Development of the KMMS
Pregnancy, childbirth and early parenting is a time of vulnerability for many women. In the general population, up to one in ten women will experience depression during pregnancy, with the rates of anxiety thought to be even higher. Up to one in seven will experience depression or anxiety in the year after baby’s birth.
Although there has been little research about depression and anxiety in perinatal Aboriginal and Torres Strait Islander women, their risk of antenatal and postnatal depression has been found to be higher than among non-Indigenous women. 
Promoting perinatal mental health and wellbeing among Aboriginal and Torres Strait Islander mothers is important not only for women but also for their children, families and community. If perinatal mental health disorders are left untreated they may have a severe impact on the mother, child and extended family. Some impacts of perinatal depression and anxiety may include: poorer birth outcomes, poorer bonding and attachment between mother and baby, ongoing emotional and cognitive difficulties for children, and enduring (and possibly escalating) mental health disorders for the woman. 
Routine clinical screening is seen as an effective way to identify and respond to mental health concerns. The development of the Kimberley Mum’s Mood Scale (KMMS) was motivated by concerns about the appropriateness of recommended perinatal mental health screening practices for Aboriginal women in the Kimberley. Was the Edinburgh Postnatal Depression Scale the best way for Kimberley health professionals to engage with women? How could Kimberley health organisations improve the identification and management of mental health disorders for Aboriginal women?
These questions were answered through an extensive community consultation process which included over 100 Aboriginal women from eight language groups and more than 70 workers from Aboriginal Community Controlled Health Services (ACCHS) and Western Australian Country Health Services (WACHS) throughout the Kimberley. Discussions and yarns about perinatal mental health and screening found that Kimberley Aboriginal women place high value on a trusting relationship with the administering health professional, time to yarn, completing tools jointly (sitting side by side), and a strengths-based approach to follow-up. The consultation resulted in the development of the two-part KMMS as a more culturally secure approach to screening for depression and anxiety during the perinatal period.
Part 1 of the KMMS adapts the Edinburgh Postnatal Depression Scale (EPDS), developed in Scotland in the 1980s, using language and graphics as determined through the Kimberley consultation.
Part 2 involves talking or yarning to explore important psychosocial protective and risk factors. The yarning topics were identified as important through the consultation process and are consistent with recent recommendations for good care in the perinatal period.
Most importantly, the KMMS enables a different approach for communicating with women. This approach prioritises time, trust, rapport and understanding as a foundation for improved perinatal care. It values improved physical health outcomes for mother and baby, early identification and management of mental health concerns, and supporting women around other broader social and emotional wellbeing concerns. The aim of the KMMS is to identify concerns as they arise during the perinatal period so women can receive appropriate support quickly. This in turn minimises the potential impact, severity and duration of the effects of perinatal depression and anxiety on the mother, child, and family.
To ensure the best possible outcomes for women and that the KMMS is used in a culturally safe way, training is strongly recommended prior to use. The KMMS project team conducts face-to-face training sessions throughout the Kimberley.
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KMMS Kimberley validation study (2013 – 2014)
The KMMS (Part 1 and 2) was validated with 91 Kimberley Aboriginal women from 15 communities and towns. Women completed the KMMS with midwives or child health nurses, and were then separately assessed by a GP (who was blinded to the midwife/child health nurse assessment). A KMMS risk assessment of moderate or high detected everyone who was diagnosed with moderate or high severity anxiety and/or depression by the GP. This confirmed the KMMS can detect women most at risk. Further, the KMMS was well-accepted by women and health care providers.
It is important to note that the validity of the KMMS comes from using both of its parts. Part 1 is a traditional screening tool assessing a woman against known criteria of depression and anxiety. It also provides an introduction to talking about ‘mood’ and how a woman has been feeling. Part 2 explores the woman’s current psychosocial situation including her protective and risk factors. Using both parts, the health professional is able to assess the risk of a woman experiencing perinatal depression and anxiety and provide follow-up support.
The validation of the KMMS found that as women opened up and talked about their lives, health professionals were able to gain a fuller understanding of the woman’s situation. Completing Part 2 and exploring the presence and number of risk and protective factors is essential to provide context for the Part 1 score and adequately determine the woman’s risk of perinatal depression and/or anxiety.
Evidence from the validation study shows that midwives and child health nurses have the skills and the experience to accurately assess risk using the KMMS. While the overall approach of the KMMS may be new, it uses the existing skills, experiences and clinical judgement of the health professional and provides a framework for classifying risk and ensuring appropriate care for the woman.
The KMMS has been endorsed by the Kimberley Aboriginal Health Planning Forum (KAHPF) and is recommended for use in the Kimberley with Aboriginal women as per the Kimberley Perinatal Depression and Anxiety Protocol.
This protocol can be found at www.kahpf.org.au/clinical-protocols.
KMMS moving forward (2017 – 2021)
In partnership with health services and Aboriginal communities in North Western Australia (WA) and Far North Queensland (FNQ) the Rural Clinical School of Western Australia (RCSWA) and its partner Aboriginal Controlled and Government run health services were successful in receiving funding from the Western Australian Department of Health and a National Health and Medical Research Council partnership grant. The aims are to:
evaluate and re-validate the KMMS in real-world settings across the Kimberley (in partnership with KAMS, KAMS member services and WACHS)
trial and validate the KMMS in the Pilbara region (in partnership with Mawarnkarra Health Service and WACHS)
trial and validate the KMMS in Far North Queensland (in partnership with Apunipima Cape York Health Council)
This study will describe the effectiveness and acceptability of the KMMS when taken outside of a ‘study context’ and implemented as a routine feature of clinical care in the Kimberley and whether the KMMS can be used in two other remote regions of Australia as a culturally secure and validated perinatal depression screening tool for Aboriginal women.
 Buist A, Bilszta J. The beyondblue National Postnatal Depression Program: prevention and early intervention 2001-2005 final report (Vol 1 national screening program). Melbourne : beyondblue; 2005.
 Austin M-P, Highet N, the Expert Working Group. Mental health care in the perinatal period: Australian Clinical Practice Guideline. Melbourne: Centre of Perinatal Excellence; 2017
 Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384(9956):1800-19. doi: 10.1016/S0140-6736(14)61277
 Kotz J, Munns A, Marriott R, Marley JV. Perinatal depression and screening among Aboriginal Australians in the Kimberley. Contemp Nurse. 2016;52(1):42-58. doi: 10.1080/10376178.2016.1198710
 Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786.