Peer support in perinatal mental health: evidence review

3. Current models of peer support in Scotland

The literature review identified a range of peer support models in use internationally, covering peer workers in perinatal services, peer volunteers and befrienders, peer groups and online and telephone support. To identify which of these models are active in Scotland, the researcher contacted (via email) a range of stakeholders known to provide perinatal services (n=88). The email included an information sheet about the research project and respondents were asked to complete a short questionnaire about their support provision. Where there was no response via email, the researcher carried out online searches to identify if the organisation provided perinatal peer support and the nature of this support.

While this report on peer support has aimed to be as robust as possible, time constraints restricted the scope of the exercise and so the findings should be viewed as indicative rather than comprehensive.

3.1 Paid peer support workers

Paid peer support work in perinatal mental health is at a very early stage in Scotland. In Scotland, paid peer support workers in mental health services are mainly employed in the third sector, with some NHS general mental health services initiating peer support work more recently. When looking at perinatal mental health specifically, this review found no evidence of paid peer support workers in the NHS in Scotland. In the third sector, one organisation (Nurture the Borders) was identified employing paid staff with lived experience to provide peer support in the perinatal period (see box below).

In England, paid peer workers are present in perinatal services, including Mother and Baby Units (MBU) (see Annex 3).The research evidence from England shows that paid peer support workers can be effective in supporting women and over time depressive symptoms can be reduced (Fogarty and Kingswell, 2002) however, no evidence has been identified which can help to define the distinct differences between paid peer support workers and volunteer peer support workers.

Service Model – Paid peer support workers

Location: Nurture the Borders, based in the Scottish Borders.

Provision: Provides a range of support services including one-to-one support by Perinatal Support Officers, who are employed on the basis of both their skills in supporting parents and their experience as parents. Through their Cherish Project, Nurture the Borders' Perinatal Support Officers support women experiencing emotional or mental health challenges during the perinatal period. This support is individualised and recovery focused, and includes providing emotional support, modelling and mentoring, signposting and information sharing. Perinatal Support Officers support mums directly and also train and supervise volunteer befrienders.

Eligibility: Perinatal Support Officers work with women from pregnancy until the child turns one.

3.2 Peer support volunteers

Evidence from this review suggests that peer support volunteers or befrienders in perinatal mental health are a much larger group in Scotland than paid peer workers. Volunteer peer supporters in perinatal mental health deliver the majority of one-to-one perinatal peer support in Scotland. This trend reflects the literature review, where the majority of studies evaluate telephone-based and face-to-face peer support delivered by trained volunteers. Peer support volunteers will:

• offer emotional and practical support for parents and families.
• offer a chance to talk about difficulties to a non-judgemental fellow parent.
• help with practical everyday tasks and advice on day-to-day challenges like housing, benefits and how to support parents' mental health and children's development.

Peer support volunteers work in a range of voluntary organisations, from small local charities to national organisations. The organisations listed in the box below provide peer support through volunteers and befrienders in Scotland.

Large organisations like Home-Start and Aberlour offer support across wider geographical areas, and have the capacity to evaluate their services using measures with a larger client base. Smaller local voluntary organisations are vulnerable to changes in funding and often function due to the commitment of a few individuals.

Service model – Peer support volunteers

Location: Home Start Scotland, while not a perinatal specific service, offer the widest geographical coverage, with 31 regional Home-Start branches covering 63% of local authority areas in Scotland (Home Start Scotland, 2019). Central Scotland has the most coverage, as Aberlour's Perinatal Befriending Support service supports mothers in Forth Valley and East Lothian, and Juno Perinatal Mental Health Support a befriending service for mothers in Edinburgh. Nurture the Borders operate a befriending service for mothers in the Scottish Borders.

Provision: Home-Start, Aberlour, Juno and Nurture the Borders all offer support to women who are experiencing poor mental health in the perinatal period. Home-Start offer support to the whole family and often work with parents during the perinatal period (although their support is not solely focused on this). Home-Start, Aberlour and Nurture the Borders all provide volunteer befriending services to support women experiencing emotional or mental health challenges during the perinatal period. Juno offer befriending for mothers. Nurture the Borders also provide a befriender as a birth partner for women who find themselves without someone to fulfil that role.

Eligibility: All organisations support women in the perinatal period, however there are varied definitions of this period. Home-Start offer peer support to families with children under 5 or expectant parents. Aberlour support women antenatally and postnatally, with specified end point for support. Nurture the Borders support women through pregnancy and till the child is one year old. Juno identify the perinatal period as through pregnancy up until the child is two years old.

