Perinatal Mental Health
Perinatal mental health illness encompasses mental health problems in women that arise during pregnancy and in the one year after childbirth. It is also concerned with the emotional and social development of babies and toddlers who can experience poor long term outcomes due to a lack of sensitive and responsive care.
Perinatal mental health illness is the leading cause of death for women during pregnancy and in the year after birth, and causes significant ill health from depressive illness and anxiety as well as post-traumatic stress disorder. The level of provision of services nationally and locally is inadequate. Across Surrey services for perinatal mental health are limited and the nearest mother and baby in-patient services are located in Winchester (Hampshire).
This chapter explores the issues around perinatal mental health illness and how local services respond to the level of need in the population. It discusses the risk factors for perinatal mental health illness in women and those for poor emotional and social development in babies and toddlers.
A number of recommendations are made to commissioners of services from Surrey’s Clinical Commissioning Groups and Surrey County Council to improve provision of universal and specialised services for affected women and infants.
Visualisation of data used in this chapter
The purpose of this JSNA chapter is to explore the issues around perinatal mental health illness and how local services respond to the level of need in the population. This chapter begins by explaining what perinatal mental health illness is, why it is an important issue, and why it deserves a chapter in the JSNA. This is followed by a description of the main risk factors that predispose women and infants to perinatal mental health (PMH) illness.
The level of need within the population is estimated on the basis of the risk factors described and the proportion of the population that is potentially exposed to them. The chapter goes on to describe the current level of provision of services available to women and their infants before examining whether gaps exist in meeting the level of need locally.
Throughout the chapter, links are made to related chapters which can provide more context for the concepts discussed.
What is perinatal mental health illness?
PMH is concerned with mental health problems in women that arise during pregnancy (the antenatal period) and in the one year after childbirth (the postnatal period). This could be a recurrence of an existing mental illness or a newly developing one. PMH also includes the mental health of the infant. Infant mental health is concerned with how well a child develops socially and emotionally from birth to 3 years of age (1).
The mental health problems that women could experience during this time cover a range of conditions including depression, anxiety disorders, eating disorders, drug and alcohol-use disorders and severe mental illness (such as psychosis, bipolar disorder, schizophrenia and severe depression). Some women will have symptoms that fall below the threshold for considering treatment while others will have mild, moderate and severe mental health problems (2) . Some of these mental health conditions are described in more detail within Table 1 of this chapter and in the glossary towards the end of the chapter.
Why is perinatal mental health illness important?
PMH illness is important because it is one of the leading causes of death for mothers during pregnancy and in the year after birth. Between 10 and 20% of women develop a mental illness during pregnancy or within the first year after having a baby. The average cost to society of one case of perinatal depression is around £74,000, of which £23,000 relates to the mother and £51,000 relates to impacts on the child (3). Maternal suicides are now the leading cause of direct maternal deaths occurring within a year after the end of pregnancy. Between 2009 and 2014, 111 women died by suicide in the UK during or up to a year after the end of pregnancy (4).
If untreated, perinatal mental illness can inhibit a mother’s ability to provide a baby with the sensitive, responsive care that he or she needs. This may be associated with poorer long-term outcomes for the child, even after the postnatal period (5).
Why does perinatal mental health deserve a chapter in the JSNA?
It is widely acknowledged that the provision of services for PHM nationally are inadequate and the local picture is not dissimilar.
Despite it being well known that up to 20% of women will develop some mental health issues during the perinatal period, services across the UK, England and the South East Region are disparate, poor and in some cases non-existent. (6, 7) , 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.
Specialist perinatal mental health services are needed for women with complex or severe conditions, but less than 15% of localities provide these at the full level recommended in national guidance and more than 40% provide no service at all.
Just 3% of Clinical Commissioning Groups (CCGs) in England have a strategy for commissioning perinatal mental health services and a large majority have no plans to develop one.(1)
In Surrey, PMH has been recognised as a local issue for quite some time. As a result, the Adult Mental Health Strategy for Surrey and North East Hampshire 2014-2017 set out to prioritise the development of a Specialist Perinatal Mental Health service as one of its key outputs during the second and third year of implementation but this service has not been set up. It is also known that local specialist perinatal mental health services fall short of national standards and this is acknowledged in Surrey’s Joint Emotional Wellbeing and Mental Health Commissioning Strategy for Children and Young People 2014-17.
Currently mainstream services are providing all the care for women during the perinatal period and some roles and pathways have been developed especially to prioritise pregnant women or those with a baby. These include IAPT (Improving Access to Psychological Therapies) services, a parent and infant mental health service and recruitment of specialist mental health midwives in maternity services.(12)
Although there are many accounts where people have received good responsive care from these mainstream services, there are recorded incidents where general mental health services have not had the relevant specialist knowledge to manage medication, safeguarding assessments or timeliness of intervention for perinatal mental health issues and therefore the experience on these occasions have been poor.(8)
Who’s at risk and why?
