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Maternal mental health

Introduction

During pregnancy and the year following birth, women may be affected by a range of mental health problems, including anxiety and depression and postnatal psychotic disorders. These are collectively called perinatal mental illnesses.

Studies estimate that more than 1 in 10 women are affected by perinatal mental illness.  However, maternal mental illness also impacts their infant and the rest of their families and poses an important public health challenge. 

Maternal mental illness has important consequences for the impact on infant health and future behaviour and learning, and is one of the key factors determining life chances for children.

Only around half of mothers are identified and treated.

Early identification, support and treatment can prevent the onset and escalation of maternal mental illness and limit the impact on the family to improve the wellbeing, health and achievement of the child.

 

 What do we know?

A recent report by the Centre for Mental Health (2015) found:

  • Perinatal mental health problems affect between 10% and 20% of women at some point during pregnancy and for the first year after birth, with around 13-15% of women experiencing common mental health problems such as perinatal depression and anxiety (O’Hara & Swain, 1996; Heron et al., 2004; Bauer et al., 2014).
  • Women with a history of severe perinatal illness have a 50% chance of it recurring in a subsequent pregnancy (Oates, 2001)
  • Only around half of all mothers with perinatal depression and anxiety are identified (Ramsay, 1993: Hearn et al., 1998)

 

Table 1: Trend in live Births (2006-12)

Area

2006

2007

2008

2009

2010

2011

2012

Bedford Borough

1953

1928

2111

2162

2119

2088

2116

Source: NCHOD

The trend in birth rates in Bedford Borough has been relatively stable over the past few years.  The average number of births per year over the last 8 years is 2067 in Bedford Borough.  Using this average, the number of women affected by perinatal mental illnesses in Bedford each year can be estimated.

 

Table 2: Rates of perinatal psychiatric disorder per thousand maternities

Rates of perinatal psychiatric disorder per thousand maternities

Estimate of number of women affected in Bedford Borough

Postpartum psychosis 2/1000

2 in 1000

<5

Chronic serious mental illness 2/1000

2 in 1000

<5

Severe depressive illness 30/1000

30 in 1000

62

Mild-moderate depressive illness and anxiety states 100-150/1000

100-150 in 1000

206-310

Post-traumatic stress disorder 30/1000

30 in 1000

62

Adjustment disorders and distress 150-300/1000

150-300 in 1000

300-600

 

Source: Guidance for commissioners of perinatal mental health services. JCPMH. http://www.jcpmh.info/wp-content/uploads/jcpmh-perinatal-guide.pdf. Accessed 9/12/15

The impact of perinatal mental illness

  • Mental illness is one of the leading causes of maternal deaths in the UK (Knight et al., 2014).
  •  Perinatal mental illness affects family relationships, including partners (Chew-Graham et al., 2008).
  • Poor maternal mental health during pregnancy and the first year has important consequences for the impact on infant health.  This is a critical time for brain development and forming a secure parent-child attachment in the early years is key to a baby’s social and emotional development (DH, 2009).  Maternal depression can be debilitating and impact on the mother’s ability to nurture.  Research shows that perinatal mental illness, most commonly depression, increases the likelihood that:

 

  • The baby will be premature or have a low birth weight
  • The baby may not develop a secure attachment relationship with the mother
  • The child will experience behavioural, social or learning difficulties
  • The child will develop depression in adolescence (CHIMAT)

 

Figure 1: Impact of maternal depression on infant health and wellbeing at age 5 years

 

Maternal mental health

Maternal mental health

 

Source : Chimat (PREview: Visualisation diagrams)

 

Current activity & services

 

Currently the management and care of mothers with mental illness in the perinatal period is undertaken by a variety of primary and secondary care services.  Since 2013 the commissioning of Maternity Services and Tiers 1-3 mental health services is the responsibility of the Bedfordshire Clinical Commissioning Group.  Health Visiting became the responsibility of Local Authorities in October 2015.  NHS England is responsible for the commissioning of Tier 4 mental health services. 

 

East London Foundation Trust (ELFT) are the current providers of mental health services in Bedfordshire and their services include:

·         Assisted self-help

·         IAPT – including Cognitive Behavioural Therapy (CBT) and Dynamic Interpersonal Therapy (DIT)

·         Community Mental Health Services

·         Crisis team

 

Midwives and Health visitors receive training on the detection of mental illnesses.  Women are asked about previous and current mental health issues at booking and during pregnancy and the postnatal period, using prediction questions and detection questions (based on the Whooley questions).  If this is positive for mental health problems they can further assess using the PHQ-9 or GAD-7 assessment tools to determine severity and the most appropriate referral.  Health Visitors can offer listening visits for mild depression/anxiety where appropriate.

 

In Bedford Borough Children’s Centres offer social support for new mothers and FACES is well-established local charity that offers practical and emotional support for new mothers.

