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Revising care to reflect CEMACH recommendations: issues for midwives and the maternity services

2 December, 2008

Revising care to reflect CEMACH recommendations: issues for midwives and the maternity services

Psychiatric illness in general and suicide in particular have been identified as the leading cause of maternal death in the UK. The Confidential Enquiry into Maternal and Child Health (CEMACH) (2004) made recommendations in its most recent report for midwifery practice and maternity services in order to address this.

EBM: September 2007

Cathy Rowan1 MA, PGCEA, RM. Debra Bick2 PhD, BAMedSci, RM.
1 Senior lecturer in midwifery, Centre for Research in Midwifery and Childbirth, Thames Valley University, 32-38 Uxbridge Road, London W5 2BS England.
Email: cathy.rowan@tvu.ac.uk
2 Professor of midwifery and women’s health, Centre for Research in Midwifery and Childbirth, Thames Valley University, 32-38 Uxbridge Road, London W5 2BS England.
Email: debra.bick@tvu.ac.uk


Background. Psychiatric illness in general and suicide in particular have been identified as the leading cause of maternal death in the UK. The Confidential Enquiry into Maternal and Child Health (CEMACH) (2004) made recommendations in its most recent report for midwifery practice and maternity services in order to address this.
Aim. To review evidence to support revisions to midwifery practice and maternity service provision in the UK in line with CEMACH recommendations, with a particular focus on women with severe mental health problems.
Method. A structured literature review was undertaken using CINAHL, MEDLINE, EMBASE, PsychLit, MIDIRS and Cochrane Library using the terms ‘mental health’ and ‘mental illness’ in combination with ‘pregnancy’, ‘childbirth’ and ‘postpartum’, as well as ‘maternal mortality’, ‘antenatal depression’, ‘postnatal depression’, ‘puerperal psychosis’ and ‘depression screening’.
Results. Evidence to inform revisions to practice in order to meet maternal mental health needs more effectively was limited and often methodologically poor, particularly for antenatal interventions. Studies did show that revision to enhance service provision across the acute and primary care sector is required to ensure seamless care of women, involving all relevant healthcare professionals. If maternal needs are to be identified and managed, midwives require additional training to identify the signs and symptoms of mental health problems and implement appropriate and timely referral for those with more severe problems. The impact of the implementation of recently published national guidance is awaited. Some inconsistency in recommendations with regard to the use of screening tools to identify depression was also noted.
Conclusions. Despite some evidence of local service development to enhance the care of women with mental health problems, larger, robust evaluation of service revision is required. Midwifery education to implement care according to the recommendations of CEMACH should be addressed as a priority.

Key words: Maternal mental health, mental illness, antenatal depression, depression screening, postnatal depression, service revision, midwifery training


The months surrounding the birth of a baby carry the greatest lifetime risk of maternal mental illness (Department Of Health, 2000). Estimates suggest that two per 1000 women who give birth will experience severe, chronic or enduring mental illness (Royal College of Psychiatrists, 2000). The most severe forms of mental illness include schizophrenia, bipolar disorder, major depressive illness, and anxiety disorders such as obsessive compulsive disorder, panic disorder and post-traumatic stress disorder (PTSD) (Moses-Kolko et al, 2002).

In its most recent report, the Confidential Enquiry into Maternal and Child Health (CEMACH) (2004) found psychiatric illness to be the leading cause of maternal death in theUK, and the majority of these were due to suicide. Half of the women who died by suicide had a history of mental illness, increasing concerns about the appropriate identification and management of women at risk when they are pregnant (Confidential Enquiry into Maternal and Child Health, 2004). In addition to the devastating impact of maternal death, maternal mental ill health can have severe negative consequences for the woman, her child, her relationship with her baby and partner, and for her baby’s later cognitive and emotional development (Boath et al, 1998; Lovestone and Kumar, 1993; Murray and Cooper, 1997; O’Connor et al, 2002). The definition of psychiatric death used by CEMACH (2004) included not only suicides but also deaths from substance misuse, physical illness, accidents and other misfortunes unlikely to have occurred in the absence of a psychiatric disorder. Of 60 deaths that were reported to the enquiry as having psychiatric aspects, half occurred either in the three months preceding or following childbirth, and 37 women had been receiving treatment for their psychiatric condition. A total of 18 women who died had a physical cause mistakenly attributed to a functional psychiatric disorder, which delayed appropriate diagnosis and management of their physical illness. There were 28 reported suicides – five women took their own lives in pregnancy and five within 42 days of giving birth – and 18 deaths were classed as later reported suicides, where women took their lives after 42 day  and up to one year of giving birth, including incidents of overdoses of illicit drugs. The profile of the women who died by suicide identified in this report differed from suicides within the general population. The majority of women were white, and just under half were over the age of 30. Women were usually from favourable social circumstances, in stable relationships and often with higher professional qualifications. Their deaths were often by violent means. Many were suffering from a serious mental illness and had a previous psychiatric history. If the risk of recurrence had been recognised and managed, outcomes may have been different.

