Assessment of clinical diagnoses for women in the perinatal period

The SCID-I is a semi-structured interview for making the major DSM-IV diagnoses (American Psychiatric Association, 1994). In this study a research version of SCID-I designed for use with non-patient populations (SCID-I/NP; Reference First, Gibbon and SpitzerFirst et al, 1996), was modified to produce an instrument for assessing postnatal depression in different cultural contexts: the SCID-PND (Reference Gorman, O'Hara and FigueiredoGorman et al, 2004, this supplement).

The EPDS is a ten-item self-completion scale used to screen for postnatal depression. Although the scale cannot be used as a diagnostic tool, a score of 12 or more is usually taken to indicate the likely presence of depression.

Psychosocial context of pregnancy and motherhood

Psychosocial adversity is a robust predictor of postnatal depression (Reference O'Hara and SwainO'Hara & Swain, 1996). The Contextual Assessment of Maternity Experience was developed to assess the social environment relevant to the maternity experience in different cultural settings (Bernazzani et al, Reference Bernazzani, Gorman and Marks2000, Reference Bernazzani, Conroy and Marks2004, this supplement). Contextual rating aims to capture the meaning of an experience based on team consensus about the likely emotional reaction of most people in biographical circumstances similar to that of the interviewee. Such consensus judgements are embodied in extensive training manuals for European settings. Reliability is ensured by interviewer training, reference to manualised examples (Reference Bernazzani, Bifulco and MarksBernazzani et al, 1998) and consensus team judgements. The CAME includes assessment of social and practical support, recent adversity, the emotional context (feelings about the pregnancy, and about motherhood and parenting), and the woman's roles and activities.

Attachment style

The Attachment Style Interview (Reference Bifulco, Figueiredo and GuedeneyBifulco et al, 2004, this supplement) is a semistructured interview to identify attachment styles which increase vulnerability to major depression (Bifulco et al, Reference Bifulco, Moran and Ball2001a ,Reference Bifulco, Moran and Ball b ). Ratings are made by interviewers from transcribed, tape-recorded interview material. Reliability is ensured by prior interviewer training, reference to manualised examples (Reference Bifulco, Lillie and BallBifulco et al, 1998) and consensus team judgements. Overall attachment style is based on eight sub-scales assessing avoidant behaviour, dependence, emotional constraints on closeness, and judgement of ability to make and maintain relationships. The ASI generates five attachment style ratings: ‘enmeshed’, ‘angry-dismissive’, ‘fearful’, ‘withdrawn’ and ‘clearly standard’.

Child assessments (interaction and environment)

The Global Rating Scales (Reference Murray, Fiori-Cowley and HooperMurray et al, 1996; Reference Gunning, Fiori-Cowley and MurrayGunning et al, 1999) were developed to assess differences in mother-infant interaction between women who were or were not depressed. The scales globally assess the quality of maternal and infant behaviours and the overall interaction between the two, during a 5 min video-recorded assessment of free play.

The Infant-Toddler version of the Home Observation for the Measurement of the Environment assesses the quality and quantity of stimulation and support available to the child in the home environment. The 45-item binary choice scale is administered in the home, with some items scored from observation and some from interview (Reference Caldwell and BradleyCaldwell & Bradley, 1984).

Service use and costs

The Client Service Receipt Inventory - Postnatal Depression version (CSRI-PND; Reference Chisholm, Conroy and Glangeaud-FreudenthalChisholm et al, 2004, this supplement) is a service use measure for women with postnatal depression which provides information for economic evaluation of the mental health care they received. The instrument is a derivation of the Client Socio-demographic and Service Receipt Inventory - European version (Reference Chisholm, Knapp and KnudsenChisholm et al, 2000), which itself is an adaptation of the CSRI (Reference Beecham, Knapp, Thornicroft, Brewin and WingBeecham & Knapp, 1992). The CSRI-PND enables the comprehensive costing of care packages for women who have recently had a child, with a view to determining the excess need and service uptake of women with postnatal depression. Information is collected on the use of a range of health care, social care and other services over a defined retrospective period. Unit costs for each of these services can then be calculated to give the total costs associated with each individual's use of services.

