Psychosocial Assessment and Depression Screening in Pregnancy
Psychosocial Assessment and Depression Screening in Pregnancy
Five key themes emerged from this analysis. The first three themes titled 'Unexpected – a bit out of the blue', 'Intrusive - very personal questions' and 'Uncomfortable - digging over that old ground' describe the impact that psychosocial assessment and depression screening had on women. The lack of preparation or surprise that women experienced in relation to being asked sensitive questions that may bring up past, difficult experiences can be modified by the approach that the midwife/CFHN takes to asking the questions. This is reflected in final two themes titled: Approach: 'sensitivity and care' and 'being watched'.
In addition to reporting the five major themes that emerged across the three data sets, the results reflect the longitudinal aspect of the study and aspects of the women's 'journey' across the two time periods when assessment occurred. Exemplars from two women are included to illustrate where women's experience and their responses either antenatally or postnatally, may have differed. These exemplars occur in the themes sensitivity and care and uncomfortable: 'digging over that old ground'.
Analysis of the observation tool (4D&4R) and interview transcript data indicate that when the midwife/CFHN first introduced the psychosocial assessment, whether that was at the start of the visit or well into the interaction, women appeared **'surprised 'or 'perplexed'. This was particularly so for women at the antenatal booking visit as this was often the first time they were asked these questions, but was also observed with some women having the home visit or clinic appointment after birth. Most of the women expressed in interview that they didn't '…expect…' the level of personal detail required to be shared at the visits and felt '…surprised…' by the personal nature and sensitivity of the questions, it came 'a bit out of the blue' (W9). However, they remained open to answering the questions stating at interview they 'understood' why the questions were being asked;
'I think the questions that they ask are sometimes very personal, but on the other side I understand why they have logic behind the asking. They want to find out about the woman so they can help her. Sometimes there were a few questions that were very personal, like about your sexual history, that a person doesn't like sharing the first visit.' (W18).
Women stated they were expecting the focus to be on either the physical progress of their pregnancy or the health and development of their baby rather than on their own emotional health and well-being, 'It seemed to be more about me than the baby' (W11); 'I felt it was more about me and it was more about my mental state, that sort of stuff…it was really more about how are you feeling? How are you coping?' (W7). Almost half, (25 out of 54) of the women observed either antenatally or postnatally, demonstrated a physical reaction when asked the psychosocial assessment questions. For example, some women showed a surprised expression (raising of the eyebrows, crinkling of the forehead skin), increased eye movement, a sudden turn of the head to face the midwife/CFHN and shifting in the seat. However, after this immediate or initial reaction, two thirds of the women, (38 out of 54) responded to the questions in an open and talkative way;
(FN5) Midwife was observed to ask the woman about asking questions related to W5 psychosocial history:
M2 - …there is also a section about you and I'll ask you some questions about your social and emotional wellbeing is that okay?
W5 – (turn her head and looks sharply at midwife) what do you mean, what sort of questions?
M2 – they're just some questions to see how you're coping and feeling stuff like that
W5 – Oh okay then (sits back in chair looks more relaxed and smiling)
Some women questioned the relevance of the psychosocial assessment questions 'She didn't check the baby's (fetal) heart rate it just seemed to be more about me, I'm not even sure why those other questions (psychosocial assessment questions) were relevant' (W19).
Women were also surprised that the antenatal and postnatal visits took much longer than they expected. They attributed this length of time to be about the paperwork or the amount of questions that were asked;
'I was surprised it took so long, I left mum in the car waiting, I didn't bring a bottle or a change of clothes with me or anything, I just didn't think it would take so long' (W7) or 'was basically paperwork, we did lots of paperwork rather than checkups' (W31).
Women's level of preparedness for the psychosocial assessment questions seemed to impact on their experience. Some of the women experienced discomfort stating that antenatally they were '…not feeling adequately prepared…' (W4).
W16 – I think they could have told me what they were going to ask before I even arrived for my appointment. I had no idea that was what was coming.
