A psychosocial risk assessment model (PRAM) for use with pregnant and postpartum women in primary care settings

  • S. R. PriestEmail author
  • M. -P. Austin
  • B. B. Barnett
  • A. Buist
Original Contribution


Recognition of high rates of mental health morbidity and mortality that affect women during the perinatal period has prompted the development of psychosocial risk assessment programs. Designed to identify women, at risk, during routine health checks and delivered by primary care health service providers, these fit within a primary prevention and early intervention strategic approach to the reduction of perinatal mental illness and reflect an integrated approach to perinatal health services delivery. This paper describes the development and use of the psychosocial risk assessment model (PRAM) at the Royal Hospital for Women in Sydney, Australia. Data is presented on 2,142 women who attended the Antenatal Midwives Clinic between 2002 and 2005. The PRAM guides primary care staff to quickly identify women experiencing emotional distress and/or psychosocial problems during pregnancy or postnatal checks. Measures used in pregnancy are the symptom-based Edinburgh Depression Scale and the psychosocial risk-based Antenatal Risk Questionnaire. In postnatal setting the Postnatal Risk Questionnaire is used. Scores can be used to compute a Psychosocial Risk Index (PRI) to guide individualized care planning, define needs for referral and classify groups for clinical and research purposes. Based on the PRI, among 2,142 women assessed in pregnancy 70.6% were classified as low/no risk (no interventions indicated currently), 24.1% as medium risk (in need of monitoring), and 5.3% as high risk (complex). The PRAM offers a conceptual framework, methods and measures for brief psychosocial assessment with clinical and research applications. Postpartum follow up studies of women assessed during pregnancy have commenced. Randomized controlled trials and cross-cultural studies are now indicated to strengthen the evidence base for the model.


PRAM Mental health Pregnant and postpartum women 



This work was supported in part by funds from Beyondblue: The National Depression Initiative under the National Postnatal Depression Program—New South Wales and Royal Hospital for Women (NSW) sections 2002–2005.

