Guidance

4. Perinatal mental health

Updated 25 October 2019

1. Introduction

The purpose of this chapter, and the mental health and wellbeing JSNA toolkit overall, is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. It provides easy access to nationally available topic focused information, guidance and knowledge. The chapter text aims to be plain English and ready to be cut and pasted. The numerous links to external sites should all be current, relevant, and provide access to material that contributes to the JSNA process.

Perinatal mental health problems affect between 10 to 20% of women during pregnancy and the first year after having a baby^{[footnote 1]}. Historically there has been a lack of integrated physical and mental health care for women during pregnancy and in the weeks and months following birth, and a lack of specialist perinatal mental health services to support women who become unwell.

A Joint Strategic Needs Assessment (JSNA) should describe the level of local need for perinatal physical and mental health education in maternity and primary care services, and how well mental health problems are being identified and responded to. Pregnant women and mothers who have or previously experienced a mental health condition will require particular support. Specialist perinatal mental health teams are important for secondary prevention.

Opportunities for service development should be identified. Services need to recognise the importance of the mother-baby relationship and relationships with partners and the wider family. There should be a focus on:

• promoting healthy pregnancies
• promoting healthy lifestyles
• primary and secondary prevention
• early identification
• timely provision of quality specialist care.

These actions can reduce both the incidence and severity of related child development issues, and also the long lasting effects on women and their families which result from untreated perinatal mental health problems^{[footnote 2]}.

Environmental and individual factors which affect mental health (including perinatal mental health) and wellbeing are included in Mental health: environmental factors and Mental health: population factors. The perinatal period provides an opportunity to promote mental health from conception and birth. This is discussed further in Children and young people.

Examples of questions that a JSNA might address for a local area include^{[footnote 3]}:

• what is the predicted local prevalence of mental health conditions during the perinatal period?
• have demographic and risk factors relating to perinatal mental health been assessed? Does this intelligence inform preventive actions?
• what are the community’s main assets which support prevention and offer early support for perinatal mental health problems?
• are preventive interventions, including parenting and child care preparation programmes available and accessed by those who need them?
• do maternity and health visiting services assess mental as well as physical health?
• what perinatal mental health support is available in primary care?
• what are the trends in the use of specialist perinatal mental health services and how does this compare with expected need?

2. Overview

The physical and mental health of the mother, and the family environment during pregnancy, infancy and childhood is of fundamental importance to mental health. A parent’s ability to bond with and care for their baby, their parenting style and the development of a positive relationship can predict a number of physical, social, emotional and cognitive outcomes through to adulthood^{[footnote 4]}.

While the relationship between mother and child is particularly important, the mental health of fathers and other caregivers should also be considered. Paternal and maternal depression is shown to have a negative impact on how parents interact with children^{[footnote 4]} and can have long-term consequences if left untreated^{[footnote 1]}.

During pregnancy and the year after birth, many women experience common mild mood changes. Some women can be affected by common mental health problems, including anxiety disorders (13%) and depression (12%)^{[footnote 2]}. The risk of developing a severe mental health condition such as postpartum psychosis (which affects between 1 and 2 in 1000 women who have recently given birth^{[footnote 1]}), severe depressive illness, schizophrenia and bipolar illness is low but increases after childbirth. The impact of poor mental health can be greater during this period, particularly if left untreated^{[footnote 9]}.

Any woman may develop mental health problems during pregnancy and in the first year after giving birth. However, risk is important - factors such as poverty, migration, extreme stress, exposure to violence (domestic, sexual and gender-based), emergency and conflict situations, natural disasters, trauma and low social support are recognised as increasing risk for specific disorders^{[footnote 5]}.

Risk factors for postpartum depression^{[footnote 6]}:

• history of mental health problems
• childhood abuse and neglect
• domestic violence
• interpersonal conflict
• inadequate social support
• alcohol or drug abuse
• unplanned or unwanted pregnancy
• migration status

A family or personal history of bipolar disorder significantly increases the risk of developing postpartum psychosis^{[footnote 7]},^{[footnote 8]}. Bereavement by miscarriage, stillbirth or neonatal death are also more likely to lead to mental health problems in both parents^{[footnote 9]}.

