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Mental health: who's supporting mothers?

Services for maternal mental illness are emerging as the UK’s secret shame. How can the situation be improved for new mothers, and what role can community practitioners play, despite the challenges faced? Journalist Phil Harris takes a look.

Mental health support for new mothers - mother and baby

'One evening I asked my mum to babysit my eight-week-old son, went straight to my bedroom and took as many pills as I could, washed down with vodka.

‘It felt blissful to be free of worry and in control for once. For a long time, absolutely nothing had felt positive. I had hit rock bottom. But suddenly I felt calm. 

‘Fortunately it didn’t work.’

For Xanathia Woods, then just 20, having her son Jackson was not the time of overwhelming love and happiness she had expected, and her attempted suicide was the consequence of many months of undiagnosed and untreated perinatal mental illness.

‘I developed anxiety when I was pregnant but didn’t tell anyone, and no one really asked,’ Xanathia recalls. ‘Then I had a traumatic birth, and felt like I couldn’t hold my son. I didn’t bond with him. I told everyone I was fine, and I did what I was supposed to do, but it felt robotic.

‘There was a constant battleground in my head. I told myself I was useless and that my son would be better off without me, and that I should die.’

Sadly, Xanathia’s story is not unique, and perinatal mental health is an area where the numbers paint a revealing – and troubling – picture. 

 

Heart of the matter 

One in five women will develop a mental illness during pregnancy or in the 12 months following birth. This equates to around 160,000 women across the UK each year (National Records of Scotland, 2017; Northern Ireland Statistics and Research Agency, 2017; Office for National Statistics, 2017). 

Some mental health problems are particularly common or linked to pregnancy and childbirth. This includes depression, anxiety, obsessive compulsive disorder, postpartum psychosis and postpartum post-traumatic stress disorder (PTSD). Depression is the most common maternal mental illness. Some women also develop eating disorders (Mind, 2017). 

And the consequences can be grave. In December 2016, the third confidential enquiry into maternal deaths found maternal suicides to be the top cause of deaths occurring in pregnancy or up to a year after birth, with figures showing 111 women had taken their own lives between 2009 and 2014 (MBRRACE, 2016).

Despite all this, half of all cases of perinatal depression and anxiety go undetected, a report by the London School of Economics (LSE) and the Centre for Mental Health found (Bauer et al, 2014). Many of those that are detected fail to receive evidence-based forms of treatment. The report also said that specialist perinatal mental health services are needed for women with complex or severe conditions.

In fact, across almost half the UK, pregnant women and new mothers have no access to specialist mental health services, and less than 15% of localities provide specialist services at the full level recommended in national guidance (RCOG, 2016). 

‘Sadly, health services are falling short when it comes to perinatal mental health, and it remains an unmet need,’ says Unite in health lead professional officer Gavin Fergie.

 

Counting the cost

As well as the human impact, perinatal mental health problems are costing the UK around £8.1bn each year – equivalent to £10,000 per birth – according to figures from the LSE report (Bauer et al, 2014). Nearly three-quarters (72%) of this cost relates to adverse impacts on the child rather than the mother.

The LSE report called on the government to spend an extra £337m a year to bring perinatal mental health care in the NHS up to the recommended levels.

Meanwhile, in 2016, Health Education England issued guidance for healthcare commissioners that called for the creation of new specialist health visitor posts in perinatal care, as part of efforts to end the ‘postcode lottery of care’. 

There at least appear to be signs the problem is being recognised. Last year, the prime minister pledged a £290m investment in the years to 2020, with the aim of helping at least 30,000 more women each year to have access to specialist mental health services (HM Government, 2016).

And in November 2016, NHS England chief executive Simon Stevens said that £40m is to be allocated to 20 areas of the country to fund new specialist community perinatal mental health services. Last month he announced four new dedicated mother and baby units for England, set to open in 2018 (NHS England, 2016).

 

What’s going on?

The current reality is that many women simply do not get help when they need it, for many reasons, according to Gavin. 

‘Of course all health services are under huge stress and financial pressures,’ he says. ‘Midwives and health visitors are stretched to the limit, and a five-minute GP appointment is unlikely to give enough time for a proper consultation.’

In fact, CPHVA research from 2015 found that 41% of health visitors thought their service did not adequately respond to postnatal depression. And now there are even fewer health visitors in the workforce (Unite-CPHVA, 2016).

Training to prepare professionals – or rather the lack of it – is another significant factor. 

A 2017 survey by PANDAS and the CPHVA produced some stark truths on training and the consequences for practice. Nearly three-quarters of the health visitors and midwives who responded, both qualified and in training, reported they did not feel their current level of training on perinatal mental illnesses was sufficient (PANDAS, 2017a).

And in June this year a National Childbirth Trust (NCT) survey showed that nearly half (42%) of new mothers’ mental health problems did not get picked up by a health professional, with over a fifth (22%) of women saying they were not asked about their emotional wellbeing (NCT, 2017).

