1. Dr J M Mathibe-Neke Department of Health Studies Unisa

2. Quantitative perspective Responses from 302 self-administered questionnaires for pregnant women Analysis of antenatal cards (302) Cross-sectional survey with midwives by use of a self - administered questionnaire at SOMSA Congress (2009)

3. Women’s feelings and emotions

4. Social support & work environment (n=302)

5. Women’s experience of family violence (n=300)

6. Midwives’ responses re: psychosocial care

7. Perception of Midwifery Education (n=232)

8. Stressful life events experienced by women Experienced one184 (61.3%) Experienced two72 (24%) Experienced three or more44 (14%)

9. Qualitative perspective Focus group Interviews with pregnant women (saturation of data reached with the 4 th group) FGI with midwives (saturation reached with the third group) In-depth interviews with Midwifery experts

10. Focus group responses Respondent 1: “If you look now the state of affairs of our antenatal card it just says social…smaaal… (emphasizing), and you can ask anything... there is nowhere psychosocial issues are recorded” Respondent 2: “Yes, something like TICK,TICK,TICK, will help maybe something like... a checklist, tick, tick just ask relevant questions, with a checklist I think we would be made aware of the things that we normally don’t ask.” The above response is in keeping with Olsson, Sandman and Jansson (1996) that topics not appearing in the printed antenatal record were seldom discussed.

11. FGI Responses (cont.) Researcher: “Is it the woman or the midwife who will tick the checklist?” Respondent 2: “The midwife will fill the checklist” “Yes, (All participants) the checklist will remind us to go deeper, you know beyond the surface, to go deeper than the care that we normally give because it’s useless to pretend as if everything is fine whereas the patient has a big problem that can lead to complications, but once we have something that will guide you to ask something, even if you don’t ask all the questions, but you know maybe you can highlight, and maybe you pick up something, that will be very helpful” Respondent 4: “There must be a tool because on the green card is just a small line, where we ask for example, it is not written clear, just says “social”... therefore if there was a guideline regarding what should be done it will be appropriate for the pregnant women”

12. Respondent no. 3 “What comes to my mind as a recommendation is let’s have the guidelines on psychosocial care…even if it cannot be implemented now, for the future, let it be incorporated into antenatal care, even if it can be small it will make a difference, you know to say what type of questions to ask”

13. Aim of pilot study To establish the midwives’ perceived or observed knowledge and skill in implementing the psychosocial assessment tool, comfort with the tool and commitment to its use in clinical practice? To determine if the use of the tool enhances antenatal psychosocial assessment and care? What barriers were encountered by midwives in implementing the tool? Is there possible value in integrating the tool into routine antenatal care?

14. Assessment tool

18. Thematic analysis regarding use of tool (n=10) ThemeA=AgreeSA= Strongly agree D=DisagreeSD= Strongly disagree Understanding the tool8110 Ability to Implement8200 Support use of the tool8200 More psychosocial risks identified 7300 Referrals increased8011 Improved wellbeing8200 Enhanced communication7300 Women’s responses10000 Barriers7120 Routine antenatal care7210

19. Open-ended responses Psychosocial risks“I have identified that most women have psychosocial problems during pregnancy and after delivery” Will to support“They need support and empowerment throughout the process” Identification of risks“The use of the tool will remind health care worker about the psychosocial aspect to prevent postpartum problems” Need for information“The primigravidas displayed fear of labour as they had no knowledge of what to expect”

20. Potential for inclusion of the tool as routine antenatal care “The tool is clear and easy to be communicated” “It encourages pregnant women to communicate with professional nurses and becomes easy to refer patient to appropriate areas” “The tool is well arranged, hope will be added on the new maternity records” “I agree that it should be included in the antenatal card as it will enhance wellbeing” Some preferred a shortened version of the assessment form: “It might be shortened so that it can be easily included on the patient’s green card”

21. Barriers to implementation Shortage of staff Resistance from women Time-factor

22. Conclusion The results reflected that the majority of participants (90%), understood and were able to use the tool to assess women during antenatal visits. All participants declared comfort with and commitment to using the tool. Literature indicates that the introduction of such an initiative for psychosocial assessment is likely to be supported by the midwives (Willinck et al 2000).

23. Recommendations/Further research A larger scale pilot of the tool that would also indicate the prevalent psychosocial problems and the resources required to address them. Inclusion of a rating scale as a criteria to classify the extent of psychosocial risks A study that focus on the pregnancy outcomes following routine psychosocial assessment. The findings might also be used to advocate for the incorporation of the tool into routine antenatal care.