In this section we discuss the individual factors that increase the risk of women developing a perinatal mental health illness followed by risk factors for poor social and emotional development in babies and toddlers.
Risk factors for perinatal mental health illness in women
Many of these risk factors are those associated with mental illness in the general population but some risk factors increase the likelihood of Maternal mental health problems.(2,9) There will also be women with none of the risk factors discussed who will go on to develop mental health problems during pregnancy or after childbirth (10). The known risk factors for maternal mental ill-health are:
- History of mental health problems
- Traumatic childbirth, stillbirth and infant mortality
- Domestic violence and abuse
- Poor social support
1. History of mental health problems
Women with a history of mental health problems before becoming pregnant are at increased risk of certain mental health conditions during pregnancy and in the year after childbirth (11,12) . If there is a higher than average rate of mental health problems in the local general population, there may be a higher level of maternal mental health problems as well.
2. Traumatic childbirth, stillbirth and infant mortality
Mental health problems, particularly post-traumatic stress disorder (PTSD), are associated with experiencing a traumatic childbirth, stillbirth or the death of a baby. NICE defines traumatic births as those which are physically traumatic and also those that are experienced as traumatic, even when the delivery is obstetrically straightforward.(2)
3. Domestic violence and abuse
Domestic violence is associated with antenatal depression, postnatal depression, anxiety and post-traumatic stress disorder (PTSD), although it is not known whether domestic violence increases the risk of mental health problems or vice versa (13). High levels of symptoms of all types of perinatal mental disorders are associated with having experienced domestic violence, although causality cannot be proven.(16)
A high level of domestic violence could indicate an increased risk to the population of mental health problems in pregnancy and during the year after childbirth. Living in a household where domestic violence is occurring is also a risk factor for poor mental health in babies and toddlers (14).
4. Poor social support
Women who lack social support have been found to be at increased risk of antenatal and postnatal depression. Having a poor relationship with a partner is also a risk factor for postnatal depression.(14)
ONS statistics show that infant mortality rates are higher among babies that are sole registered (i.e. those whose father does not appear on the birth certificate) compared to other registration types(15). The relationship between sole registration and birth outcomes is a complex one involving socio-economic and lifestyle risk factors that are known to have an impact on maternal health (16).
Risk factors for poor social and emotional development in babies and toddlers
A complex range of factors have an impact on the social and emotional development. In babies and children, knowledge of these factors may help encourage investment at a population level in early interventions to support health and wellbeing. (17)”
Being exposed to more than one risk factor may have an increased impact on a young child. The Millennium Cohort Study (MCS)(18) found that being exposed to two or more risks in first years of life was likely to disadvantage children’s cognitive and behavioural development as they grew up. The greater the number of risks experienced by the child, the greater the problems that the child would face during the lifecourse.(15)
Not all babies or toddlers with certain risk factors will have poor mental health. NICE guidance states that these risk factors can be used as indicators to identify groups of children who are likely to be vulnerable. However, not all of these children will in fact be vulnerable – and others who do not fall within these groups, could have social and emotional problems.”(19)
Key risk factors for the poor social and emotional development of babies and toddlers are:
- Insecure attachment to a main caregiver
- Parental drug and alcohol misuse
- Maternal mental health
- Being born to a teenage parent
- Being ‘looked after’ or maltreated
1. Insecure attachment to a main caregiver
When considering social and emotional development in babies, toddlers or young children, it is useful to understand the importance of attachment and how it relates to other risk factors. NICE defines attachment as ‘”a secure relationship with a main caregiver, usually a parent, allowing a baby or child to grow and develop physically, emotionally and intellectually.”
Babies and children need to feel safe, protected and nurtured by caregivers who identify and respond appropriately to their needs. Unmet attachment needs may lead to social, behavioural or emotional difficulties, which can affect the child’s physical and emotional development and learning.” (19)
Attachment can be secure, which enables the child to feel safe, secure and protected, or insecure. There are three categories of insecure attachment – ambivalent, avoidant and disorganised. Children may have experienced inconsistent or insensitive care and therefore are not able to rely upon their relationship with their primary caregiver. It is insecure attachment, particularly disorganised attachment that can lead to problems with a baby or toddler’s development.(20)
There is no reliable local data available on parent-baby attachment but other risk factors such as drug and alcohol misuse can also lead to attachment problems.
