Provision of perinatal mental health services in two English strategic health authorities: views and perspectives of the multi-professional team
Evidence Based Midwifery: September
2010
Cathy Rowan1 RM, PGCEA, MA. Christine McCourt2 BA, PhD. Debra Bick3 RM, BA, MedSc, PhD.
1 Senior lecturer midwifery, Thames Valley University, Wellington Street, Slough, Berkshire SL1 1YG England. Email: cathy.rowan@tvu.ac.uk
2 Professor of maternal and child health, City University, Alexandra Building, Philpot Street, London E1 2EA England. Email: christine.mccourt.1@city.ac.uk
3 Professor of evidence-based midwifery practice, King’s College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA England. Email: debra.bick@kcl.ac.uk
Abstract
Background. For women giving birth in the UK, psychiatric illness and suicide in particular have been a leading overall cause of maternal mortality. Although the most recent Confidential Enquiry into Maternal and Child Health indicated that this is no longer leading causes, mental health problems before and after childbirth have a significant impact on the health of women, family relationships and children’s subsequent development. Reports and policy recommendations have highlighted the need for early detection, appropriate referral and management.
Aim. To follow-up the findings of a previous survey that explored the extent to which policy recommendations had been implemented in practice in two strategic health authorities (SHAs).
Method. Health professionals from two NHS Trusts selected from the two SHAs involved in the earlier survey were identified, along with professionals from their associated mental health and primary care services. Semi-structured interviews were undertaken with eight participants to examine the facilitators and limiting factors in developing services for women with perinatal mental health problems.
Results. Although women are now being screened for mental health problems at the booking interview, identification at subsequent points during pregnancy was less consistent and those interviewed felt that many women could be missed. There were pockets of good practice, such as a service in primary care for women with mental health concerns, a community psychiatric nurse who received referrals in relation to women during pregnancy and perinatal consultant psychiatrists to whom women may be referred. However, in some instances there were difficulties ensuring that women with mental health problems were followed up in the community, especially where there were complex catchment issues. The professionals interviewed felt that the services were often fragmented with poor liaison between professionals involved.
Conclusion. Despite evidence of local service development to enhance the care of women with mental health problems, it would appear from the survey and the follow-up interviews that identification, timely and appropriate referral of women with mental health problems and effective liaison between professionals need further development to meet policy and guidance recommendations. Barriers to progress include the complexity of service provision and funding across health sectors, and the fragmented nature of maternity services.
Key words: Perinatal mental health, perinatal mental health services, screening for mental health problems, evidence-based midwifery
Introduction
Depressive disorders constitute a large proportion of the global burden of disease both in developed and developing countries (Ustum et al, 2004). For women giving birth in the UK, psychiatric illness and suicide in particular were identified in previous reports of the triannual Confidential Enquiry into Maternal and Child Health (CEMACH) (Lewis, 2001; 2004) as the leading overall cause of maternal mortality. Although the most recent report (Lewis, 2007) identified that deaths from suicide were no longer the leading overall cause of mortality, mental health problems among childbearing women remain a cause for concern. Mental health problems can range from transient depression and anxiety to severe depression and psychosis, and could have a significant impact on the woman and her relationships with her partner and other family members, and the emotional and cognitive development of her child (Beck, 1995; Murray and Cooper, 1997; O’Connor et al, 2002). Guidelines on antenatal and postnatal mental health to inform NHS care in England and Wales were published in 2007 (NICE, 2007), which recommended screening for maternal mental health problems at the first contact with a woman antenatally and postnatally. Screening for mental health problems is also a requirement for the Clinical Negligence Schemes for Trusts (NHS Litigation Authority, 2010), which handles all clinical negligence claims against NHS member bodies. There is, however, a dearth of evidence with regard to the impact of recent practice and policy recommendations for women, clinicians or the maternity services (Bick and Howard, 2010).
This paper presents findings from the second part of a two-stage study, which aimed to identify how far the recommendations identified in previous CEMACH reports (Lewis, 2001; 2004) had been implemented in two English strategic health authorities (SHAs). Data for the first part of the study were obtained from a survey of maternity units coinciding with publication of the NICE maternal mental health guideline (NICE, 2007) and the CEMACH report (Lewis, 2007), and are published elsewhere (Rowan and Bick, 2008). Key findings from this stage of the study highlighted that although units were working to develop services for women with mental health needs, gaps in service provision remained. The second part of the study, presented here, explored in more depth, factors influencing the provision of care in line with national policy and guidance for women with mental health needs in the two SHAs through interviews with a range of relevant clinicians.
Background
The key recommendations of the 2004 CEMACH report (Lewis, 2004), NICE antenatal care guidelines (NICE, 2003; 2008) and NICE guidance on perinatal mental health (NICE, 2007) included that women should be asked about family or personal psychiatric history when they first book for antenatal care. In addition, there should also be:
• Guidelines in place for women identified as at risk or having mental health problems
• Specialist health professionals available to the women.