Three-quarters of the women deemed to have been at risk of suicide had no psychiatric management plan in place, so although the risk was identified, no further action had been taken and in some cases there was little evidence of communication among service providers, including GPs, psychiatrists and obstetricians. Of further concern is that deaths from suicide within the first year of birth were likely to have been under-reported to CEMACH due to a woman’s loss of contact with maternity services (Confidential Enquiry into Maternal and Child Health, 2004). The enquiry also highlighted that the number of maternal deaths associated with drug and substance misuse, violence, accidents and misadventure were also under-reported, and some of these may also have included deaths by suicide. CEMACH (2004) recommendations included that pregnant women should be asked about any previous history of mental health problems, and that management plans should be developed for those at risk of a recurrence. These echo UK guidelines relating to maternal mental health before and since (National Institute for Health and Clinical Excellence, 2003, 2006, 2007; Scottish Intercollegiate Guidelines Network, 2002; Department of Health, 2002, 2003, 2004), which include recommendations that women should be asked about their mental health history and their psychological wellbeing at specific times during their pregnancy and after they have given birth.

Despite this guidance, it is apparent that a number of issues still need to be addressed in relation to the organisation and content of maternity care. This paper discusses key issues for midwives highlighted in the recommendations of the most recent CEMACH report (2004). These include the identification of previous psychiatric history, the use of guidelines and service organisation. Although the focus is on the situation in the UK, the process of reviewing evidence of the implementation of these recommendations is likely to be of value to midwives in countries outside the UK.


Database searches were undertaken of CINAHL from 1982, MEDLINE and EMBASE from 1996, PsychLit and Cochrane Library, and using standard searches on MIDIRS. The terms ‘mental health’ and ‘mental illness’ were utilised in combination with ‘pregnancy’, ‘childbirth’ and ‘postpartum’, as well as ‘maternal mortality’, ‘antenatal depression’, ‘postnatal depression’, ‘puerperal psychosis’ and ‘depression screening’. While a number of mental health problems may occur or pre-exist, the focus here was on postnatal depression and postnatal psychosis (including bipolar disorder) because it was women with these conditions who were most likely to die by suicide (Confidential Enquiry into Maternal and Child Health, 2004).


Identification of previous psychiatric history

The prevalence of postnatal depression ranges from 4.5% to 28% according to different diagnostic criteria and assessment times (Scottish Intercollegiate Guidelines Network, 2002). A meta-analysis of 59 studies found an average prevalence rate of non-psychotic postnatal depression of 13% and an incidence of moderate to severe depression of 3% to 5% (O’Hara and Swain, 1996). Cox et al (1993) found that in the first five weeks postpartum, the odds of an episode of major depression were three times that of a comparison group of non-pregnant females. Two per 1000 women will be admitted to hospital diagnosed with a non-psychotic condition, usually very severe postnatal depression (Oates, 2006). Women may also experience depression in pregnancy (Evans et al, 2001). A systematic review of studies by the US Agency for Healthcare Research and Quality (AHRQ) (2005) suggested that around 15% of pregnant women have a new episode of major or minor depression during pregnancy, as identified using a variety of screening instruments. Considering only major depression, around 7.5% of women may have a new episode during pregnancy (Agency for Healthcare Research and Quality, 2005). These estimates are not significantly different from the prevalence of depression reported among women of a similar age in the general population (Cooper et al, 1988; O’Hara and Swain, 1996), although it has been estimated that 50% of people in the general population with depression are not identified (Kessler et al, 2002).

