Guidance

Early years high impact area 2: Supporting maternal and family mental health

Updated 19 May 2021

Applies to England

Mental health problems in the perinatal period are very common, affecting up to 20% of women. Examples of these illnesses include antenatal and postnatal depression, anxiety, obsessive compulsive disorder, post-traumatic stress disorder and postpartum psychosis. Perinatal mental health problems occur during the period from conception to the child’s second birthday. Young mothers up to the age of 25 are at particular risk of poor mental health, up to 3 years after birth. Untreated perinatal mental health problems affect maternal morbidity and mortality, with almost a quarter of maternal deaths between 6 weeks and 1 year after pregnancy attributed to mental health related causes. One in 7 maternal deaths during this period were by suicide.

There are implications to the wider system relating to infant mental health, child and adolescent mental health, social care, adult mental health, physical health, education, housing, welfare and social justice.

Perinatal mental health problems cost the NHS and social services around £8.1 billion for each annual cohort of births. A significant proportion of this cost relates to adverse impacts on the child. The Chief Medical Officer’s Report highlighted that, ‘just as the seeds of a long and healthy life are sown in childhood so too are the origins of much mental illness’. Ensuring that all women receive access to the right type of care during the perinatal period is needed to reduce the impact of maternal mental health problems during pregnancy and the first 2 years of life on infant mental health and future adolescent and adult mental health.

Infant mental health refers to the way in which infants develop in the antenatal months through early life, and especially to understanding their capacity and need to build positive relationships with adults during this time and the unique importance of those relationships to brain development.

Infant mental health is crucial to the long-term development of good mental, physical and emotional health and wellbeing throughout the whole life course. An infant’s early social and emotional development is vital to his, or her, mental and physical wellbeing through childhood, adolescence and adulthood, and those early social and emotional experiences with parents play a crucial part in this process.

Postnatal depression can also affect fathers or partners. Some may find the transition to parenthood challenging, requiring additional support for their mental health and wellbeing. In a survey of 296 fathers, conducted to coincide with Father’s Day, around 38% reported they were concerned about their mental health.

Some partners go through a multitude of complex changes when they become parents, making the transition to parenthood a particularly important, yet vulnerable, time in their life. Having a baby can be stressful for both parents, and some partners feel unable to cope, or that they’re not giving their partner enough support. If depression is suspected, men should be advised to see their GP. The treatment for men is much the same as for women.

Children of affected mothers and fathers are at higher risk of poor mental health, physical health, social and educational outcomes. Perinatal mental health problems can impact on a mother’s and partner’s ability to bond with their baby and to be sensitive and attuned to their emotions and needs. This in turn will affect the infant or child’s ability to develop a secure attachment. Untreated perinatal mental health problems can have a devastating impact on mothers, fathers, partners and families. The effects can be of particular concern in the absence of other carers able to provide the quality emotional contact every infant needs.

About half of all cases of perinatal depression and anxiety go undetected and many of those which are detected fail to receive evidence-based forms of treatment. This is partly due to a lack of recognition and awareness of mental ill health and its signs and symptoms, particularly amongst some black and ethnic minority groups. Across all cultures, some women are reluctant to disclose how they are feeling due to the stigma associated with mental health problems and fears that they may be judged to be an unfit mother, resulting in their baby being removed from their care. This can delay mothers seeking and accepting timely treatment.

Some women are at a higher risk of experiencing perinatal mental health problems. Risk factors include:

• history of abuse in childhood
• previous history of mental health problems
• teenage mothers
• maternal obesity
• traumatic birth
• history of stillbirth or miscarriage
• relationship difficulties
• social isolation

There is an increased risk to the baby when combined with other risk factors, such as domestic violence and abuse or substance misuse. Safeguarding is central to all of the work that the health visitor does. The role includes early identification, early intervention and integrated working with social services in higher risk situations.

Adverse Childhood Experiences (ACEs) are stressful events occurring in childhood including domestic violence and abuse, parental separation or divorce, a parent with a mental health condition, being the victim of abuse (physical, sexual and, or, emotional), being the victim of neglect, a member of the household being in prison, growing up in a household in which there are adults experiencing alcohol and drug use problems.

