Psychosocial protective factors
For the vast majority of women (88/91), at least one protective factor was identified within their KMMS assessment (mean 4.0, SD 1.7; Table 1). Family-based support was the most frequently recorded psychosocial protective factor among participants overall and was mentioned by 78 women. Support was characterised as practical, emotional, ‘having someone to talk to’ and/or having someone to ‘be with’. Women described general experiences of ‘support’ within the immediate and extended family environment as well as specific family members who provided high levels of support. Mothers were the most commonly mentioned supportive family member, followed by sisters. Family support was generally present for women who lived with or close to family, but was also reported by some who were geographically separated from their family.
While only about a quarter of the women identified their partners as a source of ‘support’, more than half the women in the sample (54/91) described their intimate relationships as ‘good’ and ‘strong’. These women described their partners as ‘caring’, ‘helpful’, taking an active role in fathering and/or excited about the new baby/arrival of the baby. A small number of participants (n = 3) identified a history of intimate partner violence which they stated had now ceased; these women identified their partners as ‘good men’.
Most women who identified positive support and connectivity with their family identified themselves as ‘strong’, ‘confident’, managing or coping well, and ‘feeling good’ (64/91). Many of these women reported that they ‘stay away from humbug’ and ‘don’t let things worry me’. Spending time with children and family, going fishing, listening to music, playing sport, gardening, and reading the bible were emphasised by women as ways of enacting self-care and enhancing their sense of wellbeing.
Responsibility for children was another common psychosocial protective factor mentioned by women. Nurturing children, keeping them safe and ensuring children had access to education were common themes. Women expressed a desire to be a role model for their children (both biological and other children in their care). Generally, children were discussed as a normal part of life and a source of both comfort and distraction when life stressors were encountered.
Positive childhood memories and experiences were identified in just under half of KMMS assessments (41/91). In these assessments, childhood is associated with participants feeling ‘safe’, ‘secure’, ‘happy’, being ‘part of an extended and loving family’ and having ‘connection to country’. Women noted a range of different family structures when commenting on their positive childhoods; this included growing up with separated parents, a grandparent or another member of their extended family, and/or growing up with both parents.
Aspects of a healthy lifestyle were mentioned by 57 women. This included not currently or never having used alcohol, cigarettes or marijuana. Women who had given up alcohol and other substances often associated this with a desire to ‘do better’ or ‘set a good example’, one woman noted she was ‘much happier and free now’. Five women talked about broader healthy lifestyle activities such as fishing, walking, taking time out and ‘exercise’. Other sources of psychosocial protective factors less commonly identified were friends, employment and study, religion, and engagement with health professionals.
In univariate analyses of common protective factors, family based support, emotional regulation/self-esteem, having a healthy lifestyle, supportive intimate partner relationships and a good childhood were statistically significantly more likely to be associated with lower KMMS risk (Table 1) and be reported in women who did not have clinical depression and/or anxiety (Table 2).
Psychosocial risk factors
Only 7/91 women had no reported risk factors; the overall mean number of risk factors was 2.5 (SD 1.6; Table 1).
Adverse childhood experiences were identified by nearly half of the women (42/91). Family breakdown, having parents that were ‘drinkers’, witnessing domestic violence, childhood abuse (physical and/or sexual), and neglect were the most commonly identified features of adversity. Loss of a parent or a carer was also identified in several of the assessments as a compounding feature to a childhood already shaped by adversity. Approximately, three quarters of participants who mentioned adverse childhood experiences identified an associated protective factor. Primarily, this was being raised by grandparents (mostly a grandmother) or having a grandparent as their ‘safe’ person. Other female members in the family, aunties, or ‘other mothers’ (generally meaning maternal aunts in Western terms) were also identified as having a carer role in the face of family breakdown.
Grief and loss
Grief and loss was a pervasive theme with 39 women discussing the impact of loss on their lives. Twenty women (22% of participants) referred to a ‘recent’ death of a significant family member (including, for two women, their child). Within this group, several women identified multiple losses of family members. The death of a loved one often was identified as traumatic (accident, suicide, assault related, long illness with the family member hospitalised far away in Perth). Women often described the anniversary of deaths and the person’s birthday as ‘triggering’.
Most women who identified grief and loss as a risk factor noted talking with family and receiving support from family was a protective factor (22/39). Children were also mentioned as providing a ‘purpose’ and a sense of perspective. Many women reflected on the importance of giving themselves ‘time’ to grieve and being accepting of the grieving process. Around a one quarter of women noted no specific protective factors for grief and loss. The absence of protective factors for this risk was significantly associated with clinical depression and/or anxiety (Table 2).
Worry, stress and anxiety
Feelings of ‘worry’, ‘stress,’ or ‘anxiety’ were identified by 40% of women (36/91). Fifteen described these feelings as generalised (‘I think too much’, ‘stressing out at everything’). Other women identified more specific concerns including worry about family members or happenings within their extended family, children (particularly their children’s safety), stress relating to being pregnant (low mood, unplanned pregnancy, lack of support). Other worries/stressors included food security, finances, relationship with partner, insecure living arrangements and involvement with Department for Child Protection.
Two-thirds of women with an anxiety or stress risk factor had an associated protective factor. The majority identified that this involved talking to family and receiving support from family. Most commonly, this support was provided by mothers, aunties and sisters. Several women talked about self-care practices, this included walking, fishing, reading, and being ‘out bush’. Others talked about resiliency: ‘being strong’ and having the ability to ‘cope’ with life. Counselling, church, partners and work were other protective factors identified.