Inequalities need to be indentified. Equity of access to provison that promotes good mental health, prevents the escalation of problems and supports early access to treatment is important. Local areas should consider the needs of underserved women and communities alongside identifying assets and protective factors, using this intelligence to identify required improvements to provison. This is covered in detail in Mental health: environmental factors and Mental health: population factors.

Routine antenatal and postnatal appointments are opportunities for health professionals to discuss emotional wellbeing with women and identify potential mental health problems. Maternity, general practice and health visiting services have frequent contact with the mother, baby and family during the perinatal period and are well placed to provide support, make initial assessment and refer onwards if problems are identified^{[footnote 10]}.

All healthcare professionals referring a woman to a maternity service should ensure that information on any past and present mental health problem is shared^{[footnote 10]}.

The most common mental health problems that women in the perinatal period experience are depression and anxiety^{[footnote 2]}. Improving access to psychological therapy (IAPT) services, as described in Working age adults, should be able to meet the needs of both the mother (and/or father) and the infant^{[footnote 11]}.

Work from 2015 estimated that 85% of localities did not have specialist perinatal mental health services to the level recommended in NICE guidelines, strongly suggesting the majority of areas have work to do here^{[footnote 2]}.

The NHS Five Year Forward View implementation plan^{[footnote 12]} includes the objective that there will be increased specialist mental health support in all areas by 2020 to 2021. This will include increasing access to specialist perinatal community teams and providing additional mother and baby inpatient beds when needed. This should allow at least an additional 30,000 women each year to receive evidence based treatment, closer to home, when they need it. A phased, five-year transformation programme, backed by £365m in funding, is underway to build capacity and capability in specialist perinatal mental health services^{[footnote 12]}.

In addition to the direct impact on families, it is estimated that perinatal mental health problems cost the NHS and social services around £1.2 billion annually^{[footnote 1]}. A significant proportion of this cost relates to impact on the child.

Good quality, evidence-based perinatal mental health care pathways are shown to:

• improve access to evidence-based treatment with greater detection and improved recovery rates, improving outcomes for women and their children
• reduce pre-term birth, infant death, special educational needs, and poor school attainment, and depression, anxiety or conduct problems in children
• reduce costs per birth to NHS caused by mental health problems during perinatal period
• reduce costs to society of failure to address perinatal mental health problems, which are estimated to be £8.1bn, three quarters of which relate to health and social outcomes of the child

3. Data sources

Metrics in the profiling tool relating to perinatal mental illness include:

In risk factors:

• smoking at time of delivery (District & UA, County & UA, Region)
• domestic abuse incidents recorded by the police (County & UA)
• children in need due to abuse, neglect or family dysfunction (County & UA)

3.1 Other key data sources

• Perinatal mental health profile: contains a range of available indicators, including risk factors, measures of prevalence and relevant maternity statistics
• Perinatal mental health data catalogue: gives detail on and provides links to metrics and data sets relating to perinatal mental health, describes metrics that will be available in the future and metrics that may be collected locally
• NMHIN and ChiMat needs assessment report: information on risk factors alongside detailed estimates of local numbers of perinatal mental health disorders. Prevalence estimates are based on applying national rates to local populations, they do not adjust for local demographic factors.
• NHS Benchmarking Network: has undertaken a detailed assessment of specialist inpatient and community perinatal mental health services covering 2015 to 2016. A national report is available to download and participating organisations can gain access to local data. Regional clinical networks have all been provided with a bespoke report covering their area.
• National inquiry into maternal deaths: shows that mental health problems are a leading cause of death in pregnancy and the 12 months after birth

Local data

Historically, there has been a lack of data which identifies women with mental health problems in the perinatal period. This is being addressed nationally through the examples above and also through a project aiming to link maternity and specialist mental health datasets to help identify women in the perinatal period in contact with mental health services. In the interim, local areas may wish to consider the possibility of local linkages/information sharing to support this work.