The National Service Framework for children, young people and maternity services (Department of Health, 2004) also set standards for screening, referral and interprofessional working. Two UK-wide surveys of perinatal mental health service provision (Tully et al, 2002; Oluwato and Freidman, 2005) identified a lack of clear referral pathways for women with mental health needs, insufficient training to enable staff to identify and manage maternal mental health issues and a lack of specialist perinatal mental health services. These findings were supported in a report published by the mental health charity MIND (2006), which found that women with mental health needs often had difficulty accessing appropriate services, sometimes with a wait of weeks or even months to see a specialist in perinatal mental health. In view of these findings and the increased policy focus on the need to identify maternal mental health problems early in pregnancy and the postnatal period, the researchers wanted to explore what was happening in routine practice and barriers or facilitators to implementation of practice recommendations.
The first part of this study was a survey of service provision for women with mental health needs (Rowan and Bick, 2008). All 39 NHS Trusts with maternity units in two SHAs in the south of England were sent a questionnaire in April 2007. The aim of the survey was to assess if the services the Trusts provided reflected national policy and guidance recommendations. Information was collected on Trust policies for screening women for mental health problems, referral procedures for those identified with potential problems, use of guidelines and coordination of perinatal mental health services across the acute and secondary care sectors. The rationale for selection of two SHAs was to capture data from diverse populations across rural, urban and inner city areas. In total, 24 Trusts returned a questionnaire (62%). Key findings included that the majority of Trusts had guidelines for midwives and obstetricians to assist them in identifying women who had previously experienced mental health problems or who were experiencing problems, while the remainder were in the process of developing these. Midwives were expected to ask women at their antenatal booking appointment about their mental health in line with policy recommendations, but there was variation in practice with regard to whether women were asked about their mental health at subsequent visits. Only seven Trusts had access to a specialist psychiatrist. A range of debriefing type services were offered, despite the lack of evidence that these initiatives could make a difference to perinatal mental health outcomes (Rowan et al, 2007). It was clear that there was a wide variation in services. Many Trusts acknowledged that they did not meet all the recommendations for women with mental health needs, but most had plans to develop these. Barriers included lack of clear pathways to link with the local psychiatric team and a lack of resources ‘ring-fenced’ for specialist mental health care.
Methods
In order to gain more in-depth insights and individual perspectives on how far policy and practice recommendations had been implemented and views of barriers and facilitators to achieving change, a number of relevant health professionals were interviewed for the second stage of the study. Two NHS Trusts were selected, one from each of the SHAs originally surveyed. Each of the Trusts were chosen because they reflected different populations – an inner city area and a more urban/rural area. The health professionals interviewed included managers of maternity services, community midwives, community psychiatric nurses and psychiatrists, as it was anticipated that information from each would provide a more complete picture of the reality of practice. Professionals were identified using snowball sampling (Rees, 1997). The key professional who completed the original survey was contacted and asked to identify professionals within their Trust with a specific mental health role or interest within the field. Semi-structured interviews included questions designed to obtain more detail on issues related to screening, guidelines, referral processes, interprofessional liaison, and facilitators and barriers to achieving policy and guidance recommendations (Lewis, 2004; NICE, 2007; 2008). The topics for discussion at interview were informed by responses to the original survey. Questions included:
• ‘Would you like to comment on the guidelines and referral processes for women with mental health problems in your Trust?’
• ‘How do professionals liaise with each other when concerns have been identified?’
The opportunity was also offered for interviewees to discuss other aspects of service provision not identified in the survey, which they felt were relevant, for example, areas of good practice, innovative approaches or gaps in perinatal mental health services in the geographical area served by their Trust. The interviews were taped and later transcribed or documented verbatim in detailed notes. Data were analysed using a framework approach (Ritchie et al, 2003), which employs both a prior coding framework and more open thematic analysis. As this small, interview-based study was designed to explore the context of our survey findings in greater depth, a coding framework based on the survey topics was utilised to organise the data. The survey topics themselves had been developed from a review of policy and research literature.
Interview data were read and re-read to consider the relevance or ‘fit’ of these categories, and enabled fresh themes to emerge if appropriate. There appeared to be a reasonable fit between the themes identified in the interviews and the framework.
Due to pragmatic considerations of time and resources available, the views of women were not included in either stage of the study and further studies to elicit their views and experiences are needed.
As this was a service evaluation study, ethics approval was not required, which was confirmed in writing by the National Research Ethics Service (NRES), following contact by the lead author. Although formal ethics approval was not required, it was nevertheless considered good research practice to provide written information about the aims and objectives of the study to potential participants. A letter was sent to each identified participant in the first instance, which explained the rationale for the study and offered them the opportunity to contact the researchers to discuss the study and ask any questions prior to deciding to take part. Once they agreed to take part, their written consent was obtained. All data were treated as confidential and no names were used that could identify any of the individuals or their place of work.
