What are the Essential Referral Pathways for Perinatal Women?

Article Information

Tanya Connell*

School of Nursing and Midwifery, College of Health and Science, Sydney University, Australia

*Corresponding Author: Tanya Connell, School of Nursing and Midwifery, College of Health and Science, Sydney University, Australia

Received: 25 April 2019; Accepted: 08 May 2019; Published: 15 May 2019


Tanya Connell. What are the Essential Referral Pathways for Perinatal Women?. Journal of Women’s Health and Development 2 (2019): 001-005.

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Psychosocial screening has been implemented in the public sector in NSW for a decade, but what about the private sector? Is it applicable or even possible?. Women who experience the stressors that are related to an increased risk or an indication of perinatal mental health disorders should be assessed and offered referral to appropriate services. This paper is a discussion paper to explore the essential referral pathways for perinatal women with identified risk factors for perinatal mental illness.


Perinatal mental illness, Referral pathways, Women

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Article Details

1. Introduction

Women who experience the stressors that are related to an increased risk or an indication of perinatal mental health disorders should be assessed and offered referral to appropriate services. A system of care, ideally including a perinatal mental health care team should be established so that health professionals know, whom they should refer a women to, that is in need of mental health assessment and treatment [1]. In one study, 70% of women experienced at least 3 stressors and 21% experienced more than 6 stressors during their pregnancy [2]. 

2. Methods

This paper is a discussion paper to explore the essential referral pathways for perinatal women with identified risk factors for perinatal mental illness. This study is part of a larger study that implemented psychosocial screening and assessment in one private hospital in NSW. 

3. Results-Pathways for referral

The psychosocial screening questions, offer the booking-in midwife an opportunity to identify and discuss risk factors with women during the antenatal period. Antenatal screening implies that a referral pathway for further care or treatment of the pregnant woman is in place should any concern be identified during the screening process [3]. While standard referral pathways exist within the public hospital system, there were no obvious pathways evident for women receiving private obstetric care at the study site (Table 1). It was essential to develop a robust referral pathway before psychosocial antenatal screening was introduced at the study site. This was not only critical to ensure the safety of women being screened, but also to ensure the booking-in midwife had sufficient options to be able to refer women onto appropriate resources if necessary. 

Table icon

Table 1: Referral pathways in the private sector (for the study site). 

Referral pathway prompts; Did the woman score 10 or above the Edinburgh?; Did she score on question 10?; Are there other identified psychosocial risk factors?; If yes, then offer a referral to either; A psychologist, psychiatrist, infant mental health specialist or GP (A GP can offer referral for 12 counselling sessions). 

Local resources and services for the appropriate referral of women with anxiety or depressive symptoms identified by screening were sourced through various health care professional networks. This included consultation with midwives from the local public hospital (Gosford Public Hospital), and the social worker, obstetricians, maternity Nursing Unit Manager and midwives at Gosford Private Hospital (the study site) and the local area community Child and Family Health Nursing Unit Manager. The Perinatal Infant Mental Health Service was not able to accept referral of private patients. 

All identified resources and health care providers available to women cared for at Gosford Private Hospital were collated and developed as part of the guideline package (Table 2). Clear guidance on the appropriate referral of pregnant women who had identifiable (medium to high) risk factors on the EPDS (Table 3) and/or elicited during the psychosocial assessment, was included in the guideline package, as described above. Contents were matched to the screening questions so that appropriate referral pathways or resources could be offered to women who had been identified through the screening questions to have specific issues or risk factors. The aim was that each question on the psychosocial screening tool would relate to a specific referral pathway or choice of resource options. The referral pathways and resources in the guideline package were presented to the NUM/hospital midwives for feedback and comment. The order of resources in the folder followed the same order as the psychosocial screening questions so that the booking-in midwife undertaking the screening could easily identify the appropriate resource. While those women identified at risk could then be given the appropriate knowledge of health supports and resources to access, the decision to actually contact the service was left up to the women herself. The woman’s obstetrician was notified if any referral was made. 

Risk factors

Assessment questions

I. Lack of support

1. Will you be able to get practical support with your baby?

2. Do you have someone you are able to talk to about your feelings or worries?

II. Recent major stressors in the last 12 months.

3. Have you had any major stressors, changes or losses recently (i.e. in the last 12 months) such as, financial problems, someone close to you dying, or any other serious worries?

III. Low self?esteem (including lack of self?confidence, high anxiety and perfectionistic traits)

4. Generally, do you consider yourself a confident person?

5. Does it worry you a lot if things get messy or out of place?

IV. History of anxiety, depression or other mental health problems

6a. Have you ever felt anxious, miserable, worried or depressed for more than a couple of weeks?

6b. If so, did it seriously interfere with your work and your relationships with friends and family?

7. Are you currently receiving, or have you in the past received, treatment for any emotional problems?

V. Couple’s relationship problems or dysfunction (if applicable)

8. How would you describe your relationship with your partner?

9a). Antenatal: What do you think your relationship will be like after the birth

VI. Adverse childhood experiences

10. Now that you are having a child of your own, you may think more about your own childhood and what it was like. As a child were you hurt or abused in any way (physically, emotionally, sexually)?

VII. Domestic violence.

11. Within the last year have you been hit, slapped, or hurt in other ways by your partner or ex?partner?

12. Are you frightened of your partner or ex?partner? (If the response to questions 11 and 12 is “No” then offer the DV information card and omit questions 13-18)

13. Are you safe here at home? /to go home when you leave here?

14. Has your child/children been hurt or witnessed violence?

15. Who is/are your children with now?

16. Are they safe?

17. Are you worried about your child/children’s safety?

18. Would you like assistance with this?

Opportunity to disclose further

19. Are there any other issues or worries you would like to mention?

Table 2: Variables (Risk Factors) Suggested format for psychosocial assessment questions [4-5]. 

EPDS score

Risk of meeting formal criteria for diagnosis of Major Depressive Disorder (DSM5 F32)

Total score below 9

Low risk


Medium risk


High risk

20 and over

Risk as above of concern, particularly if also positive score on Question 10 (self-harm)

Table 3: EPDS Score Risk Categories. 


If risk factors for perinatal mental health disorders are identified, then a referral should be offered to the family. Referral sources are site and area specific. Each screening agent needs to identify appropriate resources and referral pathways, including referral criteria and cost in their geographical area. This will require networking and knowledge of services in the area. 

Ethical Statement

The University of Sydney ethics committee has approved the study as part of the authors PhD. 


There are no Grants, financial support and technical or other assistance. 


  1. Glover V. Maternal depression, anxiety and stress during pregnancy and child outcome; what needs to be done. Best Practice and Research in Clinical Obstetrics and Gynaecology 28 (2014): 25-35.
  2. Leiferman J, Sinatra E, Huberty J. Pregnant Women's perceptions of patient-provider communication for health behaviour change during pregnancy. open Journal of Obstetrics and Gynecology 4 (2014): 672-684.
  3. Clinical practice guidelines for depression and related disorders-anxiety, bipolar disorder and puerperal psychosis-in the perinatal period (2012).
  4. Austin MP, Highet N. Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline Melbourne: Centre of Perinatal Excellence (2017).
  5. The national depressive initiative mental health national action plan 2008-2010 full report. Perinatal mental health consortium (2008). 

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