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Perinatal mental health: creating new horizons

11 May 2017

As public health services remain under threat, the case for a joined-up approach has never been stronger. Jenny Thompson describes a collaborative project in Somerset that’s improving perinatal mental health outcomes.

Joint working between health visiting and talking therapy services at Somerset Partnership NHS Foundation Trust has been delivering positive results at perinatal mental health groups for mothers, fathers and their babies. 

The aims of the joint working are for health visitors to learn assertiveness and therapeutic intervention skills from their talking therapy psychological wellbeing practitioner (PWP) colleagues, and for PWPs to learn about parenting and child development from the health visitors. 

For the parents attending the Horizon perinatal mental health groups, the goals are to understand perinatal mental health, build strategies to deal with their illness, develop peer support, learn about healthy lifestyles and promote their child’s emotional wellbeing. An expected outcome is that mothers’ mood levels will improve, evidenced by scores on the Patient Health Questionnaire 9 (PHQ9) and generalised anxiety disorder (GAD) screening tools. 

The Horizon groups consist of seven three-hour weekly sessions, run by a health visitor and a PWP. Each session has a theme, such as assertiveness or learning to live with perinatal mental health issues. The groups are offered to a mother during the antenatal period until her baby is a year old. They run as a rolling programme, so mothers can attend sessions when they’re able.

Mothers can bring babies under six months to support breastfeeding and promote understanding of attachment and baby cues. Fathers are invited to the seventh session to discuss their roles and health needs. A follow-up session is held for each group of mothers so they can maintain their peer support. Following each session, the health visitor and PWP debrief and supervise each other. Health visitors and PWPs developed the session contents in consultation with mothers, and a toolkit containing all the related material is available to staff working with mothers. 

Background

In 2015 the updated perinatal mental health pathway directed health visitors to refer mothers with mild to moderate perinatal mental illness to their GPs and talking therapy services. But health visitors seemed reluctant to make referrals to talking therapies – they reported that some mothers didn’t want consultations over the phone. So the task was to identify how to improve joint working between health visiting and talking therapies to ensure mothers were receiving the best from the perinatal interventions offered by both services.

In Somerset, health visitors had been running a group called ‘Mums’ time’ for mothers with perinatal mental health problems. This had some good outcomes, including mothers developing peer support and fathers having a better understanding of perinatal mental health. 

But it also highlighted that health visitors would benefit from better knowledge and skills by working therapeutically with mothers. Health visitors reported they felt out of their depth on perinatal mental health and that they would benefit from supervision by mental health colleagues. They also said that when they liaised with mental health services, particularly on children’s safety and wellbeing, they found their mental health colleagues had little understanding about the health visitor role, children’s development and the impact a mother’s illness could have on her children. 

Out of this came the idea to run the joint perinatal mental health groups. These groups would build on the successful outcomes of the ‘Mums’ time’ programme, while attempting to improve joint working between services.

Implementation 

So the roll-out of Horizon groups began, run jointly by a health visitor and a PWP. Four planning sessions took place, including a shared training session with the health visitors and PWPs who would be running the groups, initially in two areas of Somerset. 

Just four mothers were invited to those first groups, allowing the health visitors and PWPs to familiarise themselves with the programme and to identify what worked and what needed changing. The lack of crèche funding led to the practical decision to let babies attend, though mothers were encouraged to find childcare for babies over six months. The first groups also experimented with rolling sessions, welcoming new mothers into established groups, and a session for fathers. 

The trials were a success and Horizon sessions are now established in four areas. 

A monthly steering group receives feedback from each area and evaluates outcomes and feedback in order to adapt the programme. PHQ9 and GAD scores are collated to evaluate service delivery.  

Outcomes 

All the objectives of the joint working and running of Horizon groups have been achieved with excellent results. 
These include:

  • Health visitors and PWPs understand each other’s roles, refer mothers between services, and benefit from supervision
  • Health visitors have learned assertiveness skills from PWPs, and PWPs learned about parenting and child development from health visitors
  • Mothers’ self-esteem and self-worth has improved, making them feel safe and supported. They developed self-care strategies to manage their condition
  • PHQ9 and GAD scores reduced after two to three sessions
  • Mothers and fathers understood what perinatal mental health is
  • Fathers learned about their role in the family (anxious mothers had inadvertently restricted the fathers’ input into child care and parenting)
  • Mothers and fathers increased their support systems within the community
  • Mothers understood baby cues, got to know their babies and began to enjoy parenting.

The initiative has also challenged past concerns about running groups – for example, mothers could join at any stage rather than be forced to attend every session to stay with a group, which worked well for mothers who at times felt low in mood and energy. Welcoming new mothers and returning mothers at the start of sessions allowed them to feel accepted. One said: ‘If I’m having a bad week I know I can come back another week and that’s okay.’

Health visitors and PWPs initially found it harder to run sessions with babies. But as one PWP acknowledged: ‘Mothers multitask all the time. It was me who found the babies more distracting, so I learned to deal with it.’ And the babies’ presence allowed the health visitor and PWP to discuss bonding and attachment, and to demonstrate simple interaction in play, while mothers could maintain breastfeeding.

Another positive outcome is that mothers with anxiety reported feeling calmer after attending the group. One said she was relieved to hear other mothers express feelings that she had felt ashamed of, such as resenting her baby for making her feel so anxious. Other mothers said they had laughed for the first time and had fun.

Learning points

Mothers who attended the original Horizon group formed a trusting relationship with the health visitor, but a few then stopped interacting with their mental health worker. In some cases the mother contacted the health visitor when feeling suicidal, potentially leaving herself at risk and causing stress to the health visitor. 

This was a key reason for starting the joint working. The talking therapy staff upskilled the health visitors to feel more confident in talking to mothers about suicide, while the Horizon sessions included time to discuss self-care and how mothers should ask for the right help and work with their mental health worker.

In addition, when mothers discuss thoughts of harming their children, the health visitor and PWP have to assess the situation and consider increased mental health support and/or the safety of the child. 

They also discuss confidentiality and their safeguarding responsibility at the start of each session. Health visitors inform safeguarding nurses when they rerun groups and ask for extra supervision. 

Overall, this has been an extremely successful joint service way of working, which has been shown to achieve fantastic outcomes for women and their families.


  • Jenny Thompson is manager of public health nursing teams and lead on perinatal and infant mental health, Somerset Partnership NHS Foundation Trust.
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