2. Parental drug and alcohol misuse
If a parent or caregiver misuses alcohol or drugs, there can be an impact on a baby or toddler’s development, often due to parenting problems. Parents misusing substances are at risk of a wide range of difficulties associated with their role as a parent. These may include a lack of understanding about child development issues, ambivalent feelings about having and keeping children and lower capacities to reflect on their children’s emotional and cognitive experience (21).
Problematic drinking by parents is associated with negative parenting practice and parenting capacity can be compromised when parents become increasingly focused on drinking and as a result become less loving, caring, nurturing, consistent or predictable.(23)
NICE guidance stresses the importance of taking account of the impact of the parent’s drinking on the parent–child relationship and the child’s development, education, mental and physical health, own alcohol use, safety, and social network (22) .
Parental problem drug use can and often does compromise children’s health and development at every stage from conception onwards (23). Looking at the impact at different stages of a child’s life, an inquiry looking at the needs of children of problem drug users found that;
- From birth to age two the foundation of a child’s normal development is a good relationship with a well parent or primary care giver who is consistently able to provide nourishment, stimulation and protection from danger and give the child a sense of well-being and security. Much of the potential for parental drug use to damage the child in these early months lies in the way it can obstruct or corrupt this relationship”(29)
- At 3-4 years of age parental problem drug use can continue to jeopardise the child’s development in many ways, including being left unsupervised or neglected, physical violence or emotional abuse and less time stimulated through play or reading. (29)
The National Treatment Agency for Substance Misuse (19) found that during 2011/12, one third of adults in drug or alcohol treatment lived in a household with children (including parents living with their own children and adults living in a house with children who are not theirs, for example step-children or grandchildren).
Parents who live with their own children tend to have fewer drug-related problems than others in treatment, are less likely to use the most addictive drugs, and are less likely to inject drugs when compared to non-parents in treatment. They are also less likely to be homeless or arrive in treatment via the criminal justice system (24).
3. Maternal mental health
The social and emotional wellbeing of a baby or toddler can be affected by whether the mother has a mental health problem herself, often due to the effect on the mother-baby relationship(2,12, 25) .
Emotional distress and problems during pregnancy, childbirth and the postnatal period warrant particular attention because of the longitudinal impact these difficulties have on the developing foetus and new-born baby, effects which are often mediated through the woman’s disrupted relationship with her infant (26).
Postnatal depression can have serious and long term effects on babies, and failure to treat perinatal depression promptly may result in a prolonged damaging effect on the relationship between the mother and baby and on the child’s psychological, social and educational development.(15)
There is evidence that postnatal depression may be associated with lower cognitive and language achievements in young children(14). Cognitive development is not impaired in all babies and children of mothers with postnatal depression, but appears limited to those children whose mothers find it difficult to maintain sensitive and active engagement with the infant.(15)
4. Being born to a teenage parent
Pregnancy in under-18 year olds can lead to poor health and social outcomes for both the mother and child(27) . For example, children born to teenage parents are at greater risk of low educational attainment, emotional and behavioural problems, maltreatment or harm, and illness, accidents and injuries (28) . Young mothers are also more at risk of developing postnatal depression than average(29) .
5. Being ‘looked after’ or maltreated
There are risks to babies’ and toddlers’ mental health associated with the experience of being in care. Frequent moves can adversely affect the ability of babies and very young children to form healthy attachments that lead to healthy emotional and physical development. The absence of a permanent carer at such a young age can jeopardise children’s chances of developing meaningful attachments and have adverse consequences for their long-term wellbeing. Very young children can become closely attached to foster care families and can experience great distress if moved to a new placement.(22)
Data on the number of looked after children is also useful because many children are in care due to circumstances which are likely to have affected their wellbeing. The majority are from families where parents are struggling with issues such as domestic violence, substance abuse, alcohol abuse and mental health problems, often in combination.(22)
A substantial number of children and young people are placed in local authority care as a result of maltreatment. Many children suffer combinations of different forms of abuse and neglect and, as a result, experience the kind of care-giving in which key nurturing experiences are missing. In maltreated children, the child’s primary attachment figure (usually the parent) is likely to be unavailable at times of need and may also be the cause of extreme fear and distress. This can lead to the development of insecure or disorganised attachment patterns and have an impact on brain development, which can in turn lead to impaired development.(33)
Babies and toddlers that live in families that are homeless are vulnerable to poor social and emotional wellbeing(22). This is because babies’ development is reliant on the quality of the care their parents are able to provide. Providing this care can be difficult for some parents who are homeless. (22)
The limited research on the specific impact of homelessness on babies shows that homeless infants experience a significant decline in general developmental function between 4 and 30 months. (22)
The level of need in the population
In this section we describe the level of need in the local population using estimates of the population affected by the risk factors described in the previous section. Due to limitations in the collection and availability of data, some of the risk factors do not have any estimates available at a local level or where data is collected locally, there may not be comparable regional or national data.