Findings
A total of eight in-depth interviews were conducted with healthcare professionals from the two NHS Trusts.
Study sites: service characteristics for women with mental health needs
Trust one
The maternity unit located in Trust one served a population based in an urban and rural area with around 5000 births per annum. The five health professionals interviewed included a community psychiatric nurse (CPN) based in primary care, a CPN employed by the local mental health Trust, a consultant perinatal psychiatrist, a midwifery manager and a community midwife.
A number of services were available for women with mental health needs. The maternity unit employed a perinatal consultant psychiatrist who could refer women to a local mother and baby psychiatric unit. A counselling and support service team was available at primary care level based in a general practice surgery, which comprised a CPN, an occupational therapist (OT) and a psychologist who were managed by the mental health team. Women could be referred to these services by their GP, health visitor or mental health team. An initial assessment of the woman’s needs could take place at her home if this was appropriate. Women with babies under one year of age could be referred to, and assessed by a CPN colleague in the mental health team. The counselling service was reported to be easily accessible to women and, as there was no database, social services could not access information about women who might otherwise fear stigmatisation if they were known to have concerns related to their mental health. There was good liaison with other healthcare professionals, including a local trauma service for women experiencing post-traumatic stress disorder type symptoms.
Support groups were also available for new mothers and their babies to enable women to meet and establish informal social networks. Crèche facilities were provided and social events organised to involve the women. Specific educational workshops were also organised, which included topics such as stress and anger management and self-esteem issues.
A CPN in the mental health team had developed an expanded specialist role, which consisted of working with pregnant and postnatal mothers and liaising with local midwives and health visitors to support women with mental health needs. Midwives, health visitors and GPs were able to refer women to this service, and women could also self-refer. The CPN was involved in providing support for the majority of women with mental health problems booked with the Trust maternity unit, as well as for women who had a family history of mental illness, a previous late termination, stillbirth, a previously traumatic birth or, in extremely rare cases, had committed infanticide. The CPN would also refer women to a specialist psychiatric registrar and advise other professionals, such as GPs and obstetricians, on the management of mental health issues surrounding childbirth including advice on medication.
The consultant psychiatrist linked to Trust one held two consulting sessions per week for women with severe depression, bipolar disorder or a family history of mental illness, but this service appeared to have been developed as a result of their individual interest and enthusiasm, with no identified Trust funding for these sessions. A four-bedded mother and baby unit was available for women who had an acute episode of mental illness, staffed by mental health nurses from the general psychiatric wards with facilities for partners to stay. However, if the woman became ill out of hours, she would usually be admitted to a general psychiatric ward without her baby for the first 24 hours.
Policies and guidelines for midwives were being reviewed and updated by midwifery managers at the Trust. At the time of the study, interviews were being held for a specialist midwife to coordinate the care of women with mental health needs as part of a team caring for vulnerable women that also focused on the needs of teenagers, those who misuse substances and those suffering from domestic violence.
Trust two
In comparison, the maternity unit in Trust two was based in an inner city location on the boundary of a very affluent area and a very deprived large council estate reported to have a high level of social problems. The unit was part of a teaching hospital, with around 3500 births a year, taking women from a wide catchment area. There was considerable socio-economic and ethnic diversity and mobility in the local population. In addition to the maternity unit, other Trust services included consultant psychiatric and specialist facilities, and some specialist mental health services, such as a psychotherapy centre. Three health professionals were interviewed from this Trust – a community matron who was also a midwife, an obstetrician and a GP.
Specific perinatal mental health services at this Trust were only provided within the acute care sector. In the community setting, women were dependent on care from their GP and community midwives. If the woman was already under the care of the mental health team when she booked for her maternity care, the GP and obstetrician interviewed felt that there were generally good links across the acute and primary care sector, with clear referral and liaison pathways. Women not already receiving mental health care would be asked the standardised screening questions recommended by NICE at their booking visit (NICE, 2007) and referred appropriately if necessary, but following this visit, there were no other specific policies or procedures in place for identifying mental health problems. Women with major mental health problems were always referred for consultant-led obstetric care, but the unit was in the process of revising policies and guidelines so that women who required consultant care were also seen by a midwife. There were plans for a community-based antenatal clinic run by an obstetrician and a midwife in one of the most deprived areas served by the unit to support more vulnerable women and to appoint a specialist midwife.