However, women who had a recent previous pregnancy and birth felt they were more prepared and appeared more relaxed;
'It was actually quite good. I actually quite enjoyed it. The first time you didn't know what to expect and some of the questions that they asked I thought were a bit surprising but the second time round it was like it was nothing. It was just a conversation; they just needed to know information' (W4).
During pregnancy and following the birth, it was evident that women expected the midwife or nurse was going to provide answers to their questions or advise them about caring for their baby, for example;
W6 – When I went for my first visit with the midwife I was like, right this is what we need to know and I just felt confident that the midwife would know exactly how to answer my questions
W1 - I knew that the nurse would come here to my home and help me to solve some of the problems with my baby'.
During interviews women stated that they understood why the midwife/CFHN was asking the questions and they believed that it was '...important…' and that they'…should be done…' (W16). When women had a positive experience disclosing a recent difficult personal experience, they were more likely to develop a sense of trust in the midwife that they '…could tell my story to anyone' (W12). However, women also described them as '… very personal questions…' and this evoked some discomfort at times and may have influenced whether they shared their story with the midwife/CFHN. Whilst most women explained that they responded honestly to the questions, stating they '… had nothing to hide…' (W21), some women did say that if they were experiencing distress they may not have disclosed this to the midwife/CFHN and would simply say '…no…' (W26). Due to the personal nature of the questions women reflected on whether they would discuss personal concerns with midwife/CFHN;
They ask very personal questions about your social circumstances and your relationships and things like that, which I have no problem answering but I can see how some people would if they had a problem it would be very hard to bring up like domestic violence or abuse or something like that (W26).
The observation data demonstrated support for women's level of openness and honesty. In almost all of the observation (53 out of 54) women responded to questions and some took some time to reflect on the answer. On one occasion when a woman was tearful she continued to exclaim that she was 'okay…no I'm alright' (W20) and declined to discuss any concerns with the midwife/CFHN. In 5 out of the 54 observations women were offered time to reflect on the questions they had been asked. In these instances women pondered for a moment to reflect on what they had been asked 'I guess I've never thought about it really but yes I guess I was a bit depressed when I was a teenager' (W30).
There appeared to be particular questions that caused women some discomfort. Questions about domestic violence were described as '…strange…' and '…funny…' One woman described her discomfort as '…feeling guilty…' (W11) about being asked the domestic violence questions as;
' I kind of likened it to you know when you come through customs and even though you know you've got nothing; you feel guilty because you now that customs people are there and they might think you've got something in your bags, even though you know you haven't…it was a bit like that feeling' (W11).
Similarly, some questions that were not deemed to be part of the psychosocial assessment were viewed as 'personal questions' by the women and provoked discomfort. For example, questions about previous pregnancies such as terminations or stillbirth 'I was really hoping it wouldn't come up… but when it does it's like all this emotion just exploding out of me…' (W12).
Women who did disclose a difficult current or past life event or experience in response to a question described the impact of this in varying ways. One woman described this as 'digging over that old ground' (W9). For others, talking about previous traumatic histories was '…daunting…', raising fears that women may be '…pushed back…' into reliving previous trauma. One woman stated, 'when those words come up again (postnatal depression) you don't want to be pushed back, like when the help is offered it's wonderful but I felt, no I'll be able to cope this time.' (W12) The retelling of a distressing experience may impact in a negative way on a woman's mood;
' It did feel like it brought up a lot of feelings for me, like the anxiety I had when I was developing postnatal depression with my first child, it was all there, I could feel it again' (W12).
Another woman also talked about her distress when asked to talk about a recent still birth. This was the first time she had returned to the hospital following a recent stillbirth;
it's difficult to reply to all those questions with all my background and all my past. It makes me so stressed, when I have to go through all the questions. That's my personal (feeling) . Maybe if people have a good past they'll enjoy it (W31).