Gavin says: ‘The double whammy of austerity and lack of equity for mental health has really hit the service professionals can provide. In turn this impairs educational and training opportunities for community practitioners to enhance their skills.’

 

 

Stigma strikes again

The reasons new mothers aren’t getting the help when it’s needed also go beyond lack of funds, resources and training. 

‘There is still lots of societal pressure about mental health, and it remains a strong reason why women might not want to seek help,’ highlights Gavin. 

‘Society has also become more fragmented,’ he continues. ‘When there was less mobility, mothers probably had close family members to talk to and share their burdens. Now, work or financial pressures move people from these traditional ties.’

Stigma is a particularly acute problem for new mothers, according to Donna Collins, managing director of PANDAS.

Donna believes this means problems are significantly under-reported, with many women simply going without help or treatment, and desperately trying to cope with the illness alone and in secret.

She says: ‘The incidence of reporting of perinatal illness doesn’t even scratch the surface or the reality of the situation. Although much work has gone into breaking the stigma, unfortunately there is still an element of this, which is a barrier to people reaching out for help. 

‘There is also a common misconception that by speaking out, people will judge your ability to parent, and therefore they may wish to take the child/children away from the family unit – and that simply is not the case.’ 

It’s a view Xanathia recognises, however. ‘For a long time I didn’t want anyone to know I was struggling because I was very concerned about social services getting involved.’ 

Donna is reassuring: ‘Social services and all the other elements that are supporting families do not want to break families up. They exist to find ways to keep the family together, and to support all of the individuals within that family.’

 

Hands tied

So how can community practitioners improve the situation for new mothers? Lack of resources means there is no easy answer, according to Su Lowe, a health visitor and West Midlands health-visiting representative for Unite-CPHVA.

‘Health visiting thrives on early intervention and screening’ says Su. ‘Building relationships enables practitioners with high-level specialist knowledge to spot signs of deteriorating mental health or circumstances at the earliest opportunity. 

‘By nurturing and supporting mothers we are adept at ensuring that they have an awareness of their mental wellbeing and they know when and who to go to for support. But there are less of us now, and so services are struggling.’ 

Su also believes that health-visiting service cutbacks to the minimum five mandated contacts have erased quality contact, relationships and support. ‘There is so much more to a universal perinatal mental health assessment than a list of questions from a stranger at a half-hour contact,’ she says.

Likewise, after their survey in June, the NCT called for more funding for GP checks so that new mothers get a GP appointment to address their health, not just the baby’s.

‘While not all mothers seek help, if they do, services need to be available, appropriate and accessible,’ says Su. ‘This is not always the case when our mental health teams are triaging and booking therapeutic interventions weeks later as they struggle to fund their services. Mothers are feeling let down.’

Su points out that many services have also lost the postnatal groups and breastfeeding support in communities, where often signs and symptoms could be spotted or even prevented by local peer support. 

‘People learn from each other and in a supported environment, a disclosure to friends by a mum that she may have survived postnatal depression and no one removed her baby or questioned her parenting ability can go a long way to removing stigma.’


Spotting red flags

There are some ‘red flag’ signs for severe mental illnesses. If you encounter any of
the following then urgent psychiatric assessment should be arranged: 

  • Recent significant change in mental state or emergence of new symptoms
  • New thoughts or acts of violent self-harm
  • New and persistent expressions of incompetency as a mother or estrangement from the infant.

(Source: MBRRACE-UK, 2016) 


Positive steps

Su thinks there are steps practitioners can take, such as learning about and using as many local resources as possible. 

Michelle Ostrowski, a health visitor working in Shropshire, agrees. While Michelle has been ‘quite fortunate in that our area has invested heavily with supporting mothers with PND and giving us training’, she offers the following advice. 

‘Seek out any study days you are able to attend, even if that means self-funding (within reason), as this will give you skills and more confidence supporting mothers’ mental health.

‘You can join Twitter to find a wealth of professionals and support groups at your fingertips. You can also find out what support groups are available locally for mothers and how to access them.

‘It’s also important to seek supervision for yourself. If you are doing listening visits without good headspace, how much support are you able to give?’ 

Su also advises challenging trusts and commissioners to change practice to ensure health needs are met.

Su says: ‘We have evidenced that a comprehensive quality health-visiting service supports women and prevents mental ill health from affecting mother and child adversely. With the right intervention at the right time by the right service we are in a unique position to observe parent-child interactions and intervene and support appropriately.

‘Perinatal mental health affects the next generation, not just the mother suffering here and now. By reducing services we are risking the mental health and wellbeing of our grandchildren.’

 

Making a difference

After her suicide attempt, Xanathia decided she needed to seek help. This came in the shape of Cheryl Hale from East Coast Community Healthcare’s family nurse partnership (ecch.org).

Xanathia says: ‘Cheryl was lovely and warm right from the start, and keen to help however she could, but I put up a front. Thankfully Cheryl persisted and eventually the walls broke down.