Level of need in perinatal women
Following the same order as the previous section, we will start by exploring the level of need in mothers based on the risk factors for perinatal mental health illness. After this we will describe the level of need for social and emotional development in babies and toddlers. For women, we will look at the occurrence of the following risk factors:
- Maternal mental health illness
- Traumatic childbirth, stillbirth, and infant mortality
- Domestic violence and abuse
- Poor social support
1. Maternal mental health
The estimated number of women with mental health problems during pregnancy and after childbirth for Surrey are shown in the Table 1. Adding all of these estimates together will not give a total estimate of the number of women with perinatal conditions in the Surrey, as some women have more than one of these conditions.(30) This table provides the most important predictor of the level of need for specialist perinatal mental health services.
Table 1: Estimates of women in Surrey with mental health problems during pregnancy and after childbirth 2012/13
Source: ONS, 2016. Number of Maternities in Surrey in 2015 = 13,349. Centre. Source of rates of disorders: Joint Commissioning Panel for Mental Health. Guidance for commissioners of perinatal mental health services(31). Definitions from NSPCC(11).
2. Traumatic childbirth, stillbirth, and infant mortality
A stillborn baby is one born after 24 completed weeks of pregnancy with no signs of life. The stillbirth rate is the number of stillbirths per 1,000 total (live and still) births. In 2014 there were 62 stillbirths in Surrey, a rate of 4.6 stillbirths per 1,000 total births (live + stillbirths). The rate was the same for England but higher compared to the South East region (4.4 stillbirths per 1,000 total births).
The data visualisation shows that the rate of stillbirths in Surrey has risen to exceed the regional rate and equal the national rate. If this trend continues, Surrey will become worse than the national average. A high rate of stillbirths may increase the need for mental health services due to the association particularly with post-traumatic stress disorder. There was a 0.4% increase in the number of live births across England and Wales between 2014 and 2015 (ONS, 2016).
The infant mortality rate is the number of infants dying before their first birthday per 1,000 live births. The rate of infant mortality in Surrey is lower than regionally and nationally but appears to be improving at a much slower pace (see data visualisation). There were 107 infant deaths in Surrey in the period 2013-2015: an infant mortality rate of 3.12 per 1,000 births. Nationally the rate was 3.89.
3. Domestic abuse
Table 2 shows the rate of domestic abuse recorded by police in Surrey per 1,000 population, with regional and national comparisons. The rates relate to all incidents, not only those involving households containing children or pregnant women. In line with national trends, this rate has gradually risen since 2010/10. The negative consequences of living in a household with violence affects both pregnant women and infants.
Table 2: Rate of domestic abuse incidents recorded by police, rate per 1,000 population 2014/15
4. Poor social support
The number of births which were registered by just the mother provides a rough indication of the number of women in that are likely to lack the support of the father during pregnancy and as a new mother. Table 3 shows the proportion of births that were sole registrations.
Table 3: Sole registrations of births 2015, percentage of all live births
Level of need in babies and toddlers
Now we will consider the level of need in babies and toddlers. Due to the difficulty in measuring levels of secure attachment of children to their parents, there is no data available to describe the level of need based on this risk factor. Estimates for maternal mental health illness have already been discussed previously. As in the previous section we will use the following risk factors as a basis for describing the level of need in babies and toddlers:
- Parental drug and alcohol misuse
- Being born to a teenage parent
- Being ‘looked after’ or maltreated
1. Parental drug and alcohol misuse
Table 4 shows the number and proportion of parents receiving drug and alcohol treatment in Surrey who live with children. The proportion of substance misusers who seek treatment is likely to vary according to relative levels of deprivation as well as other factors such as employment opportunities and provision for treatment. This doesn’t give any indication of the numbers of parents in Surrey who misuse drugs and alcohol who are not in treatment.
Table 4: Parents in alcohol and drug treatment who live with children under the age of 18 (2015/16)
2. Being born to a teenage parent
Table 5 shows the number and rate of live births to mothers under 18 years of age in Surrey. Not all babies born to teenage parents will be brought up by them. Also, although a high number of teenage parents in a population is a risk factor for higher levels of poor infant mental health, on an individual level many teenage parents will parent effectively and raise healthy children. Younger adult parents (those in their late teens or early twenties) may need extra support, especially those who are vulnerable or lack family support.
