substance use, family violence), which are profound risk factors for poorer child development but were too sensitive to ask in the waiting rooms.14, 15 However, the pilot study examined the associations between the BRF survey and the more sensitive antenatal risk data collected by midwives in the standard clinical appointments. Using linked data, the pilot found that BRF survey counts of 1 (28% of the women surveyed in the pilot), 2 (17%) or 3 or more adverse risk factors (22%), identified 92%, 61% and 44%, respectively, of women who reported other more sensitive risk factors (e.g. alcohol and drug use, domestic violence) in the standard clinical appointment setting.13

The pilot study’s success led to the use of the BRF survey in assessing 5586 pregnant Australian women for eligibility for the “right@home” randomised controlled trial (RCT).16, 17 Women who met an eligibility criterion of at least 2 adverse risk factors on the BRF survey were invited to enrol in the RCT and subsequently complete a sensitive risk factor interview (referred to hereafter as SRF interview, N = 735). Extending the work of the pilot study, this paper aimed to investigate whether the BRF survey identified women experiencing increased antenatal psychosocial and socioeconomic risk based on the SRF interview. We hypothesised that an increasing count of adverse BRF survey items would be associated with increased risk based on the SRF interview.

Section snippets

Design and setting

This cross-sectional study was nested within a RCT of sustained nurse home visiting (see protocol17). We investigated whether the BRF survey – used to identify pregnant women who may be eligible to participate in the RCT – concurred with the SRF interview conducted as the baseline interview of the RCT.

Participants

Pregnant women attending antenatal clinics at 10 public birthing hospitals between 30 April 2013 and 29 August 2014, who completed the BRF survey and SRF interview components of the RCT enrolment

Results

Of 9511 pregnant women approached for the BRF survey, 2534 were identified as ineligible before completing the survey (see Fig. 1). Of the remaining 6977 women, 5586 (80.1%) completed the BRF survey, 923 (13.2%) declined and 468 (6.7%) left the waiting room before completing it. Of the 5586 women surveyed, 1427 were eligible for the RCT and 4159 were not because they reported an adverse BRF count of one (n = 1658) or zero (n = 1753), or met other exclusion criteria (n = 748). Of the 1427 eligible

Discussion

This paper demonstrated that a brief survey of risk factors identified pregnant women experiencing increased psychosocial and socioeconomic risk based on a sensitive risk factor interview. For all adverse BRF survey items that women reported (except for young pregnancy (<23 years) and never having worked) there was a pattern of increased risk across a range of SRF interview risks. Notably, an increasing count of adverse BRF survey items – especially five or more – concurred with substantially

Conclusion

A brief survey of psychosocial and socioeconomic risk factors – that was acceptable to women and feasible to collect in antenatal clinic waiting rooms – concurred with more sensitive, privately-asked risk factors that are known to adversely impact children’s development. This paper demonstrates that a substantial proportion of Australian women are experiencing high levels of psychosocial and socioeconomic risk during pregnancy, and suggests that implementing a brief risk factor survey might

Clinical trial registration

International Standard Randomized Controlled Trial Number ISRCTN89962120 (for larger randomized controlled trial).

Competing interests

The authors have no competing interests to declare.

Authors’ contributions

Anna Price: Contributed to the conception of the design and paper, and interpretation of data; was responsible for first and final drafts; and approved the final manuscript.

Hannah Bryson: Coordinated and supervised data collection, assisted with data cleaning and analyses, was involved in writing and editing of drafts, and approved the final manuscript.

Fiona Mensah: Contributed to the conception of the design and paper, advised statistical analyses, was involved in writing and editing of

Funding and disclosure statement

This work is supported by the Victorian Department of Education and Training, the Tasmanian Department of Health and Human Services, the Ian Potter Foundation, Sabemo Trust, Sidney Myer fund, the Vincent Fairfax Family Foundation, and the National Health and Medical Research Council (NHMRC, 1079418). The MCRI administered the research grant for the study and provided infrastructural support to its staff but played no role in the conduct or analysis of the trial. Research at the MCRI is