There was a liaison psychiatrist for pregnant women, who held a weekly clinic at the same time as the consultant obstetrician’s clinic to facilitate joint management of women with mental health problems. Women with severe mental health problems during their pregnancy who required hospital admission would be admitted to a general psychiatric ward or a maternity ward with liaison psychiatry visits, while postnatal mothers would be referred to a regional mother and baby unit out of the area. There was a crisis outreach team who could provide intensive, community-based support for a woman to try to avoid the need for hospital admission. Weekly psychosocial meetings, where cases could be discussed and general learning about perinatal mental health could be shared, helped to support good levels of communication around care.
A counselling service for obstetric and gynaecology patients was available at the hospital, run by three counsellors. Women with a range of mental health problems, including anxiety or mild to moderate depression, could be referred to the service, which maintained close communication with the liaison psychiatrist and maternity professionals.
Key themes identified from participants’ interviews
Screening for mental health needs
CEMACH (Lewis, 2004; 2007) found that many women who developed mental illness in pregnancy had identifiable risk factors, including a previous history of mental illness or a first-degree relative affected, a finding supported in previous research reports (Jones and Craddock, 2001; Robertson et al, 2004; Leigh and Milgrom, 2008). It was evident from the findings of the original survey that midwives were asking women about current personal or family history of mental illness in line with NICE guidance, but there was no information on how questions were asked or documented. Two key questions (often referred to as the ‘Whooley’ questions, after the original authors who developed them, Whooley et al, 1997) to identify women with possible depression are recommended in the NICE antenatal and postnatal mental health guideline (2007). The two questions are: ‘During the past month, have you often been bothered by feeling down, depressed or hopeless?’ and ‘During the past month, have you often been bothered by having little interest or pleasure in doing things?’ These should be followed by a third question, if the woman answers in the affirmative to either question: ‘Is this something you feel you need or want help with?’ (NICE, 2007).
The community midwife interviewed in Trust one asked women at every visit antenatally and postnatally about their mental health, although the content of the questioning was unclear. In Trust two, the Whooley questions were asked at the antenatal booking visit, and appropriate referrals made if mental health problems were noted, but there was no clarity around how responses to the questions were documented or clear referral pathway as the following quote from the midwife highlights:
“The arrangements are a bit ad hoc in terms of picking up either newly developing mental health problems or ones that perhaps were missed – in retrospect were already there, but we didn’t pick up on. Now that’s where we hope that clinical staff, both midwifery and obstetric, are sufficiently sensitive and alert and sympathetic or empathetic to be able to pick that up” (midwife, Trust two).
Health professionals interviewed in Trust two felt that while women with significant mental health concerns were usually identified, those with more minor but still potentially significant problems could be missed. Additionally, there were complex catchment issues – such as women living outside of the area covered by the community midwives although they may have given birth in the Trust that employed the midwives – which meant that women with mental health needs in the postnatal period may not be identified following hospital discharge:
“... so we’ll have women who’ve delivered at Trust x who don’t fall in our community midwives’ catchment area and vice versa, in fact women who’ve delivered at (x) hospital or (x) hospital… if their home is in our patch, then it’ll be our (unit) community midwives. That’s an area that (the community matron) and I and our counselling team and liaison psychiatrist, that’s a phenomenon that we don’t feel we’ve quite got to grips with. We try really hard and (community matron) puts in a lot of time liaising on a case-by-case basis with (neighbouring boroughs)… but we don’t feel 100% confident that we’ve got a completely secure safety net there” (community matron, Trust two).
Referral pathways
The initial point of contact for women with mild to moderate mental health issues was, in most cases, their own GP. Midwives would usually refer women with signs and symptoms of mild depression to their GP in the first instance and to a psychiatrist via the woman’s obstetrician if there were serious concerns about her mental health, including a history of severe depression, bipolar disorder, self harm or suicidal thoughts.
The community midwife from Trust one felt that the links with mental health services could be improved. She did not always receive timely information or support from the mental health team when concerns about a woman’s mental health were identified and had experienced difficulty referring women, unless they had been ill enough to require hospital admission. In Trust two, links with hospital-based mental health services were in contrast reported to be excellent. The dedicated liaison psychiatrist, plus the availability of a counselling service for women under the care of the women’s health team at the Trust, was considered to be highly effective and facilitated good links with the multi-professional teams. However, there were difficulties ensuring women with identified mental health problems were followed up in the community setting. The psychiatrist needed to conduct negotiations with the Trust to obtain dedicated resources for their service, and Trust boundary issues meant that this specifically developed service could only be provided in hospital:
"This is where we get into the difficult business of catchment services... the community midwifery is predicated on place of residence and not place of delivery” (community matron, Trust two).
She explained they had to work quite hard to set up arrangements whereby women outside the catchment could continue to come to the hospital for follow-up, and to maintain funding for this perinatal psychiatry service. The movement out of acute Trusts to primary care Trusts (PCTs) did not help in this respect, and it was only because this service remained part of the acute Trust that the provision for postnatal women to return for visits could be maintained.