Ireland (Dublin)

For funding and administrative purposes, Ireland is divided into eight health board regions, directly responsible for providing acute general hospital, obstetric and psychiatric care in rural Ireland. In the Dublin area, voluntary organisations, directly funded by the Department of Health, have traditionally provided these services along-side those run by the health board. About a third of the population carries a medical card provided by the local health board. This card entitles the bearer to the full range of medical services free of charge on grounds of financial hardship. The remaining two-thirds of the resident population have limited eligibility for public health care.

A maternity and infant scheme, operated through general medical practitioners, provides free antenatal care for expectant mothers and medical care for mothers and infants for up to 6 weeks after the birth. Normally, women choose their own general practitioner (GP) and make at least six visits before delivery and two visits afterwards. An option of combined care is also available antenatally, with monitoring by both the hospital and the GP. Public hospital obstetric care is available free of charge to all. Domiciliary births are infrequent, the rate being 0.4% in 1998. A general community nursing service is provided through public health nurses trained in community nursing and midwifery. A public health nurse carries out a home visit soon after notification of birth is received and ideally again at 3 months and 7 months. With many nursing posts currently vacant, visits may now be less frequent, but the initial home visit almost always takes place, and mothers are well informed and pursued to have their infant's developmental checks carried out.

Psychiatric care has been progressively de-institutionalised, and a community care model with acute care provided in general hospital psychiatric units is now becoming the norm. The number of in-patient beds has steadily declined from the mid-1980s, made possible by growth in the number of community residences and day hospitals. There are no dedicated mother and baby facilities in Irish psychiatric hospitals but each of the Dublin maternity hospitals has a psychiatric liaison service, which partially meets the psychiatric needs of their patients.

Italy (Florence)

The National Health System, which provides health care for the entire population, is organised into three levels: basic medical services, supplied by general practitioners, paediatricians and emergency services; specialised care, including out- patient clinics and laboratories; and hospital care. The GP has a crucial role, both supplying first-level care and acting as a filter for patients' access to National Health System specialists and hospital care.

A pregnancy certificate entitles a woman to access public health services for routine screenings included in the National Pregnancy Protocol and provided by each Italian region. Family health centres provide care for mothers and infants from gynaecologist-obstetricians, midwives, psychologists, social workers, paediatricians and legal advisers. The majority of deliveries (80%) take place in a public hospital, with the rest in a private hospital or, rarely, at home. If all is well, the woman is discharged on the third day following delivery. Women are entitled to request three postnatal domiciliary visits by a National Health System midwife, who is able to advise on managing the baby and to assess the woman's physical and mental health.

The Mental Health Department coordinates psychiatric care. Mental health centres, with multi-disciplinary teams of psychiatrists, psychologists, nurses and educators, coordinate community services, offer out-patient units and domiciliary visits, and act as a filter for hospitalisation, psychotherapy and welfare activity. The psychiatric departments of general hospitals have in-patient facilities for patients in an acute phase. Greater Florence is subdivided into four areas, each with the above facilities. An individual may approach these services directly or be referred by a GP. In addition, the department of neurology and psychiatry at the University of Florence provides specialised hospital facilities for voluntary patients, and also functions as a day hospital and out-patient clinic. Psychiatric care facilities in the private sector exist but are difficult to quantify.

France (Bordeaux and Paris)

Most French people have state health insurance which reimburses most of the costs of medical care, and many have additional insurance to complete the reimbursement of care. Uninsured people with no income are entitled to free state assistance. Despite open access to specialist and hospital services, many French people visit a family physician (GP) for general health matters.