The perinatal period is a time when women are in regular contact with healthcare services, and midwives are in a key position to identify women with mental health problems and those who might have an increased risk. Between 20% and 40% of women with a previous history of postnatal depression are likely to suffer a relapse after a subsequent birth (Cooper and Murray, 1995), and antenatal depression may be associated with greater risk of a postpartum episode (Evans et al, 2001; Johanson et al, 2000). Identifying women with a history of depression is therefore essential.

Some social factors increase a woman’s risk of becoming depressed. These include life stresses such as bereavement, unemployment, illness, migration and a lack of social support networks (O’Hara and Swain, 1996; Austin and Lumley, 2003; Small et al, 1994). Those who have a history of abuse and domestic violence and those with drug and alcohol problems also have higher rates of mental health problems (Brockington, 1996; Buist, 1996; O’Hara and Swain, 1996; Confidential Enquiry into Maternal and Child Health, 2004).

In addition to studies that have attempted to identify risk factors for the development of depression, work has been undertaken to formulate tools to screen for women at higher risk of developing it. One of the most commonly used tools in research and practice is the Edinburgh Postnatal Depression Scale (EPDS), a ten-item self-report scale in which women are asked to rate how they have felt in the previous seven days. A maximum score of 30 can be achieved, with a score of 12 or more considered to identify those women more likely to have depression (Cox et al, 1987). Although some studies have used the EPDS in pregnancy (Murray and Cox, 1990; Johanson et al, 2000), there are concerns that administration of the EPDS once will not accurately identify those who are depressed to the extent of requiring treatment (Oates, 2003). The relationship between the woman and her professional carer, the environment and the way in which screening is administered are also important variables (Raynor et al, 2003; Shakespeare et al, 2003), and cultural differences may make it inappropriate to use the EPDS on women from minority ethnic groups (Scottish Intercollegiate Guidelines Network, 2002). A review of 16 studies by Austin and Lumley (2003) concluded that screening tools, including the EPDS, lacked sensitivity and positive predictive value and did not meet the criteria for routine application in the antenatal period.

In the UK, National Institute for Health and Clinical Excellence (NICE) guidance on the use of screening tools for depression appears somewhat inconsistent. The NICE (2006) postnatal care guideline adopted a recommendation based on a review of studies by Shakespeare (2001) that the EPDS should not be administered routinely to all postnatal women, but that it may serve as part of an assessment of postnatal mothers when used alongside professional judgement and clinical interview. The NICE (2007) antenatal and postnatal mental health guideline recommended that tools such as the EPDS, Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire (PHQ) may be used as part of a subsequent assessment or for the routine monitoring of outcomes. However, it is unclear if this is intended for women who respond positively to recommended questions put to them during their first contact with primary care services or for all women. In addition, the HADS and PHQ have not been validated for use in a postnatal population.

Evidence of interventions aimed at reducing maternal mental health problems has tended to come from studies of women with or deemed to be at risk of depression. Four studies of psychosocial interventions – mostly of the group format – for women identified in the antenatal period with or at increased risk of postnatal depression did not demonstrate effectiveness (Brugha et al, 2000; Elliott et al, 2000; Stamp et al, 1995; Zlotnick et al, 2001). Yet, given the heterogeneity of populations, screening instruments, definitions of risk and outcome measures used, it is difficult to draw overall conclusions (Agency for Healthcare Research and Quality, 2005). A review by the AHRQ (2005) identified 11 studies of screening and intervention outcomes in the postnatal period. The EPDS was used to screen women with depressive symptoms in the majority of the studies (none used a diagnostic confirmation of depression) and the interventions offered to treatment groups differed considerably, including behavioural, psychoeducational and pharmacological interventions. Seven studies used the EPDS to compare outcomes. The review found that postnatal interventions with a psychosocial component were
generally more successful at reducing the rate of postnatal depression, although none included a treatment intervention with both a psychotherapeutic and pharmacological component, considered to be the ‘gold standard’ for the treatment of major depression. Study limitations did not enable the issue of whether screening with subsequent intervention improves outcomes to be conclusively answered, a factor compounded by concerns about the limitations of the use of screening tools referred to earlier. Large, sufficiently powered studies are required to provide robust evidence of benefit.