Discussing previous trauma may not appear relevant for women at the present time of the visit '…it's not really affecting me now…my main concern is getting through the pregnancy, not worrying about my past stuff.' (W21). Women also described how they had to think carefully about how to respond to a sensitive question;
about suicidal and depressed – yeah, I was thinking actually how I put this?… because it's actually hard to know how to say it, so you go, well, 'how do I say this, yes I have had a plan to end my life cause I just didn't see a way out anymore (W18).
Women who did disclose previous trauma mostly felt the nurse or midwife responded appropriately, however, they suggested that the midwife/CFHN should review previous notes so they 'don't have to go real deep, they can just open my file instead' (W31) or;
'Why don't they take the extra time just to read over and if they have any more questions about it then they can ask. If it's already there then why bother… it is really frustrating' (W4).
At times, it was the response of the midwife or nurse to a woman's disclosure that caused them the most distress. One woman (W28) talked of her experience when she disclosed a previous history of anxiety, although this had not been formally diagnosis or treated. In this case, the midwife (M16) documented this information as a history of previous mental health problems on her medical record card. The woman saw this documented and in the interview she stated;
I didn't know that was written on the card, when I saw that there I was surprised because I don't feel like I'm depressed or have anxiety. So I think that process made me anxious. Because now they (other midwife/CFHN) ask me a lot about it and I am looking at it as a kind of an issue so it's creating like a dirty mark against my name (W28).
Some women who described a negative experience of psychosocial assessment indicated that they would inform other women and discourage other women from disclosing personal information;
I don't want her (sister) to go through the whole thing, I don't feel the need for her to bring it up, and I don't want her to go through her whole pregnancy having to see someone about her problems. So I told her about some of the stuff in regards to some of the questions they ask about your husband, whether or not he beats you up and I told her so she knows what will happen if she says anything (W4).
It's funny because when you talk to girlfriends who've had children, you hear everyone's different experiences and they say 'it's when they ask the questions it's like, you know, it's crazy (W25).
In some instances women's comfort regarding disclosure of previous negative life events to the midwife or nurse differed across the two points in time (antenatal or postnatal). The exemplar in Table 3 illustrates how W17s negative experience at the antenatal psychosocial assessment influenced her decision not to use postnatal services. At the antenatal booking visit, W17 disclosed a previous experience of domestic violence which occurred more than two years previously with an ex-husband who lives abroad. This history of domestic violence was incorrectly reported by the midwife in the medical records as occurring currently. Following birth, W17 was visited by a social worker who interviewed her about the safety of her current relationship with her husband. This was particularly distressing and intrusive for W17 and she subsequently refused ongoing services.
There were women who were dissatisfied with the health service. For example, some women were informed by the midwife/CFHN that they would be referred to services and then they did not subsequently receive any follow up. 'I waited and waited for her to call for two weeks… she said the social worker would call…but nobody called' (W18). Women suggested that a collaborative approach to recording the information gathered would demonstrate a level of respect and involve them in their care more productively 'maybe if she (the midwife) had asked me what I wanted put down on my card I would have felt she was helping me and being more considerate of me' (W28). However, the types of support that midwife/CFHN provided such as information and contact numbers was positively received 'The information she gave me I felt quite helpful and the telephone numbers so I know where to go' (W5).
Approach: Sensitivity and Care It was evident in this study that how women perceived the midwife/CFHN style or approach influenced their level of comfort with the clinical encounter in general and in particular with the psychosocial assessment and depression screening. The majority of the women described the midwife/CFHN as being 'friendly', 'warm' and 'caring' and they believed that the professionals were 'sensitive' to their needs: 'I felt she was very friendly and quite professional in the way she talked to me, I felt very relaxed.' (W1) or 'I found it a quite positive experience overall, I thought her approach was sensitive and caring, it was friendly' (W24). Some women indicated that asking the questions implied a '…sense of caring…' (W5) on the part of the midwife/CFHN.
Women were appreciative when the midwife or CFHN was sensitive and caring. For example, in the first interaction in Table 4 , Midwife (M9) demonstrated empathy and validated the woman's experience by acknowledging her difficult situation. Similarly when W11 disclosed that she had been experiencing emotional distress; she stated that she felt supported by the response from CFHN6 inviting her to discuss further (see Table 4 ).