Table 5: Live births to mothers under 18 years of age
3. Being ‘looked after’ or maltreated
A total of 870 children were under the care of the local authority at the end of 2016, and 125 (15%) of them were under the age of 5 years. Very young children require decisive action about their placement moves due to the impact this has on emotional attachment. Figure 1 shows the rate of looked after children in Surrey. It is consistently lower than the regional and national rates.
Figure 1: Looked after children, rate per 10,000 children aged under 18 years
Source: Department for Education, 2016
Table 6 shows the number of children on a child protection plan. This can be used as an indicator of the numbers of children that have experienced maltreatment and are known to authorities.
Table 6: Children subject to a child protection plan, rate per 1,000 children
Table 7 shows the number of homeless families which include children or a pregnant woman. The number of homeless people in priority need, and those accommodated in temporary accommodation in Surrey has been rising since 2008/09.
Table 7: Family homelessness: households containing children or a pregnant woman, per 1,000 households
Source: Department for Communities and Local Government
Summary of the level of need
The following key points summarise what we know about the local level of need:
- The estimates for the number of women affected by perinatal mental health illnesses in Surrey in a single year were; between 2,000 to 4,000 with an adjustment order or distress; 1,300 to 2,000 experiencing mild to moderate depressive illness and anxiety, 400 with severe depressive illness; and 400 with post-traumatic stress disorder.
- The rate of stillbirths in Surrey has risen to exceed the regional rate and equal the national rate. If this trend continues, Surrey will become worse than the national average. A high rate of stillbirths may increase the need for mental health services due to the association particularly with post-traumatic stress disorder.
- The level of domestic abuse in Surrey may be marginally lower than nationally and regionally, but the numbers of incidence involved are still significant. Mental health issues arising from domestic abuse may result in the increased demand for services and resources from a variety of stakeholders other than healthcare e.g. social care.
- The high rate of parents in drug and alcohol treatment in Surrey could mean that there is a high level of engagement with treatment services, but could also mean that there is a high level of substance misuse and potentially a high number of children at risk of harm as a result of their parents.
- A significant number of number of women are estimated to experience depressive illness, anxiety, adjustment disorder and distress in Surrey each year. There is no readily available information on how many of these women are able to access services or where the majority are seen within the mainstream services.
- The rate of family homelessness in households containing children appears to be less of a problem in Surrey than nationally, but the actual number of households is considerable. More information is needed about the age profile of the children in these households to determine whether there is a potential risk to their social and emotional development.
Services in relation to need.
In this section we describe the current level of service provision in Surrey to assess whether services are meeting the level of need in the population. The lack of routine central data collection historically across services for perinatal mental health presents a challenge in providing a detailed analysis of our local picture.
Table 8 shows the services which are available currently, and where the gaps are across Surrey and NE Hampshire. Table 9 shows the workforce that would be required for a Surrey and NE Hampshire and Farnham specialist community perinatal service against the Royal College Psychiatrists recommended workforce.
Comparing the two tables demonstrates a huge gap between the staffing levels from various disciplines that would be available in commissioned specialist service compared to what is available currently through mainstream services.
Table 8: Services currently available across Surrey and NE Hampshire for perinatal mental health (PNMH) (12)
Table 9: Numbers of Staff Required for Specialist Community Perinatal MH Service across Surrey and NE Hampshire (12)
Source: Royal College of Psychiatry(32). Estimated using ONS Total Births per CCG, 2014.
Across the Surrey and North East (NE) Hampshire Perinatal Mental Health Network, two of the local acute trusts with specialist perinatal mental health midwifes in post have received 561 and 469 referrals respectively to their services since June 2015. The experiences shared can be summarised as follows;
- Across Surrey there are very limited services for perinatal mental health. The nearest mother and baby in-patient services are located in Winchester (Hampshire).
- There is no local specialist perinatal mental health community service and not all of the acute trusts or community providers have perinatal mental health midwifes or health visitors.
- Mainstream services currently provide all the care for women during the perinatal period and some roles and pathways have been developed to prioritise pregnant women or those with a baby.
Unmet needs and service gaps
Surrey has no local specialist perinatal mental health services commissioned as a unified service.(12) This means that local standards for perinatal mental health services locally fall short of national standards.
A specialist perinatal mental health service is needed in order to provide:
- Specialist assessment and treatment for those at risk, new on-set and pre-existing perinatal mental illness
- Consultation and liaison across primary and secondary care, obstetric teams and social services
- Training and supervision across a range of agencies
- Monitoring and facilitation of admissions and discharges of our mothers into out of area mother and baby units
- Clinical leadership of the Surrey and NE Hampshire Perinatal Mental Health Clinical Network
In this section we describe what a specialist perinatal mental health service looks like and the range of services that should be available to women. We also itemise the facets of a good specialist perinatal mental health service based on best practice and commissioning guidance. A list of national policy initiatives and evidence is provided for reference to help those who commission services as well as those involved with the assessment, referral or treatment of women.