A Cochrane Library systematic review was unable to draw clear conclusions based on data from two small randomised controlled trials (RCTs) of the effectiveness of antidepressants given prophylactically to prevent postnatal depression in women with a history of depression (Howard et al, 2005). In addition to the size of the trials, neither had used an intention to treat analyses. Continuity of midwifery care was not found to affect psychiatric outcome for women with a history of depression, but was more likely to engage women in management (Marks et al, 2003). A recent cluster RCT in the UK compared existing postnatal community care (977 women) with a new model of midwifery-led protocol-based and extended community postnatal care focused on the identification and management of postnatal morbidity (1087 women). The new model of care was associated with a statistically significant reduction in maternal psychological health outcomes at four and 12 months after the birth (MacArthur et al, 2003). Armstrong et al (1999) reported on an RCT undertaken in Queensland, Australia that targeted more vulnerable families and randomised 91 women to the standard community child health service group and 90 to a structured programme of nurse home visits supported by a social worker and paediatrician. This trial found that the intervention was associated with a significant reduction in postnatal depression screening scores and improved women’s experiences of their parental role.

Although PTSD is not a focus of this paper, RCTs of debriefing interventions in the postnatal period to prevent symptoms of PTSD have not shown any benefit (Small et al, 2000; Ryding et al, 2004; Kershaw et al, 2005) and debriefing is not recommended by NICE (2006) as part of routine postnatal care. NICE (2006) does recommend that all women are offered an opportunity to talk and ask questions about their experience of childbirth as part of good postnatal midwifery care.

There has been a tendency for clinicians to use ‘postnatal depression’ as a generic term to include several psychiatric disorders (Confidential Enquiry into Maternal and Child Health, 2004). It is important to differentiate between women with mild to moderate depression and those at risk of more evere episodes of mental illness such as severe depression or puerperal psychosis. Puerperal psychosis is a serious disorder
that occurs within the first six weeks of childbirth. It tends to have an early and rapid onset, often developing over a period of 24 to 48 hours. It has been reported that half of cases will have presented by day seven and 90% by three months postpartum (Kendell et al, 1987). Symptoms may include delusions, persecutory feelings, auditory hallucinations and manic behaviour (Brockington, 1996). There are often prodromal symptoms such as insomnia, restlessness, depression, irritability and the expression of irrational or grandiose ideas, as well as a risk of suicide. The incidence of puerperal psychosis is between one and two per 1000 live births (Kendell et al, 1987; Scottish Intercollegiate Guidelines Network, 2002). Nager et al 2005) found an average rate of 0.68 per 1000 women excluding those with a psychotic episode prior to pregnancy. It is more common in women with a history of bipolar affective disorder (Chaudron and Peis, 2003), with the risk estimated to be about one in two, although psychotic relapses may also occur in women with schizophrenia (Department of Health, 2002). It is more likely to occur in women who have had a previous episode following childbirth, and those with a first-degree relative who has experienced an episode of puerperal psychosis or bipolar disorder (Jones and Craddock, 2001; Robertson et al, 2005). Medications that had been successful prior to pregnancy may have been stopped for fear of adverse effects on the fetus, and the relapsing and remitting nature of bipolar disorder means that women may be well and out of contact with mental health services. There is a strong case for identifying those with a previous history or family history of mental health disorders in addition to identifying those women who are currently depressed or anxious.

The use of guidelines

There has been little evidence of the extent to which guidelines for maternal mental health are being used, who developed them, or information to support how and when midwives and other healthcare professionals should ask about mental health problems. Prior to publication of NICE guidelines on postnatal care and on antenatal and postnatal mental health (National Institute for Health and Clinical Excellence, 2006, 2007), Tully et al (2002) surveyed all maternity units in England and Wales. The aim was to identify the use of policies and guidelines in the antenatal and postnatal periods in relation to the identification and management of depression. There were replies from 182 units (response rate=86%), and over a third had policies or guidelines relating to the management of women with psychological difficulties, although only 22% had policies that specifically covered postnatal depression and puerperal psychosis. Although most indicated that women were routinely asked about previous or existing psychological problems during their booking interview, few
had undertaken an audit of services offered to women with mental health problems. A survey of 78 mental health Trusts in England (Oluwatayo and Friedman, 2005) found that although protocols were provided by 33 Trusts, these were considered outdated or inadequate by 16 of them.