Women also described the midwife/CFHN as helpful in terms of problem solving or assisting them to accept their pregnancy and the impact this may have on their psychosocial wellbeing. For example;
M5 – How are you feeling about being pregnant?
W10 – yeah ok (ambivalently), he's (turns to look at partner) so excited, I'm kind of getting used to it
M5 – Okay, I remember feeling like that too when I first got pregnant, what sort of things would help you to feel more comfortable about the pregnancy?
The women who came from non-English speaking backgrounds emphasised the importance of the non verbal communication from professionals commenting for example, on the midwife/CFHN facial expressions as an indicator of friendliness 'she always smiles and (is) very gentle' (W14) or 'She make me like not scared because she smile a lot, her smiling and the way she spoke was really helpful' (W3). They also expressed an ease of communication when the midwife/CFHN 'spoke slow to me' (W17) and 'explained the questions, even if I didn't understand first time round' (W2).
In contrast however, there were interactions where women did not receive an empathetic or sensitive response from their midwife or CFHN, as illustrated in the following interaction. For example, one woman (W4) expressed that she would prefer the midwife to refer to her medical records where she had previously disclosed trauma when asked during her first pregnancy;
M3 – so as a child were you hurt or abused in any way either physically, sexually or emotionally?
W4 – Yes
M3 –Did you want to tell me about that?
W4 – Isn't it in my file from last time?
M3 – No… Well I haven't read it… you can tell me about it now?
FN - Woman described her experience reluctantly
There were instances where women reported different experiences of sensitivity and care in interactions with the midwife or the nurse across the two time points (antenatal and postnatal). The exemplar in Table 5 demonstrates W12s' experience of M2s' sensitive and caring approach during her disclosure of a recent termination of pregnancy. This same woman (W12) however, was distressed by the response from the CFHN7 in the postnatal assessment where she disclosed that she felt traumatic by her caesarean birth. During interview with the researcher (MR), W12 stated that the nurse lacked sensitivity and caring.
Whilst most women were approached sensitively, some women talked about feeling as though they were being watched during the home visit by the CFHN. This was particularly reported by women for example when the CFHN commented about aspects of the home environment. This was reflected in the following interaction in the home between a nurse and a woman,
CFHN10 – You'll need to get a gate for here at the bottom of these stairs…and what's that cheeping sound… you'll need a new battery for that fire alarm…do you mind if I go outside and take a look….(walks to the backdoor) no buckets of water laying around anywhere?
W25 – We're planning to do this (install gates at the bottom of the stairs)….we just waiting till the baby is a bit older
CFHN10 – You need to think about this as a safety thing
In the interview following this observation, this woman stated that she felt uncomfortable with the nurse describing the interaction as 'rude' and 'intrusive'.
W25 - That was a bit uncomfortable for me, when she's checking everything…I was surprised she wanted to see how I lived…it was a bit strange, if I'd gone to the clinic she'd never have known any of these things. That was a little bit rude I thought. I preferred not to see them (CFHN) again.
Another woman described feeling 'very upset' and 'guilty' following the home visit. She described that on entry to her home; the nurse began to survey the kitchen area as though assessing the level of cleanliness and then proceeded to involve the woman's in-laws in a discussion about breastfeeding routines. The woman was distressed by this because at the time she was experiencing some conflict about breastfeeding, she wanted to breastfeed and her parents' in-law were discouraging her;
W11 – It was a difficult thing (breastfeeding) at the time and she (nurse) made a comment about my breastfeeding to the in-laws saying 'if you don't get her feeding properly then we'll have to blah blah blah' and this just escalated things because the family got even more concerned.
The women's experience of being watched was only reported and observed in the home environment after birth and not the clinic setting. Women who were assessed in the clinic before and after birth did not report statements about being watched.