Psychiatric services
Both the psychiatrists and the CPN in Trust one felt that an expanded CPN role to care for women with mental health needs during pregnancy worked well and could be adapted elsewhere. However, there was no identified funding and the CPN’s current caseload of over 25 women was extremely time-consuming, leading to some women waiting longer than the recommended two to three weeks to be seen (NICE, 2007). The CPN felt that the profile of the service needed to be raised and information about the service more widely circulated, as many women were unaware that it was available, as the following quote illustrates:
“One of the things is the women themselves knowing the service exists... getting us out there, having a website... or mums actually knowing about our service when they attend the GPs’ surgeries or attending perhaps mother and baby clinics” (CPN, Trust one).
The community midwifery managers in both Trusts acknowledged that while their services were being developed in line with national recommendations, developments lacked dedicated funding and support from their organisations, and relied on the good will and enthusiasm of individuals with a particular interest in perinatal mental health. In Trust two, a lack of links with CPNs was identified as a problem, and catchment allocations meant that hospital-based services had to pay for the time of CPNs called in to provide care for women who were in-patients. With increased stress on finite NHS resources, there were concerns that services would be cut if dedicated resources were not available.
Liaison between the multi-professional teams
Effective management of pregnant and postnatal women with mental health problems depends on good coordination between the different services and specialists. One of the key issues raised in the CEMACH report (Lewis, 2007) and identified in the survey (Rowan and Bick, 2008) were the difficulties professionals experienced liasing with colleagues in other professional groups. This issue was further emphasised during the interviews with the health professionals. In both Trusts, respondents felt that there was a lack of continuity of care for women who had mental health problems. In one instance, a woman had remained in contact with her community midwife six months following the birth because of the relationship that had been established between them. This was somewhat problematic as the midwife had to combine the support she continued to offer the woman with her existing workload, as she had no other dedicated time to offer the woman. Women with pre-existing mental illness may have a key worker, but the professional base and level of knowledge could vary and relevant information was not always passed on. She felt that multi-professional meetings to plan the care of such women would improve the services and the communication between healthcare professionals:
“Links with mental health are not the best, it is difficult to refer women unless they need to be admitted. If they are stable the mental health team are not so interested. Sometimes there is a lack of information from the key worker and information being shared” (midwife, Trust one).
The health professionals interviewed in both Trusts were not always aware of the services available in other areas of the health service and recommended the provision and circulation of named links to support more joined up working. Professionals also identified a lack of communication between community-based professionals and between community–and hospital-based services. It was indicative, for example, that maternity professionals contacted from Trust two were not able to identify a named CPN for contact. The GP interviewed from this Trust felt that improvements could be made with greater awareness of referral systems and processes, named individuals, more continuity of midwifery care and knowing who to talk to when there were concerns identified.
There were continuing challenges raised by catchment issues particularly where funding was defined by geographical boundaries. One of the key challenges identified in Trust two was the complex organisation of services. For example, the liaison psychiatrist had a specific agreement with the PCT to provide care during pregnancy, but following birth, this agreement only extended to postnatal care at the hospital site and did not cover community care. Complex catchment issues also created difficulties for communication. Women are now supposed to be offered a choice regarding place of birth (Department of Health, 2007), but this does not yet extend to choice of place of community care. For example, there was a community midwife clinic close to the hospital, but midwives would only see women who had booked to give birth in that Trust and would not see other women who may have lived in the same catchment area. Follow-up postnatally would be dependent on the initiative of community midwives, or where relevant, hospital social workers, to provide information to their counterparts in neighbouring Trust areas. In addition, as there were several community midwives running the clinic, there was the potential for difficulties with continuity of care and contact. Following up women in an urban area was also made more difficult by the high turnover of patients registered with GP practices, including pregnant women, making it difficult for GPs to get to know the women and their families and provide continuity of care. The GPs’ perception was that as the maternity service was very fragmented, women with mental health problems may not be identified or receive appropriate care.
Those interviewed also highlighted differences in professional philosophies creating some challenges for communication. For example, some professionals such as social workers were viewed as concerned mainly with the needs of the child rather than the mental health of the mother.
It is likely that women with mental health problems will continue to be seen by a number of health professionals. Overall, multi-professional liaison was challenging with respect to both Trusts, particularly with services that were not hospital based. In Trust two, for example, although a plan of care was organised for antenatal women with a serious mental health problem, there were issues for her management if she became ill after the birth. One of the key predictors of postnatal psychosis is bipolar disorder, and antenatal depression may predispose women to depression postnatally. Therefore, women with an identified history should have a management plan for follow up after the birth.
