Perinatal mental health services: needs assessment and recommendations

2. Introduction

Mental distress and illness are common in pregnancy and the first postnatal year, affecting up to one in 5 women, and the period after childbirth is a uniquely vulnerable time for development of severe mental illness for certain groups of women (Jones et al, 2014). The consequences of perinatal mental illness may be severe. Mental health related deaths are now the leading cause of maternal death in the first postnatal year (Cantwell et al, 2018). Men may also be more vulnerable to illness at this time and there is evidence that untreated maternal mental illness may adversely affect the mother-infant relationship and infant development (Stein et al, 2014).

The way in which services are traditionally organised is not responsive to the needs of pregnant and postnatal women. Where women require inpatient care, they should be admitted with their infants to facilities that can ensure the baby is safely cared for, avoiding disruption to the developing mother-infant relationship. This is a legal requirement in Scotland (Mental Health (Scotland) Act, 2015). In community services, there is a need to respond rapidly to the timescales imposed by pregnancy and critical developmental stages in early infancy. Services require altered thresholds for referral, taking into account the particular demands brought about by pregnancy and caring for an infant.

The recognition that Adverse Childhood Experiences (ACEs) have a lasting impact on both mental and physical health has led to the development of prevention and early intervention services in at-risk populations, and trauma-informed therapeutic interventions for children and adults. ACEs are stressful or traumatic experiences occurring in childhood. They include abuse and neglect, and the experience of growing up in households experiencing adversity or where a parent is mentally unwell. Childhood adversity can create harmful levels of stress which impact on brain development and result in learning and behavioural difficulties. In perinatal mental health services attention should be paid to women and other family members who may have a history of ACEs, and infants whose risk of experiencing ACEs is high.

Those working with pregnant and postnatal women have a unique opportunity to prevent the development of illness in some women at highest risk and to improve outcomes for children growing up. There is good evidence that early intervention has better, and more cost-effective outcomes than later attempts to address child mental health problems.

In addition to maternal mental illness and the importance of promoting good infant mental health, there is an increasing understanding of the vulnerability of partners at this time. Five to 10% of fathers may develop mental health problems in the perinatal period (Cameron et al, 2016) and they require support in their own right and as parents.

Knowledge and skills required by those working with pregnant and postnatal women extend to an understanding, not just of adult mental health, but also of infant development and parent-infant relationships. Particular knowledge is required in relation to prescribing in pregnancy and breastfeeding and the timely provision of psychological therapies (SIGN, 2012; NICE, 2014).

The perinatal period is perhaps one of the most important in parents’ lives. Those working with women and their families at this time have a duty to work in partnership with the woman and to respect her need to have information and care which allows her to make the best decisions for herself, her pregnancy, her infant and family.