Results
Five key themes emerged from this analysis. The first three themes titled 'Unexpected – a bit out of the blue', 'Intrusive - very personal questions' and 'Uncomfortable - digging over that old ground' describe the impact that psychosocial assessment and depression screening had on women. The lack of preparation or surprise that women experienced in relation to being asked sensitive questions that may bring up past, difficult experiences can be modified by the approach that the midwife/CFHN takes to asking the questions. This is reflected in final two themes titled: Approach: 'sensitivity and care' and 'being watched'.
In addition to reporting the five major themes that emerged across the three data sets, the results reflect the longitudinal aspect of the study and aspects of the women's 'journey' across the two time periods when assessment occurred. Exemplars from two women are included to illustrate where women's experience and their responses either antenatally or postnatally, may have differed. These exemplars occur in the themes sensitivity and care and uncomfortable: 'digging over that old ground'.
Unexpected – 'A Bit Out of the Blue'
Analysis of the observation tool (4D&4R) and interview transcript data indicate that when the midwife/CFHN first introduced the psychosocial assessment, whether that was at the start of the visit or well into the interaction, women appeared **'surprised 'or 'perplexed'. This was particularly so for women at the antenatal booking visit as this was often the first time they were asked these questions, but was also observed with some women having the home visit or clinic appointment after birth. Most of the women expressed in interview that they didn't '…expect…' the level of personal detail required to be shared at the visits and felt '…surprised…' by the personal nature and sensitivity of the questions, it came 'a bit out of the blue' (W9). However, they remained open to answering the questions stating at interview they 'understood' why the questions were being asked;
'I think the questions that they ask are sometimes very personal, but on the other side I understand why they have logic behind the asking. They want to find out about the woman so they can help her. Sometimes there were a few questions that were very personal, like about your sexual history, that a person doesn't like sharing the first visit.' (W18).
Women stated they were expecting the focus to be on either the physical progress of their pregnancy or the health and development of their baby rather than on their own emotional health and well-being, 'It seemed to be more about me than the baby' (W11); 'I felt it was more about me and it was more about my mental state, that sort of stuff…it was really more about how are you feeling? How are you coping?' (W7). Almost half, (25 out of 54) of the women observed either antenatally or postnatally, demonstrated a physical reaction when asked the psychosocial assessment questions. For example, some women showed a surprised expression (raising of the eyebrows, crinkling of the forehead skin), increased eye movement, a sudden turn of the head to face the midwife/CFHN and shifting in the seat. However, after this immediate or initial reaction, two thirds of the women, (38 out of 54) responded to the questions in an open and talkative way;
(FN5) Midwife was observed to ask the woman about asking questions related to W5 psychosocial history:
M2 - …there is also a section about you and I'll ask you some questions about your social and emotional wellbeing is that okay?
W5 – (turn her head and looks sharply at midwife) what do you mean, what sort of questions?
M2 – they're just some questions to see how you're coping and feeling stuff like that
W5 – Oh okay then (sits back in chair looks more relaxed and smiling)
Some women questioned the relevance of the psychosocial assessment questions 'She didn't check the baby's (fetal) heart rate it just seemed to be more about me, I'm not even sure why those other questions (psychosocial assessment questions) were relevant' (W19).
Women were also surprised that the antenatal and postnatal visits took much longer than they expected. They attributed this length of time to be about the paperwork or the amount of questions that were asked;
'I was surprised it took so long, I left mum in the car waiting, I didn't bring a bottle or a change of clothes with me or anything, I just didn't think it would take so long' (W7) or 'was basically paperwork, we did lots of paperwork rather than checkups' (W31).
Women's level of preparedness for the psychosocial assessment questions seemed to impact on their experience. Some of the women experienced discomfort stating that antenatally they were '…not feeling adequately prepared…' (W4).
W16 – I think they could have told me what they were going to ask before I even arrived for my appointment. I had no idea that was what was coming.