Midwives and other healthcare professionals should be aware of signs and symptoms of mental ill health and be familiar with referral pathways. The NICE (2003) guideline on antenatal care recommends that women are asked early in pregnancy if they have had any previous psychiatric illnesses and that women who have a past history of psychiatric disorder should be referred for a psychiatric assessment. The NICE (2007) antenatal and postnatal mental health guideline includes recommendations that all relevant healthcare professionals ask women about past or present severe mental health problems, including schizophrenia, bipolar disorder and severe depression. Two set questions to identify those experiencing possible depression are recommended to be asked at the woman’s first contact with primary care, at the booking visit and in the postnatal period. A third set question, which should be considered if a woman responds positively to both initial questions is also recommended, although evidence to support the benefit of using these questions among postnatal women was not identified (National Institute for Health and Clinical Excellence, 2007). NICE (2006) guidelines for postnatal care recommend that a management plan is adhered to, based on the woman’s existing mental state and risk of relapse. Further evidence is required to inform resource needs and levels of support required for women identified as ‘at risk’. A recent survey by mental health charity Mind (2006) found that 90% of the 148 women questioned attributed problems they experienced to a lack of understanding by healthcare professionals and inadequate advice and information. They wanted more information about how to recognise symptoms and when to access services, and felt that more support should be offered to their partners and families.

Service organisation

Robust evidence of the effectiveness of maternity service organisation in meeting women’s mental health needs is lacking, with much of the available information coming from small service evaluation projects or surveys that have a potential for bias. These have included evaluations of the use of a consultant midwife clinic (Dunkley-Bent, 2004) and the provision of perinatal psychiatric services (Oluwatayo and Friedman, 2005). There have also been surveys of midwives’ views of education and multidisciplinary working with respect to maternal mental health (Stewart and Henshaw, 2002; Sullivan et al, 2003; Ross-Davies et al, 2006). Findings suggest that the organisation of perinatal mental health services do not follow a consistent pattern, and are uncoordinated across acute and primary care sectors. Implementation of CEMACH (2004) recommendations for practice – such as those regarding staff training – is variable.

The survey by Oluwatayo and Freidman (2005) identified a lack of perinatal psychiatric services and significant variation in provision. Only 35% of the 78 mental health Trusts surveyed had a perinatal multidisciplinary team, and only 37% had facilities for admissions of mothers with their babies, despite evidence of good clinical and parenting outcomes for women discharged from such units (Salmon et al, 2003; Buist et al, 2004). Around a quarter of the Trusts provided a full range of services from in-patient to liaison clinic services. Four identified having too large a geographical area and too few women who required specialist services as a problem. Lack of coordination of services was identified, and most considered their existing services to be inadequate. The Mind (2006) survey found that two-thirds of the 148 women who responded had to wait over a month for treatment, with one in ten having to wait over a year. Of those admitted to hospital (n=27), 63% were admitted to a general psychiatric ward, and 82% of this last group were admitted without their babies. Women also reported a lack of communication and coordination between services.

Midwives’ views of their educational needs in order to support women with mental health problems were reported by Stewart and Henshaw (2002). They used questionnaires with midwives in two adjacent UK health districts (n=377, response rate=71%) on perceived levels of relevant knowledge and experience, and on their potential role and skills in this area. They recognised that their knowledge needed to be improved, and many felt they would benefit from further education in this area. An audit of 119 midwives by Sullivan et al (2003) found that many reported a lack of confidence when caring for women with more serious mental health problems. Ross- Davies et al (2006) used questionnaires to ascertain midwives’ level of education, confidence, interest and knowledge in relation to screening and caring for women with mental health problems. This was done prior to and after attending a study day on mental health issues, and most of the 187 respondents reported that they asked women about mental health problems at the booking visit. Most felt confident about this, but half expressed concern about the management of a woman who disclosed a history of existing or past mental health illness and highlighted substantial problems with referral to mental health services. Many felt less confident when dealing with women with depression and schizophrenia than with women who had complex physical needs. There was significant variation in knowledge levels among midwives about mental health issues in general.