Local areas may be able to access additional statistics. Examples include:

• recording of mental health problems and risk factors in data recorded by midwives and health visitors and mental health community teams
• data held by acute trusts around payment pathways for maternity, which includes recording of mental health information
• work conducted by relevant regional perinatal mental health clinical networks (such as baseline assessments, demand and gap analyses and workforce strategies)
• data from local voluntary and charitable organisations and services working with pregnant and postnatal mothers
• data on maternal suicide through interrogation of mortality statistics, discussions with local coroners or via the local suicide audit
• data from local GP systems, for example on women of child bearing age on QOF mental health registers, preconception advice given to women with SMI
• pharmacist information on advice given to women in the perinatal period about smoking & medicines optimisation
• data on local services’ capacity and pathways, for example midwives and health visitors trained in mental health, perinatal mental health pathways in place
• data on attachment support and parenting programmes and targeted infant programmes such as Family Nurse Partnerships

Local areas may also want to consider what assets are available to improve resilience to perinatal mental health problems, such as parenting support groups and networks for mothers and families.

4. Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Centre for Mental Health: Costs of perinatal mental health problems: the report is part of the Maternal Mental Health Alliance’s ‘Everyone’s Business’ campaign, which calls on national Government and local health commissioners to ensure that all women throughout the UK who experience perinatal mental health problems receive the care they and their families need.

NHS England Perinatal mental health webpages: gives details on programmes to build capacity and capability in specialist perinatal mental health services, focused on improving access to and experience of care, early diagnosis and intervention, and greater transparency and openness.

NICE: Antenatal and postnatal mental health overview (2016): a comprehensive range of NICE products concerning the evidence based approaches to antenatal and postnatal mental health. This antenatal and postnatal pathway provides an overview of the tools and guidance.

Royal College of GPs: Perinatal Mental Health Toolkit: a set of relevant tools to assist members of the primary care team to deliver the highest quality care to women with mental health problems in the perinatal period.

Royal College of Psychiatrists: Quality Network for Perinatal Mental Health Services: the Quality Network for Perinatal Mental Health Services works with specialist perinatal mental health teams to improve the quality of mental health care for new mothers.

5. References

1. Centre for Mental Health, LSE Personal Social Services Research Unit. The costs of perinatal mental health problems – report summary (2015) ↩ ↩² ↩³ ↩⁴

2. NICE. Antenatal and postnatal mental health: clinical management and service guidance. Clinical guideline CG192 (2014) ↩ ↩² ↩³ ↩⁴

3. Local Government Association. Joint Strategic Needs Assessment Data Inventory (2011) ↩

4. Faculty of Public Health, Mental Health Foundation. Better Mental Health for All: A Public Health Approach to Mental Health Improvement (2016) ↩ ↩²

5. Royal College of GPs. Position statement about Perinatal Mental Health (2016) ↩ ↩²

6. World Health Organisation. Maternal mental health (2017) ↩

7. Pearlstein T, Howard, M., Salisbury, A., & Zlotnick, C. Postpartum depression. American Journal of Obstetrics and Gynecology (2009) 200(4):357-6 ↩

8. Jones I, Craddock N. Familiarity of the Puerperal Trigger in Bipolar Disorder: Results of a Family Study. American Journal of Psychiatry (2001)158(6):913-7 ↩

9. Howard LM, Molyneaux E, Dennis C-L, Rochat T, Stein A, Milgrom J. Non-psychotic mental disorders in the perinatal period. The Lancet (2014) 384(9956):1775-88 ↩

10. NICE. Antenatal and postnatal mental health Quality Standard QS115 (2016) ↩ ↩²

11. NHS. IAPT: Perinatal positive practive guide (2009) ↩

12. NHS England. Implementing the Five Year Forward View for Mental Health (2016) ↩ ↩²