ACEs have been found to have lifelong impacts on health and behaviour and they are relevant to all sectors and involve all of us in society. Health visitors have a part to play in preventing adversity and raising awareness of ACEs.

Birth trauma can lead to post-traumatic stress disorder (PTSD) that occurs after childbirth. It may also include those women who may not meet the clinical criteria for PTSD but who have some of the symptoms of the disorder.

The symptoms of birth trauma may sometimes overlap with those of postnatal depression. Some women can experience traumatic events during childbirth as well as in pregnancy or immediately after birth. However, there are also other factors including a sense of loss of control, loss of dignity, hostile or difficult attitudes from people around them, feelings of not being heard or the absence of informed consent to medical procedures.

Women who suffer PTSD symptoms may find themselves very isolated and detached from other mothers. This can make sufferers lonely and depressed as they often feel they are somehow ‘weaker’ than other women because they are unable to forget their birth experience. The role of the health visitor is to be vigilant to the possibility of birth trauma and to support women in seeking help.

The role of health visitors

Health visitors, as public health nurses, use strength-based approaches, building non-dependent relationships to enable efficient and effective working with parents and families to support behaviour change, promote health protection and to keep children safe.

Health visitors also undertake a holistic assessment in partnership with the family, which builds on their strengths as well as identifying any difficulties. It includes the parents’ capacity to meet their infant’s needs, the impact and influence of wider family, community and environmental circumstances. This period is an important opportunity for health promotion, prevention and early intervention approaches to be delivered. Working with parents and families, health visitors identify the most appropriate level of support and intervention for their individual needs. Some health visitors may have a higher level of expertise and knowledge within this area to provide more expert support. Health visitors work with women experiencing mild to moderate perinatal mental illness and work with partners where this presents in more severe cases.

Healthy Child Programme

The Healthy Child Programme offers every family a programme of screening tests, immunisations, developmental reviews, information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.

The Healthy Child Programme is universal in reach. It sets out a range of public health support in local places to build healthy communities and to reduce inequalities. It also includes a schedule of interventions, which range from services for all through extra help to intensive support.

The Healthy Child Programme is personalised in response. All services and interventions need to be personalised to respond to families’ needs across time. For many families, this will be met by the universal offer. More targeted, intensive or specialised support and evidence-based interventions should be provided early to meet ‘predicted, assessed and expressed need’ to improve outcomes.

Improving health and wellbeing

The high impact areas will focus on interventions at the following levels and will use a place-based approach:

• individual and family
• community
• population

The place-based approach offers new opportunities to help meet the challenges public health and the health and social care system face. This impacts on the whole community and aims to address issues that exist at the community level, such as poor housing, social isolation, poor or fragmented services, or duplication or gaps in service provision.

Health visitors as leaders in public health and the Healthy Child Programme: Pregnancy and the first 5 years of life are well placed to support families and communities to engage in this approach. They are essential to the leadership and delivery of integrated services for individuals, communities and population to provide RightCare that maximises place-based systems of care.

Individual and family

Health visitors undertake additional training and are skilled in initial assessment to identify mental health concerns. The Rapid Review to update evidence for the Healthy Child Programme provides clear guidance on best practice and the importance of a patient-centred approach.

At the antenatal and new baby mandated reviews, the health visitor will complete a holistic needs assessment which will include asking all women about any past or present severe mental illness, previous or current treatment, and any severe postpartum mental illness in a first degree relative. Whilst the antenatal and new baby mandated reviews are important to initiate an assessment, health visitors can use all contacts to assess health and wellbeing needs.

To increase identification of perinatal mental health problems, all health visitors should incorporate National Institute of Clinical Excellence (NICE) Quality Standard [QS115] Antenatal and Postnatal mental health into their holistic assessment by asking the following Whooley depression identification questions and GAD-2 anxiety questions as part of a general discussion about mental health and wellbeing. If the woman answers ‘Yes’ to any of these questions, or where there is clinical concern, further assessment is needed. Women with transient psychological symptoms (‘baby blues’) that have not resolved at 10 to 14 days after the birth should be regularly assessed for mental health problems.

