Perinatal mental health care

Jackie Rotheram is a disabled mother and Specialist Midwife and Disability Adviser at Liverpool Women’s Hospital in the UK. In her article, she describes a new service which addresses the needs of women with perinatal mental health issues. In November 2005 this new service was recognised locally as an example of good practice when it received a Focusing on Excellence Award.

The term ‘perinatal mental health’ covers a broad range of conditions. Psychiatric disorders associated with childbirth are common: 10% of new mothers are likely to develop a depressive illness, and some may go on to develop a severe depressive illness.

Extent of the problem

Suicide is the most common cause of maternal death in this country. This has been highlighted by the Confidential Enquiry into Maternal Death (CEMD) which also points out that, in most cases, severe postnatal psychiatric illness can be predicted from previous history, and therefore these deaths are preventable. The impact of serious postnatal psychiatric illness can have huge implications for a woman and her family: in its extreme it can result in infanticide.

To address this specific need a working group was set up in Merseyside and Cheshire to explore maternity care provision for women with mental health issues. The purpose of this care provision is to support women with significant mental health problems, including schizophrenia, manic depression, psychosis, severe postnatal depression, self-harm and obsessive compulsive disorders. Postnatal depression, if left untreated, can cause cognitive, emotional, social and behavioural problems both in the short and long term. Women experience almost double the rate of depression compared to men and, in women aged 18 to 44, rates of both anxiety and mood disorders peak during their ‘childbearing’ years.

Care pathway

The aim is to identify women at risk of life-threatening perinatal mental health problems. A care pathway was developed through effective inter-agency communication, which aims to reduce risk, improve mental health and enhance the maternity care experience.

Information about the new service was distributed to all general practitioners, community mental health trusts, psychiatrists, midwifery managers and consultant obstetricians within the trust to inform them of this service and let them know where to refer pregnant women for support.

A guideline was produced to manage mental health problems in pregnancy and the postnatal period. This was developed jointly with the local psychiatry services to ensure good communication and to develop direct lines for referral. A lead clinician was identified to take this service forward. Mental health is recognised by the Disability Discrimination Act (1995) as an impairment which affects someone’s ability to carry out daily activities of living, an issue which also needed to be addressed in the guideline.

A simple screening tool, based on the one used in Nottingham by Dr Margaret Oates, was developed and incorporated into the booking history for women during their first antenatal clinic appointment. Women identified as high risk are referred to the lead clinician and specialist midwives to co-ordinate care. A needs assessment is performed at the first antenatal appointment: the in-depth antenatal booking history is used to explore the woman’s mental health status, what medication she uses, her medical and social history, and her life events.

A personal and family history of psychiatric illness, either postpartum or non-partum major mental illness, is also taken. Women who have a history of significant mental health are at high risk of having a relapse in their mental health postnatally; for example, there is a 50% recurrence for women with bipolar affective disorder and 30% for women with a history of puerperal psychosis.

Further information on their mental health history is obtained from their mental health and primary healthcare teams, and other sources such as social services where necessary. As recommended by the CEMD, all women at risk will therefore have a psychiatric assessment during the antenatal period if the guideline is followed. It is important to remember, however, that screening is not just about detecting the presence of illness – it is also about identifying those at risk and putting closer monitoring in place or, in some cases, offering prophylactic treatment.

Clear protocols

Women are seen regularly by the same team members to provide continuity, control and choice, and the number of antenatal visits is determined by the woman’s needs. Networks and referrals are made for further care and support as required and, to ensure good communication, professional meetings are arranged bringing all services together to co-ordinate and manage care.

A detailed plan of care is written for the antenatal, intrapartum and postnatal periods, which is agreed with the woman and her health carers, and which is recorded in her hand-held records.

What makes the maternity experience different for this client group is that there are direct links to psychiatric services and mental health nurses, clearly written protocols for women at risk, specialist postnatal care and counselling about the potential for recurrence of illness. Experience with the protocols shows that women feel ‘safe’ because their specific needs are identified and their care is transparent. Working in partnership with other services – for example with the postnatal depression support midwife, and forging closer links with general practitioners, health visitors and other primary care services – gives further support which enables care to be managed more effectively and avoids gaps and duplication.

As this support service develops, other concerns are also being identified such as eating disorders, chronic anxiety and panic attacks. This has led to referrals for the service doubling during the last two years. The need is evident. A specialist perinatal mental health team with the knowledge, skills and experience to provide care for women at risk of or suffering from serious postpartum mental illness should be available to every woman. Women’s needs should be central to service provision: it is vital that women at risk are offered the same choices as given to all other women, that practitioners and service providers look beyond women’s mental health and see the whole person, and that women are encouraged and supported to be actively involved in their own maternity care.

References

1. Disability Discrimination Act (1995)
2. Human Rights Act (1998)
3. National Service Framework (Standard 11)
4. Health Inequalities Report
5. CEMACH (2004) Why Mothers Die 2000-2002: Report on Confidential Enquiries into Maternal Deaths in the United Kingdom
6. National Women’s Mental Health Strategy

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