3.3 Peer support groups

Peer support groups feature prominently in the literature on perinatal peer support. Some groups are organised as part of wider perinatal services and some are individual volunteer led groups. With some variation, peer support groups tend to be informal and led by volunteers with experience of perinatal mental health difficulties. Some groups are facilitated by professionals, and some introduce creative activities for parents. Many groups offer play facilities for babies and young children while parents take part in the group, and some groups offer a free crèche onsite. Some groups badge their service as for mothers only, while others are badged as accessible for mothers, fathers and other family members.

Service model – Peer support groups

Location: Home-Start branches serve a wide-geographical area in Scotland. Most other peer support groups identified are concentrated in central Scotland. Blank Canvas, Quarriers Maternal Mental Wellbeing Service, 3D Drumchapel and Paisley Abbey's Talk it Over Group operate peer support groups in the West of Scotland. PANDAs run peer support groups across central Scotland. Juno run peer support groups in Edinburgh. Nurture Parents run peer support groups in Dundee, however their service is coming to an end due to lack of funding. It is likely that other groups run in community settings across Scotland, that were not identified in this review.

Provision:

• Home-Start branches across Scotland offer weekly peer-support groups to pregnant parents/parents with a child under the age of 5, staffed by Home-Start staff and volunteers.
• Juno run peer support groups for mothers across Edinburgh, led by volunteers with experience of perinatal mental health difficulties. Women are free to attend antenatally, postnatally and drop in and out of the group to meet their own needs.
• Blank Canvas run creative workshop groups in Lanarkshire for mothers affected by perinatal mental illness during pregnancy and postnatally. Workshops are delivered by mums with lived experience of perinatal mental health difficulties.
• Nurture Parents run peer support groups with peer volunteers in Dundee, however their service is coming to an end due to unavailability of accommodation and lack of funding.
• PANDAs run peer support groups across central Scotland for parents suffering from perinatal mental health issues.
• Paisley Abbey's Talk it Over Group offers a weekly peer support group for mothers suffering from postnatal depression in Paisley. Groups are run by volunteer health professionals and children are looked after in the free crèche onsite.
• Quarriers Maternal Mental Wellbeing Service runs an antenatal and two postnatal peer support groups for mothers as a wider programme of parenting support in North East Glasgow. Both groups have an onsite crèche and transport facilities.
• 3D Drumchapel run a weekly postnatal support group for new parents called Tea & Tots in Drumchapel, Glasgow. This group offers new parents and carers the opportunity to come along and meet other families, improve their confidence as a parent, and find out about opportunities, support, information and resources available for them and their baby. The group helps to build community support by fostering social networks.

Eligibility: Many peer groups are badged as accessible to new parents and other carers, however it is likely that the majority of attendees are mothers. Some groups are for mothers only, for example Blank Canvas, Juno and Paisley Abbey's Talk it Over Group.

3.4 Informal peer support (including online)

A range of informal perinatal peer support was identified, from facilitated drop-ins to online support groups:

• Café Stork – drop in group for parents and carers
• Dads Rock – dad specific groups with creative, music based activities
• Aberdeenshire PND Peer support – online support group
• Birth Trauma Association – online support group
• Lanarkshire PND Support and Awareness – online support group
• Pandas Online support – online support group
• PND and Me – online support group

As these groups are informal and mainly facilitated by parents with experience of perinatal mental health difficulties, little evaluation evidence is available. However, Café Stork, a drop-in group facilitated by Greater Glasgow and Clyde (GGC) Health Improvement Staff, evaluated their service with a small study using interviews and questionnaires (Nihsen, 2019). This found that parents felt they benefited from attending Café Stork and that peer support occurred across different ages, cultures and socioeconomic positions, with many participants stating that Café Stork improved their mental health. However language barriers proved to be a challenge and attendance from fathers and male caregivers was very low. It is likely that support groups for new parents are attended primarily by mothers, with some father-specific parenting groups developing to address this issue(e.g. Dads Rock).

3.5 Peer support in specialist perinatal mental health services

In Scotland, there is currently no peer support work within specialist perinatal mental health services, as far as this report could identify through desk-based research and consulting with the Lead Nurse and Lead Clinician for the Perinatal Mental Health Network Scotland.