CEMACH (2004) highlighted that severe maternal mental health problems can increase the risk of death by suicide, especially if women have a previous history of mental illness. In some of the cases reviewed, although the risk of recurrence of their mental illness had been noted, no management plan was put in place. This paper has reviewed evidence relating to the identification and management of maternal mental health problems during the antenatal and postnatal periods, with particular reference to CEMACH (2004) recommendations for midwives and maternity services. A number of studies were identified, although methodological issues limit the extent to which changes in practice could be supported by robust evidence. In some situations, changes are more likely to be supported by acknowledged ‘best practice’ in the absence of an evidence base.

The need to identify women with mental health problems or at risk of developing them could be implemented within midwifery service provision, in line with CEMACH (2004) recommendations and supported by NICE (2003, 2006, 2007) guidance. Midwives have several opportunities to do this during routine antenatal and postnatal care. According to CEMACH (2004) recommendations and NICE (2003, 2007) guidance, a woman should be asked at her booking visit about her personal history of psychological or mental health problems – such as depression and previous postnatal depression or trauma – along with questions about previous treatment and
care received. She should also be asked about any family history of mental illness. Those with a history of serious psychiatric disorder prior to pregnancy or after giving birth should be counselled about the possibility of a recurrence and an appropriate referral should be made, although evidence to support the most effective approach was not identified. It is important that regular evaluation is undertaken of the outcome of the identification of women with mental health needs by midwives,  to ensure practice and care are appropriate.

Evidence that some women may develop mental illness for the first time before or after childbirth (Agency for Healthcare Research and Quality, 2005) highlights the importance of midwives being aware of the woman’s existing emotional state, her feelings about her pregnancy, and any signs and symptoms of depression (National Institute for Health and Clinical Excellence, 2006). Continuity of midwifery care that is tailored to meet individual needs may be more likely to assist with this, particularly after childbirth as women may feel more able to discuss their feelings with a midwife they know (MacArthur et al, 2003). Some changes in mental state and functioning are a normal part of pregnancy and giving birth (Bick and MacArthur, 1995), which may be associated with sleep disturbance and tiredness, and it is important to differentiate between these ‘normal’ symptoms, symptoms suggestive of mild to moderate depression and those of more severe depression or other mental illness such as bipolar disorder. No specific screening tools have been recommended for use in pregnancy (Austin and Lumley, 2003) or the postnatal period (Shakepeare, 2001), and there is some qualitative evidence that women may be reluctant to disclose their feelings and may feel stigmatised if asked to complete a tool such as the EPDS (Shakespeare et al, 2003). It is important that women are asked about how they are feeling, as questions such as asking about sleep, appetite and alcohol consumption may elicit more information than the use of a screening tool, although evidence of the benefit of this approach is required. The NICE (2007) antenatal and postnatal mental health guideline recommends that healthcare professionals ask two direct questions based on the work of Whooley et al (1997) to elicit information on a woman’s psychological health at her first contact with the primary health services, at booking and the postnatal period. The sensitivity and specificity of the use of these questions in pregnant and postnatal populations has yet to be established, and further information is required on the consistency of this approach when used by different healthcare professionals.

Although women with particular social circumstances may have an increased risk of depression (O’Hara and Swain, 1996), evidence of the benefit of psychosocial interventions during the antenatal period was inconclusive (Brugha et al, 2000; Elliott et al, 2000; Stamp, 1995; Zlotnick et al, 2001). The NICE (2003) antenatal care guideline recommends that pregnant women are not offered antenatal education interventions to reduce perinatal or postnatal depression. Midwives should note the level of social support available to a woman during pregnancy and be aware of signs of domestic violence or substance use and recent events such as bereavement, in order to provide further surveillance, support and possible referral to other agencies (National Institute for Health and Clinical Excellence, 2003). If this is to be implemented, further work is required to ensure systems are in place to support midwives and women who require crosssector referral and support.