What is a specialised perinatal mental health service?
Specialised perinatal mental health services encompass both community teams and inpatient Mother and Baby Units (MBUs). Community teams should be commissioned by CCGs on a locality basis but MBUs are highly specialised services focused on the treatment and recovery of women with the most severe and complex mental ill health.
In-Patient Mother and Baby Units enable the treatment and recovery of the mother whilst ensuring the developing relationship with the baby and its physical and emotional wellbeing. Units will have a specialised Perinatal Outreach function that provides assessments for women who would otherwise be admitted to the MBU, facilitates early discharge, the prevention of relapses and re-admission of discharged in-patients and of high risk (and admission vulnerable) women. In some areas this function may be provided by a community team commissioned by CCGs.
MBUs are staffed by clinicians with additional knowledge and skills in the impact of childbirth on maternal psychiatric disorder and the effects of maternal psychiatric disorder and its treatment on the infant both in-utero and after birth.
Both MBUs and community perinatal mental health teams (commissioned by CCGs) should work in close collaboration with maternity and obstetric services and health visitors, respond rapidly to presentations within the maternity context and address the additional risks to both mother and infant of serious perinatal mental health. (33)
A good perinatal mental health service should:
- Be based on a perinatal mental health strategy which includes a commissioning framework and service design for populations large enough to provide a critical mass for all the services required across a clinical pathway.
- Be provided on the basis of the known epidemiology
- Be based on the delivered population as the denominator for service planning and provision
- Use an integrated care pathway drawn up agreed by all stakeholders
- Provider equal access to all women
- Promote prevention, early detection and diagnosis and effective treatment
- Offer effective, personalised and compassionate, evidence based treatment which meets the needs of the mother and infant
- Accommodate cultural and religious practices
- Promote seamless, integrated and comprehensive care across the whole clinical pathway and across professional and organisational boundaries
- Ensure that no woman is needlessly separated from her infant but receives support to enable her to care for her infant
- Include an education and training programme for non-specialists
- Be part of a clinical network
- Include a range of specialised services and skilled staff
National Policy Initiatives and Evidence Base
The following evidence based national policy initiatives recommend that all women with serious mental illness in late pregnancy and the postpartum period should receive specialist perinatal psychiatric care. If they require admission, these women should be admitted with their babies to a Specialised In-Patient Mother and Baby Unit. They also recommend treatment and management guidelines for perinatal conditions and women of reproductive potential. Their aim is to reduce morbidity and mortality in mother and infants and to improve quality of life and patient satisfaction.
- NICE, Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance (2014) and Quality Standard (2016)
- Mental Health Task Force, Five Year Forward View for Mental Health for the NHS in England (2016)
- National Maternity Review, Better Births, Improving Outcomes of Maternity Services in England (2016)
- The British Psychological Society (BP8 2016), Perinatal Service provision: The Role of Perinatal Clinical Psychology
- Falling through the gaps: perinatal mental health and general practice, Centre for Mental Health (2015)
- The Royal College of Psychiatrists – Perinatal Mental Health Services College Report CR197 (2015)
- Saving Lives, Improving Mothers’ Care Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13 (2015)
- Department of Health Chief Medical Officer annual report 2014: women’s health (2015)
- Public Health England 0-19 service specification
- National Institute for Health and Care Excellence – The Management of Bipolar Disorder: Assessment and Management (2014)
- Department of Health Publication: Closing the gap: priorities for essential change in mental health (2014)
- The costs of perinatal mental health problems: LSE and Centre for Mental Health (2014)
- 1001 Critical Days: The Importance of Conception to Age Two Period. Cross Party Manifesto (2013)
- Prevention in mind: All Babies Count; Spotlight on Perinatal Mental Health. NSPCC (2013)
- Maternal Mental Health Alliance, NSPCC and Royal College of Midwives (2012) Specialist Mental Health Midwives – what they do and why they matter
- The Scottish Intercollegiate Guidelines Network – Management of Perinatal Mood Disorders: A National Clinical Guideline (2012)
- Joint Commissioning Panel – Guidelines for the Commissioning of Perinatal Mental Health Services (Royal College of Psychiatrists (RCPsych) 2012)
- Centre for Maternal and Child Enquiries – Saving Mothers’ Lives: Reviewing Maternal Deaths to make Motherhood Safer 2006-2008 (2011)
- Royal College of Psychiatrists’ College Centre for Quality Improvement – Quality Network for Perinatal Mental Health Services – Standards for Mother and Baby In-Patient Units (2014)
- Royal College of Obstetricians and Gynaecologists (RCOG) Guidelines on Management of Women with Mental Health Issues during Pregnancy and the Postnatal Period (Good Practice No 14) 2011
- The British Association of Psychopharmacology – Evidence-Based Guidelines for Treating Bipolar Disorder (2016)
- Healthy Child Programme – Pregnancy and the First Five Years of Life (2009)
- New Horizons – A Shared Vision for Mental Health (2009)
- Maternity Matters – Choice, Access and Continuity of Care in a Safe Service (2007)
- The National Service Framework for Children, Young People and Maternity Services – Maternity standard 11 (2004)
Recommendations for Commissioning
Clinical Commissioning Groups
- Women in Surrey should be able to access specialist perinatal mental health teams and inpatient units when necessary. A specialist perinatal mental health service should be commissioned in accordance with NICE Guidance in order to meet the needs of women.
