Peer support in perinatal mental health: evidence review

5. Conclusions and recommendations

Peer support is a flexible and accessible form of support for women experiencing mental health challenges in the perinatal period. Evidence from the UK and from international studies suggests that peer support can be an effective way to improve the mental health and wellbeing of women during the perinatal period. The main conclusions and linked recommendations are listed below under five main headings.

5.1 Identify and support existing good practice

Conclusions:

A wide range of perinatal peer support services exist in Scotland, however, the vast majority are voluntary and group based. Geographical coverage is limited outside the central belt of Scotland. Continuity of provision is inconsistent, with some valued and well-attended groups forced to close due to lack of funding or accommodation.

Perinatal mental health networks such as the Greater Glasgow and Clyde Perinatal Mental Health Network (PMHN) can aid shared knowledge of local services, helping NHS staff to direct people to appropriate third sector services based on clinical need. Networks also provide a forum for creating and sharing standardised 'peer principles' and a hub for expertise and continuing professional development.

Recommendations:

• Where there are examples of good practice, with evidence of appropriate training and support for peer volunteers, these should be championed, supported and built upon.
• A range of peer support models should be available, with improved access to services across geographical areas throughout Scotland.
• Regional perinatal mental health networks with statutory and third sector services should be facilitated to share best practice and aid appropriate referrals.

5.2 Ensure safety and quality

Conclusions:

For peer support services to be effective and safe for clients and peer supporters, robust and comprehensive training and regular supervision is essential. From recruitment, through training, supervision and supporting ongoing practice, processes should be tailored to the needs of peer supporters. This creates a safe working environment for peer supporters and ensures safety for clients, adequate care and due diligence.

Peer support work can be extremely rewarding for volunteers with peer experience. To be nurturing rather than draining for peer supporters, peers should be well prepared for their role and not be expected to achieve unrealistic outcomes. Peers should be supported and supervised, as they may experience guilt or worry associated with being unable to help or support clients, or anxiety when unsure of how to manage a situation.

Specialised resources are available to support organisations who introduce peer support. Resources already exist to support all stages of peer support, from recruitment to ongoing training. These are included in the existing resources
section of this report (section 4.4).

Recommendations:

• Specialised approaches to recruitment, robust and ongoing training, appropriate and timely clinical supervision and support for ongoing good practice are essential elements in ensuring quality and safety.

• Peer supporters need robust support systems and additional flexibility in their roles to enable them to maintain their own recovery and wellbeing.
• Existing evidence based and quality assured resources should be utilised when creating peer support services to ensure high quality practice from the start.
• All peer support services should have their own policy around safe-guarding peer support workers, volunteers and service users.

5.3 Prioritise accessibility and inclusivity

Conclusions:

The design and delivery of peer support services should respond to the needs of particular communities. Socioeconomic background, family situation, geographical location, culture, religion, ethnic background, disability, health problems and other factors will influence a person's ability to access services. Peer support services are effective at reducing isolation for those groups at risk of being isolated, for example, asylum seekers and refugees. These isolated groups may benefit greatly from peer support but need a tailored approach or targeted support to ensure support is accessible.

Different models of peer support will be more accessible to some groups than others.

It can be challenging to engage women living in deprived communities or marginalised groups who can be the most in need of support. Recent evidence suggests that one-to-one support in the home is more likely to consistently engage women from the most deprived backgrounds (Hann and Macleish, 2019). Women from more middle class backgrounds seem to more consistently attend support groups, meaning that a range of delivery modes is essential to ensure access to support across socio-economic demographics. For certain groups, for example those living in deprived areas, sustaining engagement is difficult, so facilitating access and engagement may help. This could mean offering support for travel, text or email reminders and more frequent individualised contact to encourage continued engagement. This is also true for groups who may be hard to engage due to rural isolation.

Peer support is not restricted to one-to-one support or formal groups. Organised social activities, for example, baby massage, walks or cooking lessons can provide women with a safe space to discuss problems at an individual pace. One model will not be the most effective at supporting all women, and so a variety of support models is required.

Stigma, both self-stigma and feeling stigmatised by others, is a significant barrier to seeking support for women experiencing poor perinatal mental health. Flexibility in provision enables peer support to tackle stigma surrounding perinatal mental health difficulties using a range of approaches. One-to-one support at home can be effective at supporting women who experience self-stigma and do not feel comfortable attending support groups. Women who feel comfortable attending groups can benefit from the acceptance of others in the group who share their experiences, reducing the external stigma by normalising the experience of perinatal mental health problems. Peer support also challenges stigma through the example of peer supporters, who model recovery and living well with the challenges of perinatal mental health problems.

Social support is a key protective factor against perinatal mental ill health and in recovery from poor perinatal mental health. Increased social contact is an important step in recovery for many women experiencing perinatal mental health difficulties. In many cases this will need to be outside current social networks for women to feel comfortable sharing their experiences.

Recommendations:

• Peer support should be available in a variety of formats, for example, one-to-one, in-person, telephone and group support. This will ensure that the support meets the needs of a wide range of mothers/carers.

• Targeted peer support services should be designed to meet the particular needs of groups who are currently underserved by services, for example: Mothers/carers living in poverty, ethnic minority groups, geographically isolated communities, families affected by domestic abuse or substance abuse, parents who experience the loss of a baby, in addition to considering the impact of religious and cultural beliefs, disability, health problems and any other pertinent factors.
• Specific peer support for men should be widely supported and become more widely available. This will help to ensure this underserved group have a range of peer support services in place to support them

5.4 Respect the unique value of peer work

Conclusions:

The recently developed Principles of Perinatal Peer Support (Maternal Mental Health Alliance et al., 2019) advocate that the unique contribution of peer support is maintained as distinct from other therapeutic or clinical roles. Research evidence also suggests that peer support is most effective when peers use their uniquely valuable experience in a way which does not try to replicate the role of clinical staff by offering advice, training or therapeutic treatment.

Peer support is most effective when clear role boundaries are put in place for peers and those people they support. Clearly defined role boundaries allow the peer supporter to feel secure in what is expected of them and enable other staff and clients to know what to expect, reducing uncertainty. For example, the case study example in Annex 3 addresses the role of peer workers in an MBU setting, identifying that clear job roles in an NHS setting help other staff recognise the distinct role of a peer support worker and their value as a member of the staff team.

Sole working peer supporters can feel isolated, so job sharing or being part of a network for peer supporters could benefit morale, staff or volunteer retention and job satisfaction. Peer workers may need to access additional flexibility in work schedules to allow them to maintain their own wellbeing and recovery.

Recommendations:

• Peer support services should recognise and celebrate the benefits of peer experience and peer workers or peer volunteers should not replace clinical staff or be asked to do their work.
• Peer support worker and volunteer roles should provide clear boundaries of the role for peers, the people they support and the wider team.

5.5 Integrate robust evaluation

Conclusions:

International evidence from large scale studies suggests that perinatal peer support can reduce symptoms recorded by the Edinburgh Postnatal Depression Scale. This is the most commonly used measure of postnatal mental health problems

Research evidence on the efficacy of perinatal peer support in Scotland is extremely scarce. This is partly because peer support is a relatively new approach and not yet embedded in statutory services, offering limited opportunity for research studies. In addition, third sector organisations who organise peer support have limited resources for research and evaluation as they direct their resource primarily toward service provision.

Recommendations:

• Evaluation should be built into peer support services to ensure they are meeting needs of clients and peer supporters and providing safe, appropriate and effective services.
• To build the evidence base for peer support, new services should measure their effectiveness using validated measures, to reinforce a commitment to a robust evaluation.