All women are entitled to free health care during pregnancy, although the majority have insurance. A distinctive feature of perinatal care is that specific conditions must be fulfilled in order to obtain the large financial maternity allowance. Women must obtain a pregnancy certificate before 15 weeks from their doctor or midwife and attend all seven state recommended antenatal visits and all required postnatal checks for the baby. Three postnatal checks are required, at 8 days, 9 months and 24 months, and these obligatory visits are free. A free examination, by a gynaecologist or GP, is recommended for the woman at 6-8 weeks post-partum. Many women are prescribed ten free abdominal and/or perineum ‘re-education’ sessions, conducted either by a kinesitherapist or a midwife. Two-thirds of all deliveries are led by midwives, approximately 6% as home deliveries. About half of all maternity care takes place within the private sector and half within the public sector, with a tendency for women with high-risk pregnancies and those requiring specialised care to be delivered in public-sector hospitals.

At the centre of the delivery of psychiatric care is a multi-disciplinary mental health team consisting of psychiatrists, psychiatric nurses, psychologists, social workers and a wide range of other paramedical mental health workers. In the Îlede-France (Paris and suburbs) most public general psychiatric care takes place on an out-patient or community basis (81%), with 17% of care provided to in-patients and 2% to day patients. A number of psychiatric mother and baby units offer acute or prophylactic pregnancy and postnatal in-patient admissions, including one in Bordeaux and several in Paris.

USA (Iowa City)

Although there is no universal national health care system in the USA, the government programme Medicaid covers health care costs for the poorest and most vulnerable. In 1997, about 10% of the Iowa population received care through Medicaid. Those not covered by government health care programmes are typically covered by private health insurance plans.

The maternity health care system is variable throughout the USA, depending on the setting and resources. The state of Iowa funds a system of maternal health care centres which provide prenatal services for women with low incomes. The majority of pregnant women begin prenatal care during the first trimester of pregnancy; obstetricians, family practice physicians and GPs are the main providers of obstetric care. Foetal testing procedures and surgical deliveries are relatively common. Physicians deliver the majority of babies in hospital (99% of births in 1993). Typically, women stay in hospital for 48 h following an uncomplicated delivery, and 3 days following a Caesarean delivery. There is virtually no provision for post-partum care at home. Most hospitals provide information about infant care or post-partum difficulties through a call-in telephone line, and some provide lactation consultants for women experiencing breast-feeding difficulties. Women typically return for a final follow-up visit to their obstetrician or family practice physician at 4-6 weeks post-partum.

Mental health care service delivery in the USA is highly complex and rapidly changing and there is currently no unified or comprehensive mental health care policy. There is a range of mental health facilities, including community mental health centres, state and county mental hospitals, private psychiatric hospitals, psychiatric units in general hospitals, residential treatment centres, multi-service mental health organisations, and free-standing psychiatric clinics. Services are also provided in private practice settings and in educational, occupational and other organisational settings. Access to mental health services depends upon many factors, including geographical location, economic status and health insurance coverage. Primary care physicians are frequently the sole source of care, particularly in rural areas. In 1997 about 22% of people in Iowa lacked access to mental health care services, almost twice the national rate (Reference Morgan and MorganMorgan & Morgan, 1999). There is no specialised mental health care service for pregnant and post-partum women.

Portugal (Porto)

During pregnancy, about half of Portuguese women are cared for by a general practitioner in their local community health service; the other half are cared for by private gynaecologists or obstetricians. Women with high-risk pregnancies see an obstetrician at the hospital; those with uncomplicated pregnancies attend either a GP or a private gynaecologist or obstetrician. In 1999, over 99% of deliveries took place in a public or private hospital, while less than 1% took place at home. Women receive a post-partum check-up 4-5 weeks after delivery. Approximately half receive this from a GP and half from a private obstetrician.

About 80% of women with mental health problems are treated initially by public-sector services. The first contact may be with either a GP or a psychiatrist from the emergency service of the local hospital, who will refer, if necessary, to a psychiatric ward or day hospital. Private psychiatrists initially see about 20% of women with mental health problems and they also will refer on, if necessary, to the same services. There is no specialised service for post-partum mental illness in mothers.

UK (Keele and London)

The National Health Service (NHS) provides the majority of health care, although the private sector is steadily growing and becoming increasingly integrated with the NHS, which buys in some of its services. Every UK citizen has a right to be registered with a local GP who supplies first-level care and acts as a filter for access to NHS specialists and hospital care.