Few studies had focused on how the content of midwifery education could be enhanced to enable the support of women with mental health problems. Three papers were identified that presented information on midwives’ knowledge of maternal mental health problems and perceptions of need for additional training and support (Stewart and Henshaw, 2002; Sullivan et al, 2003; Ross-Davies et al, 2006), but the generalisability of their findings is limited. The audit of practice undertaken by Sullivan et al (2003) would not provide an in-depth perspective regarding midwifery needs, and the survey by Ross-Davies et al (2006) was based on a survey of midwives who attended a study day more likely to attract those interested in this area of maternal health. These three studies all indicated that training would need to reflect issues in relation to information about service provision and individual practitioner needs for midwives to feel confident when working with women who had mental health needs. Evidence of the most appropriate content of training was lacking, but best practice recommendations are that training and service updates should include information on mental health problems and their signs and symptoms, the importance of good history taking and appropriate referral, and the provision of information to women (Confidential Enquiry into Maternal and Child Health, 2004; National Institute for Health and Clinical Excellence, 2006, 2007). Midwifery education may benefit from the contribution of women who have experienced perinatal mental distress (Mind, 2006), who could articulate their experiences and the impact mental health problems had on their lives and those of their families. If midwives are to be involved in assessing the emotional needs of women, it is important that they are aware of their own feelings and the feelings aroused by the woman and are sympathetic to psychological issues. Good communication skills are vital in detecting mental health problems, and midwives may benefit from training that includes role-play to develop appropriate skills. With the public health priority being accorded to this area of maternal health in the UK, a review of pre- and post-registration midwifery education curriculums would be timely, as would discussion of the value of a standardised continuing professional development programme for midwives.

Training and support needs should also reflect findings that midwives were unfamiliar with referral pathways across the acute and primary care sector and had difficulty accessing services for women with mental health problems (Ross-Davies, 2006). Midwives should be clear about whom to refer women to when a problem has been identified and be able to access mental health services directly, which may require a review of existing service contracts and arrangements for liaison among relevant healthcare professionals across acute and primary sectors, including community psychiatric teams. Management plans should be clearly documented for women identified as having a mental health problem, with an appropriate named healthcare professional taking responsibility for ensuring the plan is implemented. A woman’s partner and family may also require support and information, as they are likely to provide front-line care for the woman and could raise concerns about a woman’s mental health if her behaviour or personality altered (National Institute for Health and Clinical Excellence, 2006). The lack of appropriate service provision for the care of women who require specialist services such as admission to mother and baby units is an issue that acute, primary health and mental health care Trusts need to address if CEMACH (2004) recommendations are to be implemented. The survey by Oluwatayo and Friedman (2005) found large gaps in service provision, including lack of availability of mother and baby units. Greater problems in obtaining access for women who require specialist care could be experienced in the future if the number of women with mental health needs identified by midwives increases. As highlighted by Mind (2006), women with mental health needs frequently had to wait for a month or more before getting appropriate care. Although the Mind (2006) survey was relatively small, its findings highlight the urgent need to improve availability of services and resources for maternal mental health.

It is imperative that maternal mental health services meet the needs of all women. Although most of the 28 UK maternal deaths by suicide identified in the CEMACH (2004) report involved women who were white, four were from minority ethnic communities. Most of the studies identified for this paper reflected a limited racial and ethnic mix. Research into practice regarding the identification and management of women from minority ethnic groups, the extent to which recommendations are being achieved and the barriers that exist to access is required.


The literature review found limited evidence of revision to maternity services or midwifery practice in the UK in line with CEMACH (2004) recommendations, although postnatal midwifery-led interventions did appear to be promising. Much more work is required if implementation of the recommendations is to be achieved, with respect to the content and organisation of maternity and perinatal mental health services and midwifery training. It is encouraging tha maternal mental health issues are high on the policy and maternity service agenda in the UK, but further work informed by women who have experienced mental health problems and robust evidence of effectiveness of service provision and management pathways is essential. It is likely that the lessons learnt during this process in the UK will be of value to women and midwives internationally.


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