Maternity mental health

Perinatal mental health refers to the mother’s mental health in the antenatal period up to the birth and for a year after the baby is born.

Maternal mental health is critical in the antenatal period and in the first year of life for her baby and if severe can affect attachment and communication between the mother and baby

There is a large body of evidence which show a small but significant association between perinatal mental illness and an increased risk of poor child psychological and developmental outcomes (Stein, et al., 2014).

What do we know?

More than 1 in 10 women develop a mental illness during pregnancy or within the first year after having a baby. Examples of perinatal mental illness include antenatal depression, postnatal depression, maternal obsessive compulsive disorder, postpartum psychosis and post-traumatic stress disorder (PTSD). These illnesses can be mild, moderate or severe, requiring different kinds of care or treatment (Maternal Mental Health Alliance, 2014).

The Joint Commissioning Panel for Mental Health (2012) estimated the numbers of women affected by perinatal mental illnesses in England each year:

  • Postpartum psychosis – 2 per 1,000 maternities – approximately 1,380 women
  • Chronic serious mental illness – 2 per 1,000 maternities – approximately 1,380 women
  • Severe depressive illness – 30 per 1,000 maternities – approximately 20.640 women
  • Post traumatic stress disorder – 30 per 1,000 maternities – approximately 20,640 women
  • Mild to moderate depressive illness and anxiety state – 100-150 per 1,000 maternities – approximately 86,020 women
  • Adjustment disorders and distress – 150-300 per 1,000 maternities – approximately 154,830 women

If untreated, perinatal mental illnesses can have a devastating impact on the women affected and their families. For example, maternal mental health problems are associated with 33% to 50% of all children presenting to social care as ‘children in need’ or children at risk of being taken into care.

NICE guidance states that women should be assessed for levels of anxiety and depression in pregnancy and after birth. Midwives and health visitors are required as part of the maternal mental health pathway to ask two key questions about depression called the Whooley questions i.e.

“During the past month, have you often been bothered by feeling down, depressed or hopeless?"

“During the past month, have you often been bothered by having little interest or pleasure in doing things?”

Facts, Figures, Trends

Over 2014/15 there were 20 mothers referred by local midwifery and health visiting teams to ‘Introducing Access to psychological Therapy’ services (IAPT) commissioned by Slough CCG.

From October 2015 anonymised postcode level data on risk has been collected by health visiting teams to allow better targeting of prevention and treatment services in turure.

It has been estimated by NICE that approximately 12% of women require mental health support either during or directly after pregnancy. Applied to the number of maternities in Slough each year this corresponds to 321 pregnant women potentially requiring access to perinatal mental health services.

National & Local Strategies (Current best practices)

Public Health England (2015) recently published a rapid review of evidence for the healthy child programme. This has highlighted the best practice for perinatal mental health.

NICE guideline CG 192 for antenatal and postnatal mental health (NICE 2014) recommends that at a woman's first contact with services in pregnancy and the postnatal period, practitioners should ask two questions about depression and subsequent questions about generalised anxiety. Key risk factors are

  • any past or present severe mental illness
  • past or present treatment by a specialist mental health service, including inpatient care
  • any severe perinatal mental illness in a first-degree relative (mother, sister or daughter)

If high risk scores are identified then NICE (2014) recommends referring to a secondary mental health service (preferably a specialist perinatal mental health service) for assessment and treatment, all women who:

  • have or are suspected to have severe mental illness
  • have any history of severe mental illness (during pregnancy or the postnatal period or at any other time)

In both cases the woman's GP should know about the referral.

Where a woman has any past or present severe mental illness or there is a family
history of severe perinatal mental illness in a first-degree relative, practitioners should be alert for possible symptoms of postpartum psychosis in the first two weeks after childbirth.

If a woman has sudden onset of symptoms suggesting postpartum psychosis, she should be referred to a secondary mental health service (preferably a specialist perinatal mental health service) for immediate assessment (within four hours of referral).

When a woman with a known or suspected mental health problem is referred in pregnancy or the postnatal period, she should be assessed for treatment within two weeks of referral and provided with psychological interventions within one month of initial assessment.

What is this telling us?

National Institute for Health & Care Excellence (NICE) guidelines provide a clear statement of what is required.

For prevention
Women who receive a psychosocial or psychological intervention designed to prevent postnatal depression during pregnancy or the post-partum period are significantly less likely to develop postpartum depression compared with those who receive standard care.
Promising interventions include interpersonal psychotherapy, intensive home visiting by professionals, and telephone support (though evidence on the latter is inconsistent).

For treatment NICE (2014a) recommends that women with persistent sub threshold depressive symptoms, or mild to moderate depression, in pregnancy or the postnatal period should be offered facilitated self-help.
Where women with a history of severe depression initially present with mild depression in pregnancy or the postnatal period, pharmacological therapies should be considered.
For a woman with moderate or severe depression in pregnancy or the postnatal period, options should include a high-intensity psychological intervention, for example, cognitive behaviour therapy (CBT); or a TCA, SSRI or (S)NRI; or a high-intensity psychological intervention in combination with medication. [NEW]

Inconclusive evidence from reviews of interventions other than pharmacological, psychosocial and psychological for treating antenatal/postnatal depression include; depression-specific acupuncture, maternal massage, bright light therapy, or omega-3 fatty acids to treat antenatal depression. There is no evidence to support the use of group CBT, exercise interventions, or omega-3 fatty acids for the treatment of postnatal depression.

NICE (2014a) recommends that a woman with persistent sub threshold symptoms of anxiety in pregnancy or the postnatal period should be offered facilitated self-help. This should consist of the use of CBT-based self-help materials over 2-3 months with support (either face to face or by telephone) for a total of 2-3 hours over 6 sessions

Women with anxiety disorders in pregnancy or the postnatal period should be offered a low-intensity psychological intervention (for example, facilitated self-help) or a high-intensity psychological intervention (for example, CBT) as initial treatment in line with
the recommendations set out in the NICE guideline for the specific mental health problem.

PHE in their summary of the evidence of what works identified that NICE guidance (2014) recommends that the nature of the mother-baby relationship should be assessed, including verbal interaction, emotional sensitivity and physical care, at all postnatal contacts.
Practitioners should discuss any concerns that the woman has about her relationship with her baby and provide information and treatment for identified mental health problems. Practitioners are recommended to consider further intervention to improve the mother-baby relationship if any problems in the relationship have not resolved.

What are the key inequalities?

Apart from a present or current history of mental health problems vulnerable women at additional risk of mental health problems in pregnancy or postnatally include those who; are abused, have sought asylum or who have English as an additional language, those who are misusing drugs and alcohol or who have had a traumatic birth.

What are the unmet needs/ service gaps?

There is no commissioned perinatal mental health service in Berkshire as yet although service specifications are being developed

That data should be collected from health visiting and maternity services to enable a geographic assessment of needs as well as a personal assessment of needs

That outcomes of perinatal mental health interventions are reported geographically through the JSNA as well as through commissioned services in future

Recommendations for consideration by other key organisations:

That the CCGs who have responsibility for the commissioning of adult mental health services collect data on women referred in antenatally and postnatally to IAPT services and commission a full perinatal mental health service

See also

References

PHE 2015. Rapid Review to Update Evidence for the Healthy Child Programme 0–5

NICE 2014. Antenatal and postnatal mental health overview