However, women who had a recent previous pregnancy and birth felt they were more prepared and appeared more relaxed;
'It was actually quite good. I actually quite enjoyed it. The first time you didn't know what to expect and some of the questions that they asked I thought were a bit surprising but the second time round it was like it was nothing. It was just a conversation; they just needed to know information' (W4).
During pregnancy and following the birth, it was evident that women expected the midwife or nurse was going to provide answers to their questions or advise them about caring for their baby, for example;
W6 – When I went for my first visit with the midwife I was like, right this is what we need to know and I just felt confident that the midwife would know exactly how to answer my questions
W1 - I knew that the nurse would come here to my home and help me to solve some of the problems with my baby'.
Intrusive: Very Personal Questions
During interviews women stated that they understood why the midwife/CFHN was asking the questions and they believed that it was '...important…' and that they'…should be done…' (W16). When women had a positive experience disclosing a recent difficult personal experience, they were more likely to develop a sense of trust in the midwife that they '…could tell my story to anyone' (W12). However, women also described them as '… very personal questions…' and this evoked some discomfort at times and may have influenced whether they shared their story with the midwife/CFHN. Whilst most women explained that they responded honestly to the questions, stating they '… had nothing to hide…' (W21), some women did say that if they were experiencing distress they may not have disclosed this to the midwife/CFHN and would simply say '…no…' (W26). Due to the personal nature of the questions women reflected on whether they would discuss personal concerns with midwife/CFHN;
They ask very personal questions about your social circumstances and your relationships and things like that, which I have no problem answering but I can see how some people would if they had a problem it would be very hard to bring up like domestic violence or abuse or something like that (W26).
The observation data demonstrated support for women's level of openness and honesty. In almost all of the observation (53 out of 54) women responded to questions and some took some time to reflect on the answer. On one occasion when a woman was tearful she continued to exclaim that she was 'okay…no I'm alright' (W20) and declined to discuss any concerns with the midwife/CFHN. In 5 out of the 54 observations women were offered time to reflect on the questions they had been asked. In these instances women pondered for a moment to reflect on what they had been asked 'I guess I've never thought about it really but yes I guess I was a bit depressed when I was a teenager' (W30).
There appeared to be particular questions that caused women some discomfort. Questions about domestic violence were described as '…strange…' and '…funny…' One woman described her discomfort as '…feeling guilty…' (W11) about being asked the domestic violence questions as;
' I kind of likened it to you know when you come through customs and even though you know you've got nothing; you feel guilty because you now that customs people are there and they might think you've got something in your bags, even though you know you haven't…it was a bit like that feeling' (W11).
Similarly, some questions that were not deemed to be part of the psychosocial assessment were viewed as 'personal questions' by the women and provoked discomfort. For example, questions about previous pregnancies such as terminations or stillbirth 'I was really hoping it wouldn't come up… but when it does it's like all this emotion just exploding out of me…' (W12).
Uncomfortable: 'Digging Over That Old Ground'
Women who did disclose a difficult current or past life event or experience in response to a question described the impact of this in varying ways. One woman described this as 'digging over that old ground' (W9). For others, talking about previous traumatic histories was '…daunting…', raising fears that women may be '…pushed back…' into reliving previous trauma. One woman stated, 'when those words come up again (postnatal depression) you don't want to be pushed back, like when the help is offered it's wonderful but I felt, no I'll be able to cope this time.' (W12) The retelling of a distressing experience may impact in a negative way on a woman's mood;
' It did feel like it brought up a lot of feelings for me, like the anxiety I had when I was developing postnatal depression with my first child, it was all there, I could feel it again' (W12).
Another woman also talked about her distress when asked to talk about a recent still birth. This was the first time she had returned to the hospital following a recent stillbirth;
it's difficult to reply to all those questions with all my background and all my past. It makes me so stressed, when I have to go through all the questions. That's my personal (feeling) . Maybe if people have a good past they'll enjoy it (W31).