 

National and Local Strategies (Current best practices)

National

  • Clinical Guidance Antenatal and postnatal mental health (NICE, 2014)The Healthy Child Programme pregnancy and the first five years, (DH, 2009)
  •  No Health Without Mental Health (DH, 2011)
  • Management of women with mental health issues during pregnancy and the postnatal period (RCOG, 2011)
  • Guidance for commissioners of perinatal mental health services, (JCPMH, 2012)

 

Local

  • Bedford Borough Health and Wellbeing Strategy (2014)
  • Bedford Borough Public Health Strategy 2013/14
  • Bedford Borough Partnership Framework for Bedford Borough’s Children, Young People and Families 2014-2017.
  • Bedford Borough Early Years Strategy – Securing Firm Foundations 2015-18
  •  Bedford Borough Early Help Strategy 2015-18

.

What is this telling us          

 

Perinatal mental illness affects a significant number of women and has impacts on both the mother and child’s mental and physical health, and impacts on the wider family.. Early identification of mothers at risk of postnatal mental illness is key and a robust pathway should ensure that the treatment is appropriate and effective depending on need.  As a large proportion of women who suffer from mild to moderate depression are either not identified or do not seek help, routine antenatal and postnatal care should include regular opportunities to discuss and assess mental health.

 

What are the key inequalities?

 

Risk factors associated with increased risk of perinatal mental illnesses

o   History of mental illness

o   Family history of mental illness

o   Antenatal psychological disturbance – e.g. anxiety or depression

o   Lone parent or poor couple relationships

o   Low levels of social support

o   Stressful life events

o   Low social status

o   Teenage parenthood

o   Early emotional trauma/childhood abuse

o   Unwanted pregnancy

(Hogg, 2013)

What are the unmet needs/ service gaps?

 

Bedfordshire Clinical Commissioning Group (BCCG) identified parental mental health (including perinatal mental health) as a commissioning intention priority for 2015/16.

A mapping of services that support perinatal mental health was undertaken by Public Health in 2015.  Current provision was mapped against best practice (NICE, 2014; JCPMH, 2012, NHS England 2015; CMH, 2015) and referral pathways reviewed. Subsequent stakeholder workshops were held to discuss services for perinatal mental illness and some key themes developed.

 

Identified gaps:

  • A specialist perinatal team
  • Women “in the middle”/struggling with low mood and attachment are often missed or there is little support
  • Evidence based training in perinatal mental health for all staff involved in the pathway (e.g. midwives, mental health staff, health visitors, GPs and primary care staff)
  • An integrated pathway across primary and secondary care
  • Waiting times for IAPT are assumed to be longer than 2 weeks (NICE guidance) so health professionals are not always confident in making referrals
  • A care pathway to identify mother-baby attachment issues and lack of known services available to provide parent-infant interventions (Infant Mental Health Pathway)
  •  Inconsistent or no routine collection of data relating to women accessing mental health services in the perinatal period
  • Referral links to other relevant services including Early Help and services to support issues including domestic violence and drugs and alcohol
  • A family approach to involve partners and address their needs as appropriate

 

What should we be doing next?

 

a)    Develop local perinatal mental health services as part of an integrated care pathway that will:

 

  • Identify women with poor mental health through consistent antenatal and postnatal maternal mood assessments
  • Ensure primary and secondary health professionals involved in the perinatal period know how to access treatment to provide women access to high quality and timely support for mental health illness at all levels
  • Ensure a family approach is inherent in the services to involve partners (where agreed) and promote the mother-baby relationship.

 

b)    Ensure staff involved in the pathway are trained in perinatal mental health

 

References

 

Bauer, A et al., (2014) The costs of perinatal mental health problems. London: Centre for Mental Health

 

Centre for Mental Health (2015) Falling Through The Gaps – perinatal mental health and general practice

Chew-Graham, C. et al., (2008) GP’s and health visitor’s views on diagnosis and mangememtn of postnatal depression: a qualitative study. British Journal of Gerenal practice, Vol 58, pp. 169-176

 

Department of Health (2009) Healthy Child Programme; Pregnancy and the first five years of life

 

Department of Health (2011) No Health without Mental Health: A cross-Government mental health outcomes strategy for people of all ages. Analysis of the Impact on Equality (AIE) Annex B - Evidence Base Supporting document

 

Hearn, G et al. (1998) Postnatal depression in the community. British Journal of General Practice, Vol 48, pp. 1064-1066

 

Heron, J. et al (2004) The course of anxiety and depression through pregnancy and the postpartum in a community sample. Journal of Affective Disorders, 80(1), pp. 65-73

 

Hogg,S. (2013) Prevention in Mind All Babies Count: Spotlight on Perinatal Mental Health. NSPCC

 

Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of perinatal and mental health services

 

Knight. M et al. (2014) Saving Lives, improving Mother’s Care – Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquirires into Maternal deaths and Morbidity 2009-2012. Oxford: University of Oxford.

 

NHS England (2014) 2015-16 National Health Visiting Core Service Specification

NICE (2014) Antenatal and postnatal mental health: clinical management and service guidance CG192

Oates, M. (2001) Perinatal maternal mental health services, Reccommendations for provision of services for childbearing women. London: Royal College of Psychiatrists.

 

O’Hara , M &Swain, A. (1996) rates and risk of postpartum depression – a meta analysis. International Review of Psychiatry, 8(1), pp. 37-54.

 

Ramsay, R. (1993) Postnatal depression. Lancet, Vol 341, pp.1358

 

Royal College of Obstetricians and Gynaecologists (RCOG) (2011) Management of women with mental health issues during pregnancy and the postnatal period. Good practice No.14

 

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