‘She was quick to pick up on what was going on and never stopped contacting me. She took me to the doctor and helped me to express how I was feeling, and made me challenge the way I had been thinking.

‘Cheryl also organised so much. She helped to arrange cognitive behavioural therapy and got a mental health youth worker to help me. She also helped sort funding for Jackson to go to nursery to give me time and space to recover.’

Xanathia was diagnosed with postnatal depression, anxiety and PTSD, and started on the road to recovery. She has since gone on to have a daughter, and although she was worried about developing depression again, she feels she had the tools to cope and knew the warning signs to look out for.

She came off medication almost two years ago and is enjoying life with her young family. She is fully aware of the value of the professional support she received. 

‘Cheryl saved my life, without a doubt. She helped me through it and taught me how to see things in a different light, to talk about how I feel and that it was ok. She was the positive among all the negative.’

And that kind of impact on mothers’ lives shows just what is possible.


References

Bauer A, Parsonage M, Knapp M, Iemmi V, Adelaja B. (2014) Costs of perinatal mental health problems. London School of Economics and Political Science: London. See: eprints.lse.ac.uk/59885 (accessed 12 September 2017).

Health Education England. (2016) Specialist health visitors in perinatal and infant mental health: what they do and why they matter. Health Education England: London.

HM Government. (2016) Prime minister pledges a revolution in mental health treatment. See: gov.uk/government/news/prime-minister-pledges-a-revolution-in-mental-health-treatment (accessed 12 September 2017).

Mind. (2017) About maternal mental health. See: mind.org.uk (accessed 12 September 2017).

Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK)/National Perinatal Epidemiology Unit. (2016) Saving lives, improving mothers’ care: surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14. See: npeu.ox.ac.uk/mbrrace-uk/reports (accessed 12 September 2017).

National Childbirth Trust. (2017) The hidden half: bringing postnatal mental illness out of hiding. See: nct.org.uk/sites/default/files/related_documents/739-NCT-theHiddenHalf-report-150dpi_0.pdf (accessed 12 September 2017).

National Records of Scotland. (2017) Vital events – births. See: nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/births (accessed 12 September 2017).

NHS England. (2016) NHS England sets out steps to improve mental health care for pregnant women and new mums and help those attending A&E in crisis. See: england.nhs.uk/2016/11/improving-mh (accessed 12 September 2017).

Northern Ireland Statistics and Research Agency. (2017) Births. See: nisra.gov.uk/statistics/births-deaths-and-marriages/births (accessed 12 September 2017).

Office for National Statistics. (2017) Births in England and Wales 2016. See: ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths (accessed 12 September 2017).

PANDAS. (2017a) Survey results. See: pandasfoundation.org.uk (accessed 24 September 2017).

PANDAS. (2017b) Prenatal (antenatal) depression. See: pandasfoundation.org.uk/preantenatal-depression (accessed 12 September 2017).

Royal College of Midwives. (2017) More needs to be done for women’s mental health in pregnancy says RCM on new survey. See: rcm.org.uk/news-views-and-analysis/news/more-action-needed-for-mental-health-in-pregnancy%E2%80%99 (accessed 12 September 2017).

Royal College of Obstetricians and Gynaecologists. (2016) Breaking down the barriers in maternal mental health. See: rcog.org.uk/globalassets/documents/news/membership-news/og-magazine/june-2016/feature.pdf (accessed 12 September 2017).

Unite-CPHVA. (2016) Health visiting in England: May 2016. See: unitetheunion.org/uploaded/documents/Health%20visiting%20in%20England%20May%20201611-26805.pdf (accessed 12 September 2017).


Maternal mental health services Across the UK

According to Gavin Fergie, Unite in health lead professional officer, the situation and prospects in Scotland are slightly better for maternal mental health care than in many parts of England and Northern Ireland, as both of these administrations have been more affected by cuts and austerity than the rest of the UK.

He says: ‘It could be argued that as Wales and Scotland move towards their increased contact points with mothers that they can develop their knowledge of and relationship with the mothers on their caseload. 

‘With increased contact, hopefully a therapeutic relationship can develop where the mother feels more at ease to raise their feelings with a trusted professional rather than with someone who visits once.’

However, the provision of specialist services is very limited in some areas. Wales and Northern Ireland do not have any specialist mother and baby units, meaning that mothers have to travel long distances for treatment where they can stay with their child.


Resources

There are lots of online resources on maternal mental health, both for health professionals and to offer to women, including:

  • Health Education England: Produced a perinatal mental health care skills competency framework to support professionals bit.ly/HHE_professional
  • The Maternal Mental Health Network: A network for health professionals, with resources and a secure discussion forum maternalmentalhealth.org.uk
  • Mind: Details on perinatal mental health issues, including treatment, support and advice
  • bit.ly/Mind_perimental_health
  • PANDAS: Information and support for women with perinatal mental health problems, including peer support groups pandasfoundation.org.uk
  • PND & Me: Online network for women with postnatal depression pndandme.co.uk 
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