Patient versus professional based psychosocial risk factor screening for adverse pregnancy outcomes

Identifying psychosocial vulnerabilities in pregnancy: A mixed-method systematic review of the knowledge base of antenatal conversational psychosocial assessment tools

BACKGROUND

Early identification of psychosocial vulnerability among expectant parents through psychosocial assessment is increasingly recommended within maternity care. For routine antenatal assessment, a strong recognition exists regarding conversational assessment tools. However, the knowledge base of conversational tools is limited, inhibiting their clinical use.

OBJECTIVE

Synthesising existing knowledge pertaining to antenatal conversational psychosocial assessment tools, including identifying characteristics, acceptability, performance, effectiveness and unintended consequences.

DESIGN

Mixed-method systematic review based on searches in CINAHL, PubMed, Embase, PsycINFO, Cochrane and Scopus. 20 out of 5394 studies were included and synthesised with a convergent integrated approach using a thematic analysis strategy.

FINDINGS

We identified seven antenatal psychosocial assessment tools that partially or completely utilised a conversational approach. Women's acceptability was high, and tools were generally found to support person-centred communication and the parent-health care professional relationship. Evidence regarding effectiveness and performance of conversational tools was limited. Unintended consequences were found, including some women having negative experiences related to assessment of intimate partner violence, lack of preparation and lack of relevance. High acceptability was reported by health care professionals who considered the tools as valuable and enhancing of identification of vulnerability. Unintended consequences, including lack of time and competencies as well as discomfort when assessment is very sensitive, were reported.

CONCLUSIONS

Evidence regarding conversational tools' effectiveness and performance is limited. More is known about the acceptability of conversational tools, which is generally highly acceptable among women and health care professionals. Some unintended consequences of the use of included conversational tools were identified.

Missingness patterns in a comprehensive instrument identifying psychosocial and substance use risk in antenatal care

BACKGROUND

Psychosocial vulnerabilities (e.g. inadequate social support, financial insecurity, stress) and substance use elevate risks for adverse perinatal outcomes and maternal mental health morbidities. However, various barriers, including paucity of validated, simple and usable comprehensive instruments, impede execution of the recommendations to screen for such vulnerabilities in the first antenatal care visit. The current study presents findings from a newly implemented self-report tool created to overcome screening barriers in outpatient antenatal clinics.

METHODS

This was a retrospective chart-review of 904 women who completed the Profile for Maternal & Obstetric Treatment Effectiveness (PROMOTE) during their first antenatal visit between June and December 2019. The PROMOTE includes the 4-item NIDA Quick Screen and 15 additional items that each assess a different psychosocial vulnerability. Statistical analysis included evaluation of missing data, and exploration of missing data patterns using univariate correlations and hierarchical clustering.

RESULTS

Three quarters of women (70.0%) had no missing items. In the entire sample, all but four PROMOTE items (opioid use, planned pregnancy, educational level, and financial state) had < 5% missing values, suggesting good acceptability and feasibility. Several respondent-related characteristics such as lower education, less family support, and greater stress were associated with greater likelihood of missing items. Instrument-related characteristics associated with missing values were completing the PROMOTE in Spanish or question positioning at the end of the instrument.

CONCLUSIONS AND IMPLICATIONS

Conducting a comprehensive screening of theoretically and clinically meaningful vulnerabilities in an outpatient setting is feasible. Study findings will inform modifications of the PROMOTE and subsequent digitisation.

Saving time, signaling trust: Using the PROMOTE self-report screening instrument to enhance prenatal care quality and therapeutic relationships

OBJECTIVES

Comprehensive screening of psychosocial vulnerabilities and substance use in prenatal care is critical to promote the health and well-being of pregnant patients. Effective implementation of new screening procedures and instruments should be accompanied by an in-depth investigation to assess their feasibility and impact on care delivery.

METHODS

In 2020, following implementation of the Profile for Maternal and Obstetric Treatment Effectiveness (PROMOTE) an innovative self-report screening instrument developed for outpatient prenatal clinics in the U.S., we conducted individual interviews and focus groups with twenty-two midwives, nurse practitioners, and obstetric residents focused on the PROMOTE and its impacts on care delivery. We used interpretive description for the qualitative analysis of the interviews.

RESULTS

Five themes were identified: Guiding Time Efficiently: "The Time I Don't Have," Preventing Missed Care, Signaling Trustworthiness, Establishing Trauma-Informed Foundations, and Promoting "Honest" Patient Disclosure.

CONCLUSION

Interviews suggest that patient completion of the PROMOTE before the medical encounter helps reduce previously reported barriers, is more time-effective, and makes history-taking easier. It also facilitates the patient-provider relationship.

INNOVATION

Findings offer insight into the breadth and depth of clinical impact resulting from the PROMOTE, and provide guidance for the implementation of such tools to optimize health outcomes.

Applying machine learning methods to psychosocial screening data to improve identification of prenatal depression: Implications for clinical practice and research

We utilized machine learning (ML) methods on data from the PROMOTE, a novel psychosocial screening tool, to quantify risk for prenatal depression for individual patients and identify contributing factors that impart greater risk for depression. Random forest algorithms were used to predict likelihood for being at high risk for prenatal depression (Edinburgh Postnatal Depression Scale; EPDS ≥ 13 and/or positive self-injury item) using data from 1715 patients who completed the PROMOTE. Performance matrices were calculated to assess the ability of the PROMOTE to accurately classify patients. Probability for depression was calculated for individual patients. Finally, recursive feature elimination was used to evaluate the importance of each PROMOTE item in the classification of depression risk. PROMOTE data were successfully used to predict depression with acceptable performance matrices (accuracy = 0.80; sensitivity = 0.75; specificity = 0.81; positive predictive value = 0.79; negative predictive value = 0.97). Perceived stress, emotional problems, family support, age, major life events, partner support, unplanned pregnancy, current employment, lifetime abuse, and financial state were the most important PROMOTE items in the classification of depression risk. Results affirm the value of the PROMOTE as a psychosocial screening tool for prenatal depression and the benefit of using it in conjunction with ML methods. Using such methods can help detect underreported outcomes and identify what in patients' lives makes them more vulnerable, thus paving the way for effective individually tailored precision medicine.