Access to mother and baby units
Only Trust one had a local mother and baby unit, although midwives could not refer women directly. The service appeared to work well for women with an acute episode of mental illness. The psychiatrist interviewed from Trust one commented that the incidence of psychosis appeared to be reducing, but that a number of women with schizophrenia were becoming pregnant and may need their mothering skills assessed on the unit. While he felt that mother and baby units should be provided on a more regional basis, he also recognised the advantages of a smaller unit for families:
“I would recommend mother and baby units are on a more regional basis so that there are more beds and greater expertise available. The advantages of a smaller unit are that dads can stay” (psychiatrist, Trust one).
In Trust two, postnatal mothers would be referred to a regional mother and baby unit outside of the area, with delays reported in transfer. The obstetrician interviewed felt that distance was a challenge in terms of maintaining family links and support.
Training of health professionals
The need for ongoing training of health professionals in mental health issues has been identified (Stewart and Henshaw, 2002; Sullivan et al, 2003; Ross-Davies et al, 2006) and was also raised as an issue in the first-stage survey (Rowan and Bick, 2008). Those interviewed from the two Trusts reported that while some training for staff was available, attendance was not mandatory and competed with other demands on study time. The community midwife in Trust one felt that there was a lack of knowledge among her midwifery colleagues and the need for more support to care for women who often feared disclosing their difficulties. The CPN also identified a need for further training:
“Everyone thinks they know what depression means but it means something different for everybody, but also in terms of picking up psychosis afterwards. I think midwives and health visitors are often quite scared of mental health and asking the question” (CPN, Trust one).
However, the weekly psychosocial liaison meetings in Trust two, potentially involving midwives, obstetricians, counsellors and social workers provided opportunities for more informal and interprofessional learning.
Discussion
The interviews with health professionals from the two Trusts substantiated the findings of the earlier survey (Rowan and Bick, 2008) that although there were examples of good practice within and between maternity units, services were often fragmented with variation in the provision of care for pregnant and postnatal women with mental health needs. Of the two Trusts, one had developed practice in line with current policy and guidance in more informal and community-based services, and the other in acute care and more specialised care for women with serious problems, but identifying gaps in community-based care. From the healthcare professionals interviewed, it is evident that in their view, women are being routinely asked about their personal or family history of mental illness at the initial antenatal visit. However, this form of screening may be less consistent at subsequent antenatal and postnatal contacts. In some cases, staff highlighted that women with less severe problems may have a risk of not being identified following postnatal hospital discharge.
Although the NICE Antenatal and postnatal mental health guidelines (2007) recommend the use of the two screening questions, it is not known whether all midwives ask these specific questions of antenatal or postnatal women, or whether the questions have sufficient sensitivity and specificity to accurately identify mental health needs (Bick and Howard, 2010). As the antenatal booking interview is already very comprehensive, with the requirement to ask women about a number of health issues, including current and previous medical history, midwives may perceive difficulties in being able to give sufficient time to sensitive discussion of women’s needs. An observation study of the antenatal booking visit (McCourt, 2006) found that a primarily checklist approach was used by time-pressured midwives in busy clinics, very limited discussion took place, and women asked few questions and raised few topics of their own concern. Additionally, women may be reluctant to disclose concerns about their mental health because of fear of the potential consequences.
Based on these findings, NICE guidance to inform effective perinatal mental health care (NICE, 2007) appeared to be in the process of adaptation and implementation for local use for the acute service. However, it was clear that concerns existed as to what priority this implementation was being given within primary care services. This is perhaps even more important given the rapid transfer home of women following birth, who may not have had their mental health needs assessed as an integral part of their hospital discharge planning. Women whose mental health needs had been identified appeared to be in contact with a range of different health professionals, but the level of effective communication between the maternity and psychiatric services was sometimes lacking. A review of current contracts and service arrangements to promote liaison between professional groups across the acute and primary care sector in health and social care in the UK is required, to ensure local healthcare needs are addressed. It is encouraging that specialist roles with identified funding streams were being developed, which may support better coordination of services and improve continuity of care for women. Nevertheless, service provision was dependent on the initiative of individual professionals with a specific interest in perinatal mental health. As these roles were frequently undertaken alongside other clinical commitments and did not have identified funding, services are vulnerable when individuals are not available (for example, because of annual leave) or leave the employment of the NHS Trust. Unless structures and resources are developed as part of core service provision, it is unclear if the NHS can support these initiatives in the longer term.
Counselling services were provided within primary care in Trust one and were hospital based in Trust two. This finding was in contrast to other NHS Trusts included in the original survey (Rowan and Bick, 2008), where such services appeared to be less well developed and few were based in primary care. In the initial survey, it was found that waiting lists of between four and six weeks existed in some areas delaying women’s mental health needs assessment (Rowan and Bick, 2008). Psychological and psychosocial therapies have been found to help women with mild postnatal depression or anxiety. A recent Cochrane library review, which included ten trials and data on 956 women, found that any psychosocial or psychological intervention compared to usual postnatal care was associated with a reduction in the likelihood of continued depression, however measured, at a final assessment within the first year of the birth (Dennis and Hodnett, 2007). Although the methodological quality of trials was not strong, meta-analysis results suggest that psychosocial and psychological interventions are an effective treatment option, although longer-term effectiveness remains unclear. Cochrane library reviews of psychological and psychosical interventions to treat antenatal depression found that the evidence was inconclusive (Dennis et al, 2007; Dennis and Allen, 2008).
