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Let's end the postcode lottery

05 July 2019

New research calls for five key actions to help community practitioners support women and families living with perinatal mental illness in Northern Ireland. Caroline Cunningham and Susan Galloway discuss.

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Northern Ireland is widely accepted as having the poorest provision of specialist services for perinatal mental health in the UK (Maternal Mental Health Alliance (MMHA), 2017; Regulation and Quality Improvement Authority, 2017). Within primary care, identifying and responding to women and their families experiencing perinatal mental illness is an important element of the roles of health visitors and their midwife counterparts. Perinatal mental illnesses are common during pregnancy and the postpartum year, with at least 10% to 20% of women developing mental ill health during this time (Public Health Agency (PHA) (Northern Ireland), 2017). Recognition of the challenges that identification brings for both health visitors and midwives is imperative.

In partnership with Unite-CPHVA and the RCM, the NSPCC undertook survey research in Northern Ireland to explore the views and experiences of health visitors and midwives who care for women during this critical period (Cunningham et al, 2018).

Early identification and support

Perinatal mental illness is often described as a major public health issue (Hogg, 2013). The long-term cost is estimated to be approximately £8.1bn for each one-year cohort of births in the UK. The majority of this cost (72%) relates to the adverse impacts of these illnesses on children (Bauer et al, 2014). Nevertheless, it is important to emphasise that negative impacts on children or parenting are not inevitable (Stein et al, 2014).

There is strong evidence that the risks to children are highest in the most socioeconomically disadvantaged populations experiencing multiple adversities, with high levels of parental education and resources operating as a mediating factor (Pearson et al, 2013; Ban et al, 2012; Lovejoy et al, 2000).

Early identification and provision of appropriate and timely expert care can minimise the harm to women, children and their families and, in some cases, prevent it from occurring in the first place. Historically, a low level of identification by universal services has been one of the greatest barriers to families receiving help (Khan, 2015; Hearn et al, 1998).

An overstretched health service means a heavy burden of work pressures on practitioners, mitigating against the time and continuity of care needed to develop trusting relationships (Health Education England, 2016). Screening tools can offer an important aid to identification. However, experts caution against an overreliance on screening, and urge appropriate training for primary care professionals so that tools are used as part of a wider psychosocial or clinical assessment and that, where identified, support and treatment are made available (Milgrom and Gemmill, 2014; Austin et al, 2008; Oates, 2003; Leverton and Elliott, 2000).

Primary care professionals must be enabled to develop professional skills, judgement and confidence in spotting signs of mental health adversity. They need to detect issues in the mother-infant interaction where they exist, and help mothers become more attuned and responsive to their babies’ needs (Hogg, 2013).

Where support for perinatal mental illness can be given within primary care, timely and appropriate care must be made available. When specialist support is required, primary care professionals must have effective care pathways in place and appropriate services to refer to. For women in Northern Ireland, specialist provision continues to operate as a postcode lottery (MMHA, 2017). Just one of five health and social care trusts provides a specialist service, which is small-scale in nature. In addition, there is no mother and baby unit. 

Study aim and method

The NSPCC research aimed to explore the views and experiences of health visitors and midwives in Northern Ireland by identifying and responding to perinatal mental illnesses. An online survey was completed by a total of 332 respondents, including 130 health visitors and 202 midwives. A cautious estimate based on 2016 workforce headcount data put the final survey sample at approximately 23% of the health visitor population and 15% of the midwife population in Northern Ireland (rounded to the nearest percentage) (Department of Health and Northern Ireland Statistics and Research Agency, 2016). All survey results reported below are statistically significant, unless otherwise stated (Cunningham et al, 2018).


Key findings


Training

Training in perinatal and infant mental health is vital for understanding the importance of early detection. It is also key to the development of skill-sets to strengthen how practitioners work with women to build trusting relationships, identify mental illness and to give an appropriate response.

A large majority of professionals said they had received training in perinatal mental illness at some point (80%, n=265). One in five respondents (n=64) had never received training. Very few caseload-holding health visitors were untrained (5%, n=5). Health visitors also reported higher mean levels of satisfaction with training than midwives. Of those who have received training, the majority (71%, n=189) said it covered the potential impact on the child. This was significantly higher for health visitors and health visiting managers (90%) than for midwives. Of those respondents who answered an additional question on whether they had received training on infant mental health, half answered in the affirmative. This included more than three-quarters of health visitors and health visiting managers.

Confidence

The self-reported confidence of health visitors and midwives was explored in relation to the following areas: their ability to recognise a woman with perinatal mental illness; making a referral; the management of women with a mental illness within their service; and their confidence as to whether women receive the treatment they need.

Health visitors reported higher mean levels of confidence than midwives in all areas. More than 40% of health visitors reported being ‘very confident’ in their ability to