For an example of the integration of peer work into a Mother and Baby Unit service in England, please see the case study below and Annex 3 (developed through interviews with staff and consultation of key documents).This is an innovative approach which could act as a model for promoting peer support in perinatal mental health in Scotland. However it should be noted that the case study is descriptive and not evaluative, or an indication of the quality of the service or organisation.

Service model – Peer support workers in specialist perinatal mental health services

Location: Jasmine Lodge Mother and Baby Unit (MBU), Devon Partnership NHS Trust, Exeter

Provision: Jasmine Lodge Mother and Baby Unit (MBU) is a specialist inpatient perinatal mental health unit for mothers and babies from 32 weeks of pregnancy up to one year after birth. Jasmine Lodge is an example of several MBU services in England who have recently incorporated peer work in perinatal inpatient services. The community perinatal mental health service has been operational for the last 10 years, and since inception has incorporated the experience of mums who have used the service. The focus on the involvement of peer workers is based on the clinical experience of staff, who recognise the benefits of peer work for mothers using the service.

3.6 Peer support for more marginalised groups

Organisations that represent the perspectives of more marginalised groups were asked for their perspectives on the provision of perinatal mental health peer support, and provided some information about the ways they felt peer support could be helpful in their sector.

Black, Asian and Minority Ethnic women

There are very few ethnic minority women's organisations providing perinatal peer support and they are in mainly urban, central Scotland. The Council of Ethnic Minority Voluntary Organisations (CEMVO), told us that ethnic minority women experience general difficulties accessing mainstream services due to a lack of awareness; cultural and language barriers; and non-sensitive or inappropriate services. Terminology is also important due to the stigma of mental health difficulties which can be particularly widespread among ethnic minority communities. They suggested that research was needed to identify the peer support needs of ethnic minority women and the barriers that they experience in seeking support. Existing models of support may not be appropriate as they are based on Western cultural and social models.

Refugee and asylum seeker women

The above issues are relevant in relation to the needs of refugee and asylum seeker women, who can often be isolated from family and experience language and cultural barriers in accessing perinatal support services. Based in Glasgow, Amma Birth Companions offer trauma-informed support to asylum-seeking and refugee women and those with insecure immigration status before, during and after the birth. They also offer post-natal support and group activities that provide opportunities for friendships and integration for the women.

Drug and alcohol problems

Organisations such as Scottish Families Affected by Alcohol and Drugs and Addaction offer advice and support for women and their families affected by drug and alcohol problems, however the research did not identify any specific perinatal peer support services for women affected by alcohol and drug in the perinatal period.

Young parents

In Glasgow, based at Smithycroft Secondary School, the Young Parents Support Base offers a range of activities for school age parents that utilise a peer support approach. They offer antenatal work via Mellow Bumps' to support young parents to meet each other and share experiences. When the baby arrives, group work continues and the Young Parents Support Base offer support to young parents and families up to the age of 19 to give young parents opportunity to learn from their peers. This is designed to support young parents to re-engage with education, become successful learners and confident parents. This was the only example of a peer support approach for young parents identified in the research, however there may be other examples.

Baby loss and miscarriage

There are a range of specialist organisations working in Scotland who support parents experiencing baby loss and miscarriage^[3]. Peer support from parents who have experienced baby loss and miscarriage is central to how many of these organisations work with parents.

Through engaging with stakeholders in this area, several significant issues were identified. Mothers who experience miscarriage or the death of a baby often no longer meet eligibility requirements to be cared for within perinatal mental health services, but are experiencing poor mental health related to their pregnancy. Stakeholders also highlighted the importance of awareness around how baby loss and miscarriage can impact of further pregnancies, heightening the risk of poor mental health for mothers and families.

Fathers and partners

The review found no peer reviewed literature or third sector evaluations on perinatal peer support for fathers or other partners.

Research evidence suggests up to 10% of fathers experience depression during the perinatal period. Paternal depression is associated with lower satisfaction with parenting and poor emotional and behavioural outcomes for children (Cameron et al., 2016). Paternal depression is also closely associated with maternal depression, increasing the risks to children from exposure to two parents with depression (Foley et al., 2001).

To counter the negative outcomes associated with paternal perinatal depression, the provision of peer support could be beneficial for fathers in a similar way to mothers. Consultation with stakeholders who work to support the wellbeing of fathers (Fathers Network Scotland and Dads Rock) suggests that support for fathers in the perinatal period is desirable and would benefit fathers, mothers and infants.