Discussing previous trauma may not appear relevant for women at the present time of the visit '…it's not really affecting me now…my main concern is getting through the pregnancy, not worrying about my past stuff.' (W21). Women also described how they had to think carefully about how to respond to a sensitive question;
about suicidal and depressed – yeah, I was thinking actually how I put this?… because it's actually hard to know how to say it, so you go, well, 'how do I say this, yes I have had a plan to end my life cause I just didn't see a way out anymore (W18).
Women who did disclose previous trauma mostly felt the nurse or midwife responded appropriately, however, they suggested that the midwife/CFHN should review previous notes so they 'don't have to go real deep, they can just open my file instead' (W31) or;
'Why don't they take the extra time just to read over and if they have any more questions about it then they can ask. If it's already there then why bother… it is really frustrating' (W4).
At times, it was the response of the midwife or nurse to a woman's disclosure that caused them the most distress. One woman (W28) talked of her experience when she disclosed a previous history of anxiety, although this had not been formally diagnosis or treated. In this case, the midwife (M16) documented this information as a history of previous mental health problems on her medical record card. The woman saw this documented and in the interview she stated;
I didn't know that was written on the card, when I saw that there I was surprised because I don't feel like I'm depressed or have anxiety. So I think that process made me anxious. Because now they (other midwife/CFHN) ask me a lot about it and I am looking at it as a kind of an issue so it's creating like a dirty mark against my name (W28).
Some women who described a negative experience of psychosocial assessment indicated that they would inform other women and discourage other women from disclosing personal information;
I don't want her (sister) to go through the whole thing, I don't feel the need for her to bring it up, and I don't want her to go through her whole pregnancy having to see someone about her problems. So I told her about some of the stuff in regards to some of the questions they ask about your husband, whether or not he beats you up and I told her so she knows what will happen if she says anything (W4).
It's funny because when you talk to girlfriends who've had children, you hear everyone's different experiences and they say 'it's when they ask the questions it's like, you know, it's crazy (W25).
In some instances women's comfort regarding disclosure of previous negative life events to the midwife or nurse differed across the two points in time (antenatal or postnatal). The exemplar in Table 3 illustrates how W17s negative experience at the antenatal psychosocial assessment influenced her decision not to use postnatal services. At the antenatal booking visit, W17 disclosed a previous experience of domestic violence which occurred more than two years previously with an ex-husband who lives abroad. This history of domestic violence was incorrectly reported by the midwife in the medical records as occurring currently. Following birth, W17 was visited by a social worker who interviewed her about the safety of her current relationship with her husband. This was particularly distressing and intrusive for W17 and she subsequently refused ongoing services.
There were women who were dissatisfied with the health service. For example, some women were informed by the midwife/CFHN that they would be referred to services and then they did not subsequently receive any follow up. 'I waited and waited for her to call for two weeks… she said the social worker would call…but nobody called' (W18). Women suggested that a collaborative approach to recording the information gathered would demonstrate a level of respect and involve them in their care more productively 'maybe if she (the midwife) had asked me what I wanted put down on my card I would have felt she was helping me and being more considerate of me' (W28). However, the types of support that midwife/CFHN provided such as information and contact numbers was positively received 'The information she gave me I felt quite helpful and the telephone numbers so I know where to go' (W5).
Women's Perception of Midwife/CFHN Style and Approach
Approach: Sensitivity and Care It was evident in this study that how women perceived the midwife/CFHN style or approach influenced their level of comfort with the clinical encounter in general and in particular with the psychosocial assessment and depression screening. The majority of the women described the midwife/CFHN as being 'friendly', 'warm' and 'caring' and they believed that the professionals were 'sensitive' to their needs: 'I felt she was very friendly and quite professional in the way she talked to me, I felt very relaxed.' (W1) or 'I found it a quite positive experience overall, I thought her approach was sensitive and caring, it was friendly' (W24). Some women indicated that asking the questions implied a '…sense of caring…' (W5) on the part of the midwife/CFHN.