- CCG commissioners should work together with NHS England Specialised Commissioning in order to ensure that specialised perinatal Mother and Baby Units are made available more locally to Surrey.
- Universal services (especially GPs, midwives and health visitors) should be supported to identify issues early on and ensure that all women get the support they need before the postnatal period.
- In the absence of a specially commissioned perinatal mental health service, commissioners and providers should reliably and systematically collect timely data on perinatal mental illness across Surrey in order to inform strategy and service developments. For example, adult mental health services, including IAPT, could routinely collect data on whether patients are pregnant or parents, and the ages of their children.
- Commissioning and funding arrangements for specialist perinatal mental health services must support preventative work. Only a small number of women are at risk of developing serious mental illness, but the vast majority will have mild to moderate depressive illness which may go undetected. With the proper care from expert services, further episodes of mental illness in these women can be prevented. To do this work, specialist mental health services must be able to work with women who are currently well and would not normally meet the thresholds for care.
- There should be adequate commissioning of parent-infant interventions and that these are well publicised to GP practices and mothers and integrated within integrated care pathways.
Surrey County Council
- Surrey County Council should ensure that they include at least one Specialist Health Visitor Perinatal and Infant Mental Health (PIMH). Whilst health visitors, through their ‘universal’ service, are best placed to identify those families requiring additional support, they have many other roles to fulfil and would benefit from specialist support from a specialist health visitor PIMH.
- All health visitors should receive pre and post-registration education in perinatal and infant mental health. This will enable them to identify, prevent and intervene early in the care of women with mental health problems. Alongside this knowledge, training must also equip health visitors with the skills and confidence to talk with women and their families about their mental health.34 The Surrey and NE Hampshire Perinatal Mental Health Network already has it in their objectives to ensure that a Perinatal training strategy for the workforce involved is developed and delivered.
Surrey & NE Hampshire Perinatal Mental Health Network
- A Surrey-wide perinatal mental health strategy should be developed which includes a commissioning framework and service design for all the services required across the clinical pathway. Strategy development should involve participation from all providers of care for perinatal mental health.
Voluntary sector and patient groups
- Services should address the impact of perinatal mental health illness on babies and other family members. In order to do this, commissioners should work closely with patient groups to seek views of patients and family members. This will enable provision of sensitive and responsive care and identify opportunities for linking families with further sources of support.
Shannon Katiyo – Author: email@example.com
Maya Twardzicki – Public Health Mental Health Lead: firstname.lastname@example.org
Jon Walker – JSNA Coordinator: email@example.com
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2. NICE. Antenatal and postnatal mental health: clinical management and service guidance. NICE guidelines (CG192) Updated edition. London: National Institute for Health and Care Excellence, 2014 (cited 28 October 2016). www.nice.org.uk/guidance/cg192
3.Annette Bauer, Michael Parsonage, Martin Knapp, Valentina Lemmi & Bayo Adelaja. (2014). The Costs Of Perinatal Mental Health Problems. London School of Economics and Centre for Mental Health.
4. MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) 2016. Saving Lives, Improving Mothers’ Care Surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14
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6. NMHDU (2011) National Perinatal Mental Health Project Report – Perinatal Mental Health of Black and Minority Ethnic Women: A Review of Current Provision in England, Scotland and Wales National Mental Health Development Unit
7. NSPCC. (2012) Prevention in mind : All Babies Count: Spotlight on Perinatal Mental Health – NSPCC
8. Agnieszka Klimowicz, Beverley Lignum (2016) Perinatal Mental Health Scoping Paper and Recommendations. South East Strategic Clinical Networks.
