title: Antenatal mental health referrals: review of local clinical practice and pregnant women's experiences in England.
abstract: OBJECTIVE
  to investigate (i) the consistency and completeness of mental health assessment documented at hospital booking; (ii) the subsequent management of pregnant women identified as experiencing, or at risk of, mental health problems; and (iii) women's experiences of the mental health referral process.
  
  
  METHODS
  mixed methods cohort study
  
  
  METHODS
  large, inner-city hospital in the north of England
  
  
  METHODS
  women (n=191) booking at their first formal antenatal appointment; mean gestational age at booking 13 weeks.
  
  
  METHODS
  women self-completed the routine mental health assessment in the clinical handheld maternity notes, followed by a research pack. Documentation of mental health assessment (including assessment of depression symptoms using the Whooley and Arroll questions, and mental health history), mental health referrals and their management were obtained from women's health records following birth. Longitudinal semi-structured interviews were conducted with a purposive sub-sample of 22 women during and after pregnancy.
  
  
  RESULTS
  documentation of responses to the Whooley and Arroll questions was limited to the handheld notes and symptoms were not routinely monitored using these questions, even for women identified as possible cases of depression. The common focus of referrals was on the women's previous mental health history rather than current depression symptoms, assessed using the Whooley questions. Women referred to a Mental Health Specialist Midwife for further support were triaged based on the written referral and few met eligibility criteria. Although some women initially viewed the referral as offering a 'safety net', analysis of health records and subsequent interviews with women both indicated that communication regarding the management of referrals was inadequate and women tended not to hear back about the outcome of their referral.
  
  
  CONCLUSIONS
  mental health assessment was introduced without ensuring that identified needs would be managed consistently. Care pathways and practices need to encompass identification, subsequent referral and management of mental ill-health, and ensure effective communication with patients and between health professionals.
authors.affiliation: School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK. Electronic address: z.j.darwin@leeds.ac.uk.
authors.forename: Zoe
authors.initials: Z
authors.lastname: Darwin
authors.affiliation: School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK.
authors.forename: Linda
authors.initials: L
authors.lastname: McGowan
authors.affiliation: Manchester Academic Health Science Centre, University of Manchester, St Mary's Hospital, Manchester M13 9WL, UK.
authors.forename: Leroy C
authors.initials: LC
authors.lastname: Edozien
mesh_terms: D000328:Adult; D015331:Cohort Studies; D004739:England; D005260:Female; D006801:Humans; D008603:Mental Health / Q000639:trends; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D017060:Patient Satisfaction; D010818:Practice Patterns, Physicians' / Q000592:standards; D011247:Pregnancy; D037841:Pregnant People; D011295:Prenatal Care / Q000379:methods; D011785:Quality Assurance, Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires
keywords: Antenatal care; Midwifery; Mixed methods; Perinatal mental health; Screening; Whooley questions