Family as stress
While most women identified family as a protective factor, family was also raised by some women as a risk factor for their psychosocial wellbeing (25/91). Eleven women referenced family stress in relation to a family member’s behaviour when intoxicated. Having little or no support from family, arguments and demands from family members, kinship caring responsibilities and family ‘judgement’ were other commonly identified aspects of family-related stress.
Approximately, three quarters of women with a family risk factor identified having protective factors to manage this psychosocial risk. Most commonly, these protective factors emphasised women having a sense of autonomy, ‘good boundaries’ and being able to exercise control over their life. Additionally, women talked about close relationships with other family members as a means of mitigating the stress of a problematic or absent relationship.
Intimate partner violence
Sixteen women identified intimate partner violence (IPV). Aspects of IPV included physical abuse, sexual violence, coercion (‘forces me to do things’; ‘forces me to buy drugs’), and jealousy (‘I can’t go anywhere by myself’, ‘doesn’t like [me] spending time with [my] daughter’). One woman identified the violence as ‘worse’ during pregnancy. Problematic drinking and drug taking of partners was mentioned by six women experiencing IPV.
Two women identified the violence occurring in relationships that had recently ended. One of these women stated she is still ‘frightened and shaky’ when talking to her ex-partner but identified the separation as a protective factor against further violence. Ten other women identified family as a protective factor to the IPV. These women characterised support from their family as having someone to talk to or someone to be with, without pressure or expectation. For some women, this included ‘stopping’ with family when her partner is violent or when she can see his behaviour is escalating.
Intimate partner stressors
A further 15 women identified a range of other stressors from intimate partners including annoyance, arguing, alcohol and drug use, jealousy, infidelity, relationship breakdown, unstable relationships, ex-partner causing ‘stress’ and communication issues (specific to loss of a child). These women did not report intimate partner violence.
All but one of these women reported associated protective factors, most commonly women adopted self-regulating behaviours (‘Think and talk to myself. I say forget about that—don’t cause a fight’) or physically removed themselves (‘Leave house when partner drinks’) as a means of mitigating the stressor. Other women identified positive communication with their partner and an ability to see the ‘big picture’ and/or an overall sense of satisfaction with the relationship as the means to managing this stressor.
Feelings of loneliness, sadness, poor self-esteem and poor emotional regulation.
Twenty women identified feelings of loneliness, sadness, poor self-esteem and emotional dysregulation. Loneliness was identified as a feeling of disconnection as opposed to physical isolation from people and was raised by ten women. Overall women spoke about their desire to ‘stay well and safe for children’ and to be ‘self-motivated and determined’, work and family were other noted protective factors. Two women however spoke about feeling ‘no good’ in themselves, neither woman identified any protective factors.
Suicidal ideation, self-harm, history of mental health disorders and substance misuse
Six women discussed recent feelings of suicidal ideation. Five of the six women identified their children and family as the reasons why they would not harm themselves despite the feelings arising in them. One participant had very clear intentions of harming herself and the KMMS notes documented that the primary health care provider arranged for immediate support and intervention.
In addition to the six women above, one woman discussed current self-harming behaviours and a previous suicide attempt. She identified friends as her protective factor. Two women identified a history of depressive disorders. One woman identified a previous history of perinatal depression and anxiety. The other woman identified being on antidepressants and receiving support through counselling services.
Thirty participants identified consuming alcohol, cigarettes and/or other drugs during the perinatal period. Many of these women described attempts to reduce or cease alcohol, cigarettes or marijuana/other drugs either during pregnancy or in the post-natal period.
Statistically significant risk factors
Of the more common risk factors, family as stress, lack of emotional regulation/self-esteem, and intimate partner violence were individual significantly associated with higher KMMS risk (Table 1) and having clinical depression and/or anxiety (Table 2).
Relationship between protective and risk factors, KMMS risk and diagnosis of depression and anxiety
There was a consistent relationship between recorded protective and risk factors and the overall KMMS risk assessment. Women recorded at higher risk less commonly had protective factors recorded (11–33% high risk vs 61–100% no risk) and more commonly had risk factors recorded (22–67% high risk vs 6–28% no risk) than women with lower KMMS-assessed risk (Table 1). Consistent with this, the mean number of protective factors decreased with increasing KMMS risk category (4.9–1.6), with an inverse pattern for risk factors (1.1–3.8) across categories (from no to high risk).
This relationship was also apparent in the independent GP assessments which were blinded to the results of the KMMS. Women diagnosed with clinical depression and/or anxiety had a mean of two protective factors and four risk factors recorded on the KMMS, and frequently had risk factors that did not have a corresponding protective factor. Conversely, those who did not receive a clinical diagnosis of depression and/or anxiety had a mean of approximately four protective factors and two risk factors recorded.
None of the women with protective factors and no risk factors were diagnosed with depression and/or anxiety, while all the women with risk factors and no protective factors were diagnosed (Table 3). Of the women who had an equal or higher number of risk factors compared to protective factors, approximately half were diagnosed with depression and/or anxiety. Of the 50 women who had a greater number of protective factors than risk factors, only four (8%) were diagnosed with mild or moderate anxiety or depression. Notably, all four had a risk factor of grief and loss and three of these did not have an identified protective factor to this risk.