Sabine Merz, Research Assistant

Nicole Reilly, Editing assistance

Clinical Staff at RHW

Nursing Administration at RHW especially Helen Jarman

All participants who gave time


  1. ACOG (2000) Psychosocial risk factors: perinatal screening and intervention. ACOG Educational Bulletin Number 255, November 1999. Int J Gynecol Obstet 69:1999Google Scholar
  2. Adams RE, Bromet EJ, Panina N, Golovakha E, Goldgaber D, Gluzman S (2002) Stress and well-being in mothers of young children 11 years after the Chernobyl nuclear power plant accident. Psychol Med 32:143–156PubMedCrossRefGoogle Scholar
  3. Alder J, Fink N, Bitzer J, Hosli I, Holzgreve W (2007) Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. J Matern Fetal Med 20(3):189–209CrossRefGoogle Scholar
  4. Armstrong S, Small R (2007) Screening for postnatal depression: not a simple task. Aust N Z J Public Health 31(1):57–61PubMedGoogle Scholar
  5. Austin M-P (2003) Psychosocial assessment and management of depression and anxiety in pregnancy: key aspects of antenatal care for general practice. Aust Fam Physician 32:119–126PubMedGoogle Scholar
  6. Austin M-P, Lumley J (2002) Antenatal screening for women at-risk of postnatal depression. Acta Psychiatr Scand 106:1–8CrossRefGoogle Scholar
  7. Austin M-P, Priest SR (2005) Clinical issues in perinatal mental health: new developments in the detection and treatment of perinatal mood and anxiety disorders. Acta Psychiatr Scand 112:97–104PubMedCrossRefGoogle Scholar
  8. Austin MP, Hadzi-Pavlovic D, Saint K, Parker G (2005) Antenatal screening for the prediction of postnatal depression: validation of a psychosocial Pregnancy Risk Questionnaire. Acta Psychiatr Scand 112(4):310–317PubMedCrossRefGoogle Scholar
  9. Austin MP, Kildea S, Sullivan E (2007) Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. Med J Aust 186:364–367PubMedGoogle Scholar
  10. Austin M-P, Frilingos M, Lumley J, Hadzi-Pavlovic D, Roncolato W, Acland S, Saint K, Segal N, Parker G (2008a) Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomized controlled trial. J Affect Disord 105(1–3):35–44CrossRefGoogle Scholar
  11. Austin M-P, Priest SR, Sullivan E (2008b). Antenatal psychosocial assessment for reducing perinatal mental health morbidity. Cochrane Database Syst Rev 2005, Issue 1. Art No.: CD005124. doi: 10.1002/14651858.CD005124
  12. Barnett B, Glossop P, Matthey S, Stewart H (2005) Screening in the context of integrated perinatal care. Chapter 6. In: Henshaw C, Elliot S (eds) Screening for perinatal depression. Jessica Kingsley, London, pp 68–82Google Scholar
  13. Beck CT, Gable RK (2001) Comparative analysis of the postpartum depression screening scale with two other depression instruments. Nurs Res 50(4):242–250PubMedCrossRefGoogle Scholar
  14. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4:561–571PubMedGoogle Scholar
  15. Beck CT, Records K, Rice M (2006) Further development of the postpartum depression predictors inventory-revised. J Obstet Gynecol Neonatal Nurs 35(6):735–745PubMedGoogle Scholar
  16. Bernazzini O, Marks MN, Bifulco A, Siddle K, Asten P, Conroy S (2005) Assessing psychosocial risk in pregnant/postpartum women using the contextual assessment of maternity experience (CAME). Soc Psychiatry Psychiatr Epidemiol 40:49–508Google Scholar
  17. Blackmore ER, Carroll J, Reid A, Biringer A, Glazier RH, Midmer D, Permaul JA, Stewart DE (2006) The use of the antenatal psychosocial health assessment (ALPHA) tool in the detection of psychosocial risk factors for postpartum depression: a randomised controlled trial. JOGC 28(10):873–878PubMedGoogle Scholar
  18. Buist A, Condon J, Brooks J, Speelman C, Milgrom J, Hayes B, Ellwood D, Barnett B, Kowalenko N, Matthey S, Austin M-P, Bilszta J (2006) Acceptability of routine screening for perinatal depression. J Affect Disord 93:233–237PubMedCrossRefGoogle Scholar
  19. Buist A, Ellwood D, Brooks J, Milgrom J, Hayes BA, Sved-Williams A, Barnett B, Karatas J, Bilszta J (2007) National program for depression associated with childbirth: the Australian experience. Best Pract Res Clin Obstet Gynaecol 21(2):193–206PubMedCrossRefGoogle Scholar
  20. Carroll JC, Reid AJ, Biringer A, Midmer D, Glazier RH, Wilson L, Permaul JA, Pugh P, Chalmers B, Seddon F, Stewart DE (2005) Effectiveness of the antenatal psychosocial health assessment (ALPHA) form in detecting psychosocial concerns: a randomised controlled trial. CMAJ 173(3):253–259PubMedGoogle Scholar
  21. Cox J, Holden J (2003) Perinatal mental health: a guide to the Edinburgh Postnatal Depression Scale (EPDS). Gaskell, LondonGoogle Scholar
  22. Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150:782–786PubMedCrossRefGoogle Scholar