Formal measures such as the patient health questionnaire (PHQ-9), the Edinburgh Postnatal Depression Scale (EPDS) or GAD-7 are recommended, as well as referral to a general practitioner, Improving Access to Psychological Therapies (IAPT) services, specialist mental health services or perinatal mental health professional, depending on the severity of the presenting problem.

At all subsequent contacts during pregnancy and the first year after birth, the health visitor may use a range of evidence based tools and should consider asking the 2 depression questions and using GAD-2 as well as the EPDS or the PHQ-9 as part of monitoring.

Health visitors provide direct support to parents and infants at a more specialist level offering a personalised response, acting as advocates, linking women up with other specialist services and voluntary sector agencies and working in partnership with these services.

Health visitors have an opportunity to Make Every Contact Count, promoting the importance of healthy lifestyles and the value of health as a foundation for future wellbeing, for example:

• healthy eating, including Healthy Start
• physical activity
• accident prevention
• improving parents’ confidence in managing minor illnesses and reducing unnecessary antibiotic use
• couple support, sun safety and skin cancer prevention
• oral health
• promotion of smoke-free homes and cars
• responsive parenting
• behaviour management, including sleep
• promotion of development, play and a language-rich home learning environment
• the promotion of free early years childcare offer for eligible families

Community

As important local leaders, health visitors work collaboratively with local authorities, primary, secondary and specialist services. They are innovators in service development, assessing health needs and helping to influence changes where needed, ensuring that perinatal mental health problems are identified, and women, men and partners receive high quality care within health visiting services and beyond.

Health visitors can provide direct support to parents and act as advocates. They can link and work together with families and other specialist services and voluntary agencies. Health visitors can raise awareness of gaps in service delivery and be proactive in mobilising services to offer preventative solutions.

The health visitor can lead the implementation and delivery of group-based support and other preventive or early interventions to promote mental health, such as promoting physical activity, peer support groups and fathers’ groups. They can also provide information on issues that impact on mental health and signposting to support from other agencies such as benefits, housing and relationship advice.

Population

Health visitors lead the Healthy Child Programme: Pregnancy and the first 5 years of life and provide leadership at a strategic level to contribute to development and improvement of policies, pathways and strategies to support delivery of high quality, evidence-based, consistent care for improving mental health and wellbeing.

Health visitors also make links and work with the local authority and multi-agencies on wider determinants of mental health, such as housing, health and safety. As advocates for families with perinatal mental health difficulties, health visitors have a crucial role within multi-disciplinary pathways delivering effective mental health care to mothers, fathers and their infants during the perinatal period and usually up to the baby’s second birthday. They play a central role in an integrated service model which includes health visitors in perinatal and infant mental health as recommended by Health Education England.

Health visitors can provide specialist training, consultation and support for peers and other professionals and the wider early years workforce working with mothers, fathers, partners and young children.

When women have access to specialist interventions at an early stage in the development of perinatal mental health difficulties, they can make a good recovery and there need not be long term effects on their relationship with the baby and on the child’s later development. Trained and skilled professionals can often prevent the onset, escalation and negative impact of perinatal mental health problems.

This can happen through early identification and expert management of a woman’s condition, including the provision of specialist therapeutic support to promote a positive relationship with the baby, where this is affected by mental health difficulties.

Using evidence to support delivery

A place-based, or community-centred approach, aims to develop local solutions that draw on all the assets and resources of an area, integrating services and building resilience in communities so that people can take control of their health and wellbeing and have more influence on the factors that underpin good health.

The All Our Health framework brings together resources and evidence that will help to support evidence-based practice and service delivery, Making Every Contact Count, building on the specialist public health skills of health visitors.

Most health and care professionals focus on interventions which tend to be delivered on an individual basis, however health visitors and school nurses focus on individuals, families and communities’ approaches. It is critical that all professionals consider the importance of population health as an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population.

Social prescribing complements such approaches enabling public health nurses and other health and care professionals to refer people to a range of local, non-clinical services. Health visitors recognise that children and young people’s health is determined primarily by a range of social, economic and environmental factors. Social prescribing seeks to address individuals’ needs in a holistic way, taking greater control of their own health.