Ethical statement

This study was approved by the Human Research Ethics Committees of: The Royal Children’s Hospital (HREC 32296, Date of approval: 14/3/2013); Peninsula Health (HREC/13/PH/14, Date of approval: 22/4/2013); Ballarat Health Services (HREC/13/BHSSJOG/9, Date of approval: 23/4/2013); Southern Health (HREC 13084X, Date of approval: 17/5/2013); Northern Health (HREC P03/13, Date of approval: 7/5/2013) in Victoria, Australia; and The University of Tasmania (HREC H0013113, Date of approval: 13/5/2013),

Acknowledgements

The “right@home” sustained nurse home visiting trial is a research collaboration between the Australian Research Alliance for Children and Youth (ARACY); the Translational Research and Social Innovation (TReSI) Group at Western Sydney University; and the Centre for Community Child Health (CCCH), which is a department of The Royal Children's Hospital and a research group of Murdoch Children’s Research Institute. We thank all families, the research assistants, and nurses and social care

References (32)

  • C.T. Ramey et al.

    Early intervention and early experience

    Am Psychol

    (1998)
  • J.T. Hart

    The inverse care law

    Lancet

    (1971)
  • Organization WH. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health:...
  • Australian Institute of Health and Welfare 2013. Australian hospital statistics 2011–12. Health services series no. 50....
  • Australian Government Department of Health and Ageing

    Clinical practice guidelines — pregnancy care guidelines

    (2018)
  • M. Rollans et al.

    Digging over that old ground: an Australian perspective of women’s experience of psychosocial assessment and depression screening in pregnancy and following birth

    BMC Women’s Health

    (2013)
  • Cited by (14)

    • The Impact of Nurse Home Visiting on the Use, Dose and Quality of Formal Childcare: 3-Year Follow-Up of a Randomized Trial

      2022, Academic Pediatrics
      Citation Excerpt :

      Researchers recruited pregnant women attending antenatal clinics of 10 public maternity hospitals across Victoria and Tasmania from April 30, 2013 to August 29, 2014 (details previously published).17,18 Eligible women: 1) had due dates before October 1, 2014, 2) were less than 37 weeks gestation, had 3) sufficient English to complete interviews, 4) at least 2 of 10 risk factors identified via a brief screening survey,19–21 and 5) home addresses within study boundaries. Women were excluded if: 1) enrolled in an existing Tasmanian NHV program, 2) did not comprehend recruitment (eg, intellectual disability or insufficient English), 3) had no mechanism for contact (telephone, email), or 4) experienced a critical event (termination of pregnancy, stillbirth, child or parent death).

    • Examining longitudinal associations between self-reported depression, anxiety and stress symptoms and hair cortisol among mothers of young children

      2021, Journal of Affective Disorders
      Citation Excerpt :

      While the focus of the current study was on mental health and HCC, associations between proxy measures of socioeconomic status selected as potential confounders (mothers’ education levels, source of household income, count of screening survey risk factors, SEIFA) and HCC were also examined. Given the known relationship between lower socioeconomic status and greater psychological stress (Giallo et al., 2014; Price et al., 2018), other studies have hypothesized associations between socioeconomic adversity and higher HCC. However, we found no evidence of associations between these socioeconomic measures and HCC, supporting existing research which indicates that evidence of these relationships is limited (Abell et al., 2016; Feller et al., 2014; Fischer et al., 2017; Staufenbiel et al., 2015).

    • A comparison of two measures to screen for mental health symptoms in pregnancy and early postpartum: the Matthey Generic Mood Questionnaire and the Depression, Anxiety, Stress Scales short-form

      2021, Journal of Affective Disorders
      Citation Excerpt :

      The current study was developed in response to the larger trial's need to include a short measure of significant emotional difficulties in a brief survey of psychosocial and sociodemographic risk factors (termed ‘adversity’ throughout) known to impact children's development. Assessing risk factors in a way that is acceptable to women and feasible in the public setting of antenatal waiting rooms can be challenging, and the process was thoroughly piloted (published in Price et al. 2017, Price et al. 2018). The resulting 10-item brief risk factor (BRF) survey included the MGMQ and was used to identify women who were experiencing adversity and thus eligible to participate in the trial.

    View all citing articles on Scopus
    View full text