Suicide is the leading cause of death for new mothers in the UK. As many as one in five women develop a mental health problem during pregnancy or in the year following birth. While depression and anxiety are the most common, conditions can range from low mood to PTSD and psychosis.
In England, as part of a five-year perinatal mental health program, the National Health Service has opened and expanded specialist services across the country, ensuring more new mums receive the care they need at this critical time. The UK government has pledged £365million to the cause, released in phases up to 2020/2021.
The goal is to ensure all mothers can access a specialist perinatal service to meet their needs, wherever they live in England. It’s an ambitious plan, part of the Five Year Forward View for Mental Health, a blueprint for the overhaul of mental health care in the country, launched in 2016.
While progress has been praised so far, with the British Medical Association noting “tangible improvements” in perinatal services nation-wide, continued success will rely on meeting the challenges of training the workforce and ensuring funding remains focused on the plan.
“These are very specific conditions that need to be treated in a very specific way,” said Dee Noonan, Project Manager for Building Capacity in Perinatal Mental Health Services, one stream within the five-year plan.
People might mistakenly think that “depression is depression” or talk about “baby blues”, she said, but perinatal care is a complex area, involving a highly sensitive relationship. “They need specialist services. If you get these cases in at the right time, the success rate is very, very good.”
Yet perinatal has historically been under-funded across the UK. A 2017 survey found that only 7% of women who reported experiencing a perinatal mental health problem in Britain were referred to specialist care. Preventing or mitigating these problems with early intervention and treatment can avoid deep and long-lasting consequences, both for the family and the child.
This need is finally being met. By 2020/201, the program aims to provide treatment for an additional 30,000 women each year. The first wave in 2017 /2018 exceeded its target, with 7,000 more women accessing specialist services. The second has released more funding, awarded to 134 local commissioning groups.
New mother-and-baby units have also been set up, and more beds were provided in existing ones, so that in-patient and out-patient perinatal mental health services are now available across the country.
Given the rapid expansion, a key challenge has been training.
The Royal College of Psychiatrists, the top professional body for British mental health clinicians, was commissioned to run the Building Capacity project to help develop skills and expertise.
“The perinatal community is small,” said Noonan: it’s not one of the set specialisms for doctors in the UK. So unless a practitioner has a personal interest or happens to work at a site that has a service, they might be starting with very little knowledge.
The right skills
Building Capacity worked around workforce shortages by implementing a hosting and mentoring phase, training ten consultant psychiatrists by embedding them for six months in perinatal services that were already shining examples in the field.
Noonan said they benefited from “enormous goodwill” from staff in the host services who were “very willing to participate” in training the consultants.
The project then ran a series of masterclasses and conferences, for additional consultants as well as senior trainees, training roughly 280 psychiatrists to date. Academics were brought in, dealing with cutting-edge research, as well as parents to talk about their experiences and expert clinicians who had seen “the worst of the worst and the best of the best.”
“You can’t just expect to suddenly have a whole system in place,” said Sally Hogg, Head of Policy and Campaigning at the charity Parent Infant Partnership. “There are questions around the quality of the services” at present, she said, due to the lack of long-term experience in the workforce, which can’t be replaced by small training packages. But she said that experience will come with time “if there’s concerted momentum and people don’t take their eye off the ball”.
Funding may be an issue in future. The plan had been ring-fenced for the first few years. The British Medical Association’s report noted that the success of the program thus far “can be largely explained” by the protection of this funding. However in the final phase it will form part of CCG baseline allocations. “The risk then is that it could be pulled away into all the other things that CCGs want to prioritise,” said Hogg.
Through her previous work for the children’s charity NSPCC, Hogg had campaigned for a perinatal program with a broader scope. She said the government is doing a good job at delivering on their pledges, but to improve outcomes significantly “you need the whole system to be working together”.
“While there’s been investment in high-end specialist services there’s been a massive disinvestment in the rest of the pathway, particularly health visiting,” she said.
Health visitors support new parents, doing everything from advising on breastfeeding and ensuring babies are vaccinated, to spotting abuse in the home and identifying mothers who are struggling to bond with the child. Their number has fallen by more than 1000 since 2016, in line with shrinking real terms investment in public health in England. Health visitors are crucial for referring mums who are struggling, particularly as they are likely to be the only practitioners who see mothers in their home environments.
A good base
Noonan believes the five-year program, and the ‘Building Capacity’ project within it, is a good base from which to move forward. The program has certainly ignited interest in an area that has been overlooked.
“The feedback we’ve got from senior trainees was that it was an eye-opener,” she said, adding that all the trainees whose plans she is aware of want to move into perinatal service.
England is leading the field with its establishment of specialist services, a model that Noonan said has attracted global interest. Scotland has put aside £50 million, while Northern Ireland has pledged to improve specialist services.
It’s a complex service to provide and expand, but the challenges and costs are well worth the rewards. As the Chair of the Maternal Mental Health Alliance, Dr Alain Gregoire, put it, suicide is “the tip of an iceberg of suffering that has been ignored for too long.” —Niki Seth-Smith
(Picture Credit: Maresa Smith/Deathtothestockphoto)