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Perinatal screening and assessment tools

The 2017 Clinical Practice Guideline recommends the following tools to undertake screening and assessment.

Psychosocial risk assessment (ANRQ/PNRQ)

The antenatal period

If using a tool to assess a woman’s risk or likelihood of developing mental health problems in the antenatal period, the Antenatal Risk Questionnaire (ANRQ) is recommended. Instructions of how to use the tool, it’s adaption to include family violence and drug and alcohol use and the scoring guide can be downloaded in the links below.

*Note:  The original ANRQ questionnaire does not contain questions to enquire about family violence or drug and alcohol use. These areas have been added to the alternative version provided in the link below for use if these areas are not asked at other times.

ANRQ Instructions

ANRQ _Questionnaire* (original version)

ANRQ Questionnaire – with D&A and Family violence questions 

ANRQ Scoring Guide

The postnatal period

For those health professionals assessing risk in the postnatal period, we also recommend asking additional items pertaining to adaption to the birth and postnatal period through the inclusion of three additional items – as displayed in the postnatal questionnaire below.

ANRQ Questionnaire with D&A, family violence and postnatal items

For more information about the ANRQ/PNRQ, it’s application and when follow-up care is required here.

Assessment of symptoms – depression and anxiety (EPDS)

The Edinburgh Postnatal Depression Scale (EPDS) is the recommended tool for use both antenatally and postnatally to identify whether a woman is likely to be experiencing depression and/or anxiety in pregnancy or the postnatal period. A score of 13 or more indicates an increased likelihood that anxiety and depression is present.

The Edinburgh postnatal depression scale (EPDS)

EPDS Scoring Guide

For more information about the EPDS, it’s application, when follow-up care is required and cultural considerations click here.

Training in the use of recommended screening and assessment tools

Free, comprehensive training is currently available to support midwives in the use and interpretation of the ANRQ and EPDS. This information is contained in Module 2 of the COPE Basic Skills in Perinatal Mental Health Program.

Further information about the program and a preview is available in the online training program tab here.