Women were appreciative when the midwife or CFHN was sensitive and caring. For example, in the first interaction in Table 4 , Midwife (M9) demonstrated empathy and validated the woman's experience by acknowledging her difficult situation. Similarly when W11 disclosed that she had been experiencing emotional distress; she stated that she felt supported by the response from CFHN6 inviting her to discuss further (see Table 4 ).
Women also described the midwife/CFHN as helpful in terms of problem solving or assisting them to accept their pregnancy and the impact this may have on their psychosocial wellbeing. For example;
M5 – How are you feeling about being pregnant?
W10 – yeah ok (ambivalently), he's (turns to look at partner) so excited, I'm kind of getting used to it
M5 – Okay, I remember feeling like that too when I first got pregnant, what sort of things would help you to feel more comfortable about the pregnancy?
The women who came from non-English speaking backgrounds emphasised the importance of the non verbal communication from professionals commenting for example, on the midwife/CFHN facial expressions as an indicator of friendliness 'she always smiles and (is) very gentle' (W14) or 'She make me like not scared because she smile a lot, her smiling and the way she spoke was really helpful' (W3). They also expressed an ease of communication when the midwife/CFHN 'spoke slow to me' (W17) and 'explained the questions, even if I didn't understand first time round' (W2).
In contrast however, there were interactions where women did not receive an empathetic or sensitive response from their midwife or CFHN, as illustrated in the following interaction. For example, one woman (W4) expressed that she would prefer the midwife to refer to her medical records where she had previously disclosed trauma when asked during her first pregnancy;
M3 – so as a child were you hurt or abused in any way either physically, sexually or emotionally?
W4 – Yes
M3 –Did you want to tell me about that?
W4 – Isn't it in my file from last time?
M3 – No… Well I haven't read it… you can tell me about it now?
FN - Woman described her experience reluctantly
There were instances where women reported different experiences of sensitivity and care in interactions with the midwife or the nurse across the two time points (antenatal and postnatal). The exemplar in Table 5 demonstrates W12s' experience of M2s' sensitive and caring approach during her disclosure of a recent termination of pregnancy. This same woman (W12) however, was distressed by the response from the CFHN7 in the postnatal assessment where she disclosed that she felt traumatic by her caesarean birth. During interview with the researcher (MR), W12 stated that the nurse lacked sensitivity and caring.
Approach: Being Watched
Whilst most women were approached sensitively, some women talked about feeling as though they were being watched during the home visit by the CFHN. This was particularly reported by women for example when the CFHN commented about aspects of the home environment. This was reflected in the following interaction in the home between a nurse and a woman,
CFHN10 – You'll need to get a gate for here at the bottom of these stairs…and what's that cheeping sound… you'll need a new battery for that fire alarm…do you mind if I go outside and take a look….(walks to the backdoor) no buckets of water laying around anywhere?
W25 – We're planning to do this (install gates at the bottom of the stairs)….we just waiting till the baby is a bit older
CFHN10 – You need to think about this as a safety thing
In the interview following this observation, this woman stated that she felt uncomfortable with the nurse describing the interaction as 'rude' and 'intrusive'.
W25 - That was a bit uncomfortable for me, when she's checking everything…I was surprised she wanted to see how I lived…it was a bit strange, if I'd gone to the clinic she'd never have known any of these things. That was a little bit rude I thought. I preferred not to see them (CFHN) again.
Another woman described feeling 'very upset' and 'guilty' following the home visit. She described that on entry to her home; the nurse began to survey the kitchen area as though assessing the level of cleanliness and then proceeded to involve the woman's in-laws in a discussion about breastfeeding routines. The woman was distressed by this because at the time she was experiencing some conflict about breastfeeding, she wanted to breastfeed and her parents' in-law were discouraging her;
W11 – It was a difficult thing (breastfeeding) at the time and she (nurse) made a comment about my breastfeeding to the in-laws saying 'if you don't get her feeding properly then we'll have to blah blah blah' and this just escalated things because the family got even more concerned.
The women's experience of being watched was only reported and observed in the home environment after birth and not the clinic setting. Women who were assessed in the clinic before and after birth did not report statements about being watched.
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