9. National Collaborating Centre for Primary Care. Clinical guidelines and evidence review for post-natal care: routine post-natal care of recently delivered women and their babies. NICE guideline (CG37). London: National Collaborating Centre for Primary Care and Royal College of General Practitioners, 2006 (cited 2015 Jun 8). http://www.nice.org.uk/guidance/cg37/evidence
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12. Scottish Intercollegiate Guidelines Network (SIGN). Management of perinatal mood disorders SIGN guideline 127. Edinburgh: SIGN, 2012 (cited 2015 Jun 8). Available from: www.sign.ac.uk/guidelines/fulltext/127/index.html
13. Howard LM, Oram S, Galley H, Trevillion K, Feder G. Domestic violence and perinatal mental disorders: a systematic review and meta-analysis. PLOS Medicine. 2013;10 (5):e1001452. doi: 10.1371/journal.pmed.1001452.
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19. NICE. Looked-after children and young people. NICE guidelines (PH28). London: National Institute for Health and Clinical Excellence, 2010. www.nice.org.uk/guidance/ph28
20. Hogg S. Prevention in mind. All babies count: spotlight on perinatal mental health. London: NSPCC. www.nspcc.org.uk/services-and-resources/research-and-resources/2013/all-babies-count-spotlight-perinatal-mental-health/
21. Rayns G, Dawe PS, Cuthbert C. All babies count: spotlight on drugs and alcohol. London: NSPCC, 2013 www.nspcc.org.uk/services-and-resources/research-and-resources/2013/all-babies-count-drug-alcohol/
22. NICE. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE guidelines (CG115). National Institute for Health and Clinical Excellence, 2011 www.nice.org.uk/guidance/cg115
23. Advisory Council on the Misuse of Drugs. Hidden harm- responding to the needs of children of problem drug users. London: Advisory Council on the Misuse of Drugs, 2011. www.gov.uk/government/publications/amcd-inquiry-hidden-harm-report-on-children-of-drug-users
24. National Treatment Agency for Substance Misuse. Parents with drug problems: how treatment helps families. London: NTA, 2012. www.nta.nhs.uk/uploads/families2012vfinali.pdf
25.. NICE. Social and emotional wellbeing: early years. NICE guideline (PH40). London: National Institute for Health and Clinical Excellence, 2012. www.nice.org.uk/guidance/ph40/
26. National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical management and service guidance. Updated edition. NICE guideline (CG192). Leicester and London: The British Psychological Society and The Royal College of Psychiatrists, 2014. www.nice.org.uk/guidance/cg192/evidence
27. . NICE. Prevention of sexually transmitted infections and under 18 conceptions. NICE guidelines (PH3). London: National Institute for Health and Clinical Excellence, 2007. www.nice.org.uk/guidance/PH3/chapter/About-this-guidance
28. NICE. Contraceptive services with a focus on young people up to the age of 25. NICE guidelines (PH51). London: National Institute for Health and Care Excellence, 2014. www.nice.org.uk/guidance/ph51
29. Mental Health Foundation. Young mums together: promoting young mothers’ wellbeing. London: Mental Health Foundation, 2013 www.mentalhealth.org.uk/content/assets/PDF/publications/young-mums-together-report.pdf
30. Jo Goldsmith (SABP), Diane Woods (Surrey CCG Collaborative), S&NEH PMH Network 2016. Surrey and North East Hampshire Perinatal Mental Health Business Case & Integrated Pathway
31. Joint Commissioning Panel for Mental Health. 2012. Guidance for commissioners of perinatal mental health services. Volume Two: Practical mental health commissioning. http://www.jcpmh.info/resource/guidance-perinatal-mental-health-services/
32. Royal College of Psychiatrists. 2015. College Report CR197. Perinatal mental health services Recommendations for the provision of services for childbearing women. http://www.rcpsych.ac.uk/files/pdfversion/CR197.pdf
33. NHS England (2016). Schedule 2 – The Services. Service specification: Specialised Perinatal Mental Health Services (In-Patient Mother and Baby Units and Linked Outreach Teams). https://www.england.nhs.uk/wp-content/uploads/2016/12/c06-spec-peri-mh.pdf
34. Health Education England (2016). Specialist Health Visistors in Perinatal and Infant Mental Health. What they do and why they matter. http://everyonesbusiness.org.uk/wp-content/uploads/2016/09/Specialist-Health-Visitors-in-Perinatal-and-Mental-Health.pdf
35. Royal College of Psychiatry. http://www.rcpsych.ac.uk/healthadvice/moreinformation/definitions/diagnosesorconditions.aspx Accessed on 29/12/2016 at 1553hrs.
Signed off by
Julie George – Public Health Consultant