Measuring success or outcome

High quality data, analysis tools and resources are available for all public health professionals to identify the health of the local population. This contributes to the decision-making process for the commissioning of services and future plans to improve people’s health and reduce inequalities in their area, including child and maternal health profiles, measures of access and service experience. Health visitors and teams need to demonstrate impact of improved outcomes. This can be achieved by using local measures.

Access

Measures include:

• number of women who are asked the recommended questions for prediction and detection of mental health issues at the antenatal booking appointment
• number of infants who received a first face-to-face antenatal contact with a health visitor
• percentage of infants who receive a new birth visit with a health visitor
• percentage of infants who receive face-to-face contact at 6 to 8 weeks

Effective delivery

Measures include:

• evidence of development and implementation of local multi-agency perinatal mental health pathways setting out evidence-based assessments, identification and interventions for perinatal mental health problems and communication required between all relevant professionals
• the development of evidence-based, integrated local pathways for infant mental health (this area overlaps significantly with integrated perinatal mental health pathways and includes Specialist Health Visitors in perinatal and infant mental health as recommended by Health Education England). It also overlaps with pathways with Child and Adolescent Mental Health Services (CAMHS) pathways
• evidence of service development and the implementation of evidence-based training and the use of validated tools to identify infants who may be at risk of poor attachment and parents who need additional support to attune and bond to their infants. Neonatal Assessment Behaviour Scale, Solihull Approach
• use of tools including perinatal mental health data profile
• mental health in pregnancy and the postnatal period, and babies and toddlers needs assessment reports – available through PHE’s Fingertips tool for each local authority, clinical commissioning group and sustainability and transformation plan

Measuring impact

Measures include:

• number of women in contact with mental health services who were new or expectant mothers, as published in the Mental Health Services Monthly Statistics

User experience

Measures include:

• feedback from NHS Friends and Family Test, via local commissioner and provider data

Other measures can be developed locally and could include measures such as initiatives within health visitors’ building community capacity role, such as developing peer support, engaging fathers, joint developments with parent volunteers and early years services.

Connection with other areas

The high impact area documents support delivery of the Healthy Child Programme and 0 to 5 agenda, and highlight the link with a number of other interconnecting policy areas such as the maternity transformation programme, childhood obesity, speech, language and communication, immunisations, troubled families, mental health and social mobility action plan. The importance of effective outcomes relies on strong partnership authority including early years services, and voluntary sector services.

Best Start in Life has been identified as a priority as part of PHE’s 5-year strategy, which runs from 2020 to 2025. Best Start in Life is a priority for the government and as such is included the Prevention Green Paper Advancing our Health: prevention in the 2020s.

Improving services for children and young people is part of the NHS Long Term Plan. The Child Digital Strategy and Maternity Programme is currently developing and implementing infrastructure to improve access and timeliness of data with the aim to know where every child is and how well they are. This includes the development and implementation of a Digital Parent Child Health Record. This programme supports the ambitions and modernisation of the Healthy Child Programme.

Collaborative working

Approaches to improving outcomes through collaborative working include:

• PHE Best Start in Life and beyond: Improving health outcomes for children, young people and families. Guidance to support the commissioning of the Healthy Child Programme 0 to 19: Health visiting and school nursing services
• information sharing agreements in place across all agencies
• generating and using information from Joint Strategic Needs Assessment, including Fingertips (Public Health Profiles), information about families, communities and the quality of local services to identify and respond to agreed joint priorities
• local adoption of the Prevention Concordat for Better Mental Health and the inclusion of perinatal mental health as a theme in geographical prevention planning arrangements
• development of competencies to identify perinatal mental health issues
• demonstrating value for money and return on investment

Improvements

These include:

• improved accessibility for vulnerable groups
• integrated IT systems and information sharing across agencies
• development and use of integrated pathways
• systematic collection of user experience for example NHS Friends and Family Test to inform action
• increased use of evidence-based interventions and links to other early years performance indicators
• improved partnership working, for example maternity, specialist perinatal mental health teams, and school nursing
• consistent information for parents and carers
• create and strengthen ‘father inclusive’ services to engage fathers or partners
• identify early predictors of perinatal mental illness
• direct referral to primary care and specialist perinatal mental health services, including IAPT services in place to ensure adequate supply against demand