A pregnant woman is usually first seen by her GP and then booked for antenatal care either in a hospital or in a community midwifery booking clinic. Antenatal care is usually shared between hospital, GP and community midwife, although high-risk pregnancies receive mostly hospital care while very low-risk pregnancies may receive only community care. Ninety-eight per cent of deliveries take place in hospital. Following a normal delivery, women typically stay in hospital for less than 48 h (5 days after a Caesarean section). Midwifery home visits are made for 10 days after delivery and up to 28 days if circumstances require. A health visitor sees the mother at home at around 10-14 days, with subsequent contacts at a child health clinic, general practice surgery, or at home. Health visitors have a preventive role in relation to both maternal and child health. Women routinely have a 6-week postnatal check with the GP or the hospital.

Community mental health services for people with more severe mental health problems are provided by multi-disciplinary teams, typically consisting of a psychiatrist, psychiatric nurses, social workers and an occupational therapist. General practitioners and health visitors treat most women with postnatal depression. Several areas in the UK have a perinatal psychiatric service catering specifically for the mental health needs of pregnant and postpartum women, and there are a number of in-patient mother and baby units, for acute or prophylactic postnatal admissions.

Austria (Vienna)

The provision of health services in Austria is mainly a public task under the control of federal, provincial and communal authorities. Social and health insurance (SHI) is obligatory, financed with contributions from the consumer and the employer. Members have the right to consult any GP or medical specialist who has a contract with the SHI. Community medical services are mainly provided by independent GPs and medical specialists. The former provide primary medical care and are usually the first point of contact, although patients can also approach specialists or out-patient hospital wards directly.

There is a standardised prevention programme to ensure maternal and child health, consisting of obligatory free medical check-ups for pregnant women and their children until the age of 4 years. Information about the mother's health during pregnancy, the birth process and well-baby visits are recorded in the ‘mother-child passport’. The first contact for a pregnant woman is typically her gynaecologist, who gives her the passport and informs her about the programme. In rural areas with few specialists the woman's first contact may be her GP. Ninety-eight per cent of deliveries take place in hospital. If the woman leaves the hospital within 24 h after childbirth, she is entitled to the service of a midwife for the first week at home, with the costs covered by health insurance.

Vienna is divided into eight psychosocial service areas, each equipped with a community-based out-patient department. In addition to these and several associated day clinics, within each service area psychiatric in-patient departments offer 24 h out-patient services. These facilities offer treatment free of charge, including counselling, support for family members, rehabilitation programmes, financial support, self-help groups and assisted living services, primarily serving patients with chronical illness. There are also several residential facilities offering programmes for patients with chronical illness. At present there is no facility for women with mental illness to be admitted with their babies.

Switzerland (Zurich)

Typically, a pregnant woman will register with a gynaecologist or, less frequently, a GP whom she already knows; however, if medical complications are identified, the woman is usually referred to one of the large maternity hospitals. Seven antenatal checks are required by the general medical guidelines approved by the health insurance and two ultrasound scans are paid for by health insurance. Ninety-nine per cent of deliveries take place in hospital and health insurance pays for up to 5 days of hospital care after delivery. After birth, the woman remains in the care of her private obstetrician or GP, with an entitlement to 10 days of midwifery care. On the perinatal ward, mothers are encouraged to register their baby with a paediatrician or GP for future routine checks.

A network of mostly free advice centres provide advice and assistance prenatally and postnatally on breast-feeding, nutrition, sleep problems, maternal and paternal emotional and psychological problems, and problems with older siblings. Individual counselling by nurses and psychologists, social workers and other professionals may be provided, and referral to psychiatric services or day support services may be organised if necessary. There is no specialised psychiatric unit for pregnant women or mothers with babies, but some obstetric departments provide prolonged or preventive in-patient treatment for women with psychiatric needs, and many psychiatric hospitals try to arrange joint mother and baby admissions on general wards.