  23. Drewett R, Blair P, Emmett P, Emond A, The ALSPAC Study Team (2004) Failure to thrive in the term and preterm infants of mothers depressed in the postnatal period: a population-based birth cohort study. J Child Psychol Psychiatry 45(2):359–366PubMedCrossRefGoogle Scholar
  24. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T (2005) Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 106(5–1):1071–1083PubMedGoogle Scholar
  25. Glover V, O’Connor TG (2002) Effects of antenatal stress and anxiety: implications for development and psychiatry. Br J Psychiatry 180:389–391PubMedCrossRefGoogle Scholar
  26. Gunn J, Hegarty K, Nagle C, Forster D, Brown S, Lumley J (2006) Putting woman-centred care into practice: a new (ANEW) approach to psychosocial risk assessment during pregnancy. Birth 33:1Google Scholar
  27. Howard LM, Goss C, Leese M, Appleby L, Thornicroft G (2005) The psychosocial outcome of pregnancy in women with psychotic disorders. Evid-Based Mental Health 8(2):33CrossRefGoogle Scholar
  28. Mares S, Newman L, Warren B (2005) Clinical skills in infant mental health. ACER, AustraliaGoogle Scholar
  29. Matthey S, Phillips J, White T, Glossop P, Hopper U, Panasetis P, Petridis A, Larkin M, Barnett B (2004) Routine psychosocial assessment of women in the antenatal period: frequency of risk factors and implications for clinical services. Archives of Women’s Mental Health 7:223–229PubMedCrossRefGoogle Scholar
  30. Milgrom J, Gemmill AW, Biltszta JL, Hayes B, Barnett B, Brooks J, Ericksen J, Ellwood D, Buist A (2008) Antenatal risk factors for postnatal depression: a large prospective study. J Affect Dis 108:147–157PubMedGoogle Scholar
  31. Murray D, Cox JL (1990) Screening for depression during pregnancy with the Edinburgh Depression Scale (EPDS). J Reprod Infant Psychol 8(2):99–107CrossRefGoogle Scholar
  32. Murray L, Cooper P (eds) (1997) Postpartum depression and child development. Guildford, LondonGoogle Scholar
  33. Murray L, Woolgar M, Murray J, Cooper P (2003) Self-exclusion from health care in women at high risk of postpartum depression. J Public Health Med 25(2):131–137PubMedCrossRefGoogle Scholar
  34. NICE (2006) Antenatal and postnatal mental health: clinical management and service guidance.
  35. Oates M (2003) Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. Br Med Bull 67:219–229PubMedCrossRefGoogle Scholar
  36. Orr ST, Blazer DG, James SA, Reiter J (2007) Depressive symptoms and indicators of maternal health status during pregnancy. J Women’s Health 16(4):535–542CrossRefGoogle Scholar
  37. Priest SR (2006) Midwife-led antenatal psychosocial screening in a primary care obstetric setting: A case study. Unpublished Master of Public Health thesis, University of New South Wales School of Public Health and Community MedicineGoogle Scholar
  38. Priest SR, Henderson J, Evans SF, Hagan R (2003) Stress debriefing after childbirth: a randomised controlled trial. Med J Aust 178:542–545PubMedGoogle Scholar
  39. Priest SR, Barnett B (2008) Perinatal anxiety and depression: issues, outcomes and interventions chapter in Sued Williams A and Cowling V (eds). Infants of parents with mental illness: developmental, clinical, cultural and personal perspectives. Australian Academic PressGoogle Scholar
  40. Rahman A (2005) Maternal depression and child health: the need for holistic health policies in developing countries. Harvard Health Policy Rev 6:70–80Google Scholar
  41. Robertson E, Grace S, Wallington T, Stewart D (2004) Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry 26(4):289–295PubMedCrossRefGoogle Scholar
  42. Ross LE, Sellers EM, Evans SE, Gilbert Romach MK (2004) Mood changes during pregnancy and the postpartum period development of a biopsychosocial model. Acta Psychiatr Scand 109(6):457–466PubMedCrossRefGoogle Scholar
  43. Webster J, Pritchard MA, Creedy D, East C (2003) A simplified predictive index for the detection of women at risk for postnatal depression. Birth 30:101–110PubMedCrossRefGoogle Scholar
  44. Webster J, Hall L, Somville T, Schneider P, Turnbull R, Smith P (2006) Prospective testing of the Brisbane Postnatal Depression Index. Birth 33(1):56–63PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • S. R. Priest
    • 1
    • 2
    • 6
    Email author
  • M. -P. Austin
    • 3
  • B. B. Barnett
    • 4
  • A. Buist
    • 5
  1. 1.School of Medicine and Public Health, Perinatal and Infant Psychiatry ProgramUniversity of NewcastleNewcastleAustralia
  2. 2.Visiting Fellow School of Public Health and Community MedicineUniversity of New South WalesKensingtonAustralia
  3. 3.School of PsychiatryUniversity NSWSydneyAustralia
  4. 4.Sydney South West Area Health ServiceSydneyAustralia
  5. 5.Austin Health and Northpark HospitalsUniversity of MelbourneParkvilleAustralia
  6. 6.Locked Bag 1014WallsendAustralia

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