Treatment options for women with postnatal depression have been neglected despite the large public health impact. Given the potential risks and side-effects involved in taking medication, further research into the effectiveness of psychological therapies particularly during the antenatal period needs to be prioritised, with postnatal interventions more widely available for women who may benefit from their use. Additionally, the obstetrician interviewed for Trust two identified that a number of women were seen who had stopped taking their medication in an unplanned way because of fears about effects on their babies. Such women clearly need prompt care and advice, with further research required to compare different antidepressants in the treatment of postnatal depression and provide more evidence of the adverse effects of antidepressants including long-term effects (Hoffbrand et al, 2001).
Effective management will also be compromised if a woman referred to the mental health services does not take up the referral. A recent qualitative study from the US of 51 perinatal women – identified by screening as at risk of depression or via calling a perinatal mental health hotline – were followed up by survey and interview to understand patient behaviour, and barriers and facilitators to acceptance of mental health referrals at four steps in the treatment engagement process (Kim et al, 2010). Although 30 (59%) of the women accepted mental health referrals, only 14 (27%) actively engaged in treatment. A number of barriers and facilitators to successful mental health treatment linkage were identified at patient, service provider, patient/service provider interaction and system levels. Lack of time was a commonly cited barrier at patient level, with availability a key factor having an impact on treatment linkage at service provider level. Other commonly described barriers included poor match of referral to need, geographic boundaries and lack of response from the service provider. Conversely, women’s recognition of their need for treatment was a facilitator. The authors highlight the concern that women and families may remain at significant risk, even if clinical follow-up to positive screening is uniformly applied. Despite differences in healthcare funding and context of care between the US and the UK, it is notable that many of the issues raised are similar to this study and findings of the survey of women undertaken by the mental health charity MIND (2006).
The findings further show the concerns raised in the current study about the follow-up and care of women identified with mental health needs and need for management plans to be in place for those at risk as well as good liaison between professionals involved (Lewis, 2004). Although the recommendations of the most recent CEMACH report (Lewis, 2007) are that women with more severe mental health illness following birth should be admitted to a mother and baby unit, there is clear variation in availability. Processes for referral and provision of care are needed for those women who develop an acute episode of mental illness following the birth (MIND, 2006), with a recent Cochrane library review also recommending that research is needed into the effectiveness of units (Irving and Saylan, 2007).
If the care of women with mental health problems is to improve, health professionals clearly need realistic access to appropriate in-service training to develop the confidence and knowledge to identify women with signs and symptoms of mental health problems, to support these women, to understand cultural differences and approaches to mental health, and ensure familiarity with local referral pathways. The NHS Scotland Perinatal mental health curricular framework (NHS Scotland for Education, 2006) provides broad educational goals for educationalists to use when planning the development of perinatal mental health aspects of pre-registration, undergraduate, post-registration and postgraduate programmes. It provides a useful starting point for those developing local training initiatives and is included as part of the implementation guidance for the antenatal and postnatal mental health guideline (NICE, 2007). It is nevertheless important that whichever approach is developed and used locally, that outcomes for the multi-professional team and the women they care for are regularly evaluated and updated.
Conclusion
This study has reported the in-depth views of relevant healthcare professionals on the extent to which perinatal mental health services are meeting policy and practice guidance. Their views highlight that although there have been developments in service provision, gaps persist particularly with respect to appropriate ongoing identification of needs and appropriate follow-up of women. Real challenges for the maternity services persist in relation to complex boundary issues that impacts on opportunities to support effective continuity of care and funding issues. Additionally, examples of good practice may still depend on the initiative and commitment of individual professionals, rather than the support of the organisation, including dedicated resources. Further research is required to ascertain the extent to which resource issues and the drive to cut NHS healthcare budgets are limiting appropriate service provision for women with perinatal mental health needs. There is also an urgent need to elicit the views of the women who use the service.
References
Beck CT. (1995) The effects of postpartum depression on maternal-infant interaction: a meta-analysis. Nursing Research 44(5): 298-304.
Bick D, Howard L. (2010) When should women be screened for postnatal depression? Editorial. Expert Review of Neurotherapeutics 10(2): 151-4.
Dennis CL, Ross LE, Grigoriadis S. (2007) Psychosocial and psychological interventions for treating antenatal depression. Cochrane Database Syst Reviews 3: CD006309.