Professional or partnership mobilisation

These include:

• multi-agency training and supervision to identify risk factors and early signs of perinatal, paternal and other mental health issues
• multi-agency communication skills training to address stigma and enable patient centred, open discussions about perinatal mental health to improve identification. Multi-agency training in evidence-based early intervention and safeguarding practices
• effective delivery of universal prevention and early intervention programmes with evidence-based outcome measures
• improved understanding of data within the Joint Strategic Needs Assessment and at the local Health and Wellbeing Board to better support integrated working of health visiting services with existing local authority arrangements to provide a holistic or joined-up and improved service for young children, parents and families
• identification of skills and competencies to inform integrated working and skill mix
• increased integration and working with early years services or specialist perinatal mental health teams or voluntary sector mental health organisations to offer a range of services or activities to promote emotional wellbeing and positive mental health
• improved accessibility through a local cohesive approach demonstrated through a perinatal mental health pathway

Associated tools and guidance

Policy

Better Beginnings, NHS Institute for Health Research, 2017

Children and young people’s health benchmarking tool, PHE, 2014

Child and Maternal Health Profiles, PHE

Healthy Child Programme: Pregnancy and the first 5 years of life, Department of Health and Social Care (DHSC), 2009

NHS Long term Plan, NHS England, 2020

Prevention Concordat for Better Mental Health, PHE, 2017

Prime Minister promises a revolution in mental health treatment, DHSC and NHS England, 2016

Public Health Outcomes Framework 2013 to 2016, DHSC, 2013

Rapid review to update evidence for the Healthy Child Programme 0 to 5, PHE, 2015

SAFER communication guidelines, DHSC, 2013

The 1001 Critical Days: The Importance of the Conception to Age 2 Period, A cross-party manifesto, 2014

The 5 years forward view for mental health, NHS England, 2016

The mental health strategy for England, DHSC, 2011

UK physical activity guidelines, DHSC, 2011

Working together to safeguard children, HM Government, 2018

Mental Health Taskforce, NHS England, 2016

Research

Adverse Childhood Experiences (ACEs), Centres for disease control and prevention, England, 2019

All babies count: Spotlight on perinatal mental health, National Society for the Prevention of Cruelty to Children (NSPCC), 2013

Building Community Capacity, e-learning for Healthcare

Child and Maternal Health, PHE

Conception to age 2: the age of opportunity, WAVE Trust, 2013

Costs of perinatal mental health problems, Centre for Mental Health, 2014

Place-based systems of care: A way forward for the NHS in England, Ham and Alderwick, NHS England, 2015

MBRRACE-UK, Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK, National Perinatal Epidemiology Unit, 2015

National Perinatal Mental Health Project Report: perinatal mental health of black and minority ethnic women, National Mental Health Development Unit, 2011

Perinatal mental health services for London: Guide for commissioners, NHS London Clinical Networks, 2017

The Prevention Green Paper: A chance to turn talk into action, Selby D, PHE, 2019

Specialist health visitors in perinatal and infant mental health, Health Education England, 2016.

The Best Start at Home, Early Intervention Foundation, 2015

The Parent–Infant Interaction Observation Scale: reliability and validity of a screening tool, Svanberg and others, 2013

Psychology: Volume 31, Issue 1, 2013.

Universal screening and early intervention for maternal mental health and attachment difficulties Milford and Oates, Community Practitioner, 2009

Guidance

A framework for supporting teenage mothers and young fathers, PHE and Local Government Association (LGA), 2016, updated 2019

Health visiting and midwifery partnership: Pregnancy and early weeks, PHE, 2015

Maternal Mental Health Pathway, PHE, 2015

NICE guidance

Antenatal and postnatal mental health, NICE quality standard [QS115], 2016

Postnatal care, NICE quality standard [QS37], 2013

Pregnancy and complex social factors, NICE clinical guideline [CG110], 2010