Perimental services failing pregnant women

There are few specific mental health services for pregnant women and new mothers. But the need is there, finds Andrew Mickel

Given the range of professionals who come into contact with women during and after pregnancy, it is incredible to think that their mental health needs are being overlooked. But according to research from Coventry University, many professionals think that is exactly what’s happening for the estimated one in six women who suffer mental ill health either during or after pregnancy.

There are some dedicated perinatal services around the country, but in many places, the work is left to generic services. Maureen Brown, the associate head of midwifery at Coventry University who worked on the research, says they can’t be expected to meet the complex and specific needs of new and expectant mothers.

“The [mental health disturbance] may be new or it may be exacerbated,” she says. “Anything could cause you to be disturbed – it could be about your body image being altered by your pregnancy. For some women it could be about having a being inside them which is alien to them which they have no control over. You need a specialist team who understands those mental health issues.”

Building effective support

Building up effective support is complex. Frontline professionals need to know how to identify those women who need extra support, and what services there are to refer them on to. Perinatal mental health specialists need to be in place to provide the services they need in the community. (While the term ‘perinatal’ conventionally refers to the period around the time of birth, mental health teams may help a mother for up to a year after birth.) And for the most serious cases, access to mother and baby units allows a mother to stay with her child with both psychiatric and nursery support on hand.

A national survey in 2005 by the Royal Society of Psychiatrists found that only a third of surveyed trusts had dedicated perinatal multi-disciplinary teams. The university’s research showed a similar mixed picture – while there was a dedicated perinatal mental health team in Coventry, in the rest of Warwickshire (the county that Coventry falls under) women would be referred back to GPs or to mother and baby units, according to Brown.

Theresa Xuereb, the consultant psychiatrist who leads Coventry’s team, which consists of her in a part-time role and two community psychiatric nurses, says: “We’ve limited resources so we can only help those with severe needs, not normally those with mild ones.”

Xuereb adds that there are difficulties in referring to mother and baby units, and that it is “almost impossible” to refer to nearby Birmingham, albeit with other options in the Midlands. Although there are now 19 mother and baby units in the UK, they are not evenly distributed – there are none, for example, in Northern Ireland.

Additionally these services are often over-subscribed and can be difficult to refer in to. Peter Thompson, programme manager for the Royal College of Psychiatrists’ quality network for perinatal mental health services, says that some units need to be better publicised: “You hear stories of how frontline practitioners haven’t heard of them and mothers have been put in inappropriate places. Nice [National Institute for Clinical Excellence] guidelines don’t say much about inpatient services. Many people would argue that there aren’t a lot of beds nationally, and that they aren’t very well spread.”

Coherent structure

With national guidance on service provision thin on the ground, it takes a local focus to get effective support networks up and running. Northumberland, Tyne and Wear NHS Trust has a six-bed mother and baby unit to serve North East England and Cumbria, and a local perinatal mental health team with a dedicated psychiatrist and six community psychiatric nurses. Angela Walsh, the psychiatrist there, is now trialling the expansion of the team into Northumberland, which used to be part of a separate trust.

Pulling together the different services into a coherent structure has helped mothers but it has taken effort to make the connections, she says. “Management agreed to join it up. Before, I was working in just the mother and baby unit and the community team had to work without a dedicated psychiatrist.

“And there were no specialised nurses there [in Northumberland] – they used to refer directly to community mental health teams instead. There used to be an outpatient clinic there once a week, but it couldn’t access specialist teams.”

Walsh says she now aspires to set up a full clinical network, to have mental health and maternity teams working tightly alongside each other. That is something that has happened in just a handful of locations in the country so far, despite joint working being flagged in a 2004 children, young people and maternity services National Service Framework as necessary to improve provision.

“Now, we do work very closely with maternity services,” she says. “We take pregnant women so we have to work very closely – community teams, health visitors and midwives can refer directly into us.”

Knowledge gap

The knowledge of those frontline practitioners is another area which needs more work, according to Coventry University’s research. This is one area where there is specific national guidance. Nice specifies three questions which staff should ask pregnant women to assess their mental health status: Have you felt down, depressed or hopeless during the last month? Have you been bothered by having little interest or pleasure in doing things? Is this something you feel you need or want help with?

Gail Johnson, the education and professional development advisor for the Royal College of Midwives, says: “It’s hard to monitor everyone but there’s an expectation to do it. It’s a start and we’ve got to be asking those questions – if we’re doing that, then it also shows the problem is common and women don’t think there’s now stigma.”

But Brown says this isn’t the picture on the ground in Coventry and Warwickshire because midwives know there isn’t necessarily somewhere to refer them on to, so don’t ask the questions.

“Health visitors, on the other hand, do [ask the questions] and use a questionnaire to measure the response to find out if a woman is postnatally depressed.”

While the keen attention of health visitors is welcome, all frontline practitioners need to understand these disorders because making the right connections between maternity and mental health services is vital if women are to receive appropriate perinatal support.

HOME START HELPS FILL THE GAP

With many specialist services over-subscribed, some third sector organisations have sprung up to help those with lower levels of need.

Beth Jenkins gave birth to Alexander in 2006 and says: “I realised I had post-natal depression when I burst into tears for no reason whatsoever,” she says. “Part of me told myself I was just being daft but it was the emotional part of me that just took over.”

Her GP put her on anti depressants after confirming that she did have post-natal depression and her health visitor put her in touch with Home Start, a network of volunteers who support parents who are struggling to cope for various reasons, including post-natal illness.

After talking to a community mental health nurse Jenkins decided she only needed day-to-day help rather than intensive services. Her assigned volunteer, Dorothy, helped with minor tasks like putting out the washing or guidance on where to go swimming.

“The most important thing is for someone to be there and talk to you. Dorothy didn’t only care about Alexander, but about me too and she checked how I was doing,” she says. “It gives you your self-confidence back and reinforces that you can do well.”

• More about Home Start
• Royal College of Psychiatrists survey

This article is published in the 7 May 2009 edition of Community Care under the headline “Pregnanat pause”