Dennis CL, Allen K. (2008) Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression. Cochrane Database Syst Reviews 4: CD006795.
Dennis CL, Hodnett ED. (2007) Psychosocial and psychological interventions for treating postpartum depression. Cochrane Database Syst Reviews 4: CD006116.
Department of Health. (2004) National Service Framework for children, young people and maternity services. HMSO: London.
Department of Health. (2007) Maternity matters: choice, access and continuity of care in a safe service. HMSO: London.
Hoffbrand SE, Howard L, Crawley H. (2001) Antidepressant treatment for postnatal depression. Cochrane Database Syst Reviews 2: CD002018.
Jones I, Craddock N. (2001) Familiarity of the puerperal trigger in bipolar disorder: results of a family study. American Journal of Psychiatry 158(6): 913-7.
Irving CB, Saylan M. (2007) Mother and baby units for schizophrenia. Cochrane Database Syst Reviews 1: CD006333.
Kim JJ, La Porte LM, Corcoran M, Magasi S, Batza J, Silver RK. (2010) Barriers to mental health treatment among obstetric patients at risk for depression. American Journal of Obstetrics and Gynecology 202: 312.e1-5.
Leigh B, Milgrom J. (2008) Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry 8: 24.
Lewis G. (2001) The Confidential Enquiry into Maternal and Child Health (CEMACH) Why mothers die 1997-1999: the fifth report of the confidential enquiries into maternal deaths in the United Kingdom. RCOG: London.
Lewis G. (2004) The Confidential Enquiry into Maternal and Child Health (CEMACH). Why mothers die 2000-2002. The sixth report of the confidential enquiries into maternal deaths in the United Kingdom. RCOG: London.
Lewis G. (2007) The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer – 2003-2005. The seventh report of the confidential enquiries into maternal deaths in the United Kingdom. RCOG: London.
McCourt C. (2006) Supporting choice and control? Communication and interaction between midwives and women at the antenatal booking visit. Social Science and Medicine 62(6): 1307-18.
MIND. (2006) Out of the blue? Motherhood and depression. MIND: London.
Murray L, Cooper P. (1997) Postpartum depression and child development. Psycho Med 27: 253-60.
NICE. (2003) Antenatal care: routine care for the healthy pregnant woman. NICE: London.
NICE. (2008) Antenatal care: routine care for the healthy pregnant woman. NICE: London.
NICE. (2007) Antenatal and postnatal mental health. NICE: London.
NHS Scotland for Education. (2006) Perinatal mental health curricular framework. NHS Scotland for Education: Edinburgh.
NHS Litigation Authority. (2010) Clinical negligence scheme for Trusts: maternity. Clinical risk management standards version one – 2010/11. NHS Litigation Authority: London.
O’Connor TG, Heron J, Golding J, Beveridge M, Glover V. (2002) Maternal antenatal anxiety and children’s behavioural/emotional problems at four years: report from the ALSPAC. British Journal of Psychiatry 180: 502-8.
Oluwato O, Freidman T. (2005) A survey of specialist perinatal mental health services in England. Psychiatric Bulletin 29: 77-179.
Rees C. (1997) An introduction to research for midwives. Books for Midwives: Oxford.
Ritchie J, Spencer L, O’Connor W. (2003) Carrying out qualitative analysis: In: Ritchie J, Lewis J. (Eds.). Qualitative research practice: a guide for social science students and researchers. Sage: London.
Robertson E, Grace S, Wallington T, Stewart DE. (2004) Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry 26: 289-95.
Ross-Davies M, Elliott S, Sarkar A, Green L. (2006) Public health role in perinatal mental health: are midwives ready? British Journal of Midwifery 14(6): 330-4.
Rowan C, Bick D, Bastos MH. (2007). Postnatal interventions to prevent mental health problems after birth: the gap between the evidence and UK midwifery practice and maternity policy. World Views on Evidence-Based Nursing 4(2): 97-105.
Rowan C, Bick D. (2008) An evaluation of the provision of perinatal mental health services in two English strategic health authorities. Evidence Based Midwifery 6(4): 76-82.
Sullivan A, Raynor M, Oates M. (2003) Why mothers die: perinatal mental health. British Journal of Midwifery 11(5): 310-2.
Stewart C, Henshaw C. (2002) Midwives and perinatal mental health. British Journal of Midwifery 10(2): 117-21.
Tully L, Garcia J, Davidson L, Marchant S. (2002) Role of midwives in depression screening. British Journal of Midwifery 10(6): 374-8.
Ustum T, Ayuso-Mateos J, Chatterji M. (2004) Global burden of depressive disorders in the year 2000. British Journal of Psychiatry 184: 386-92.
Whooley MA, Avins AL, Miranda J, Browner WS. (1997) Case finding instruments for depression. Two questionnaires are as good as many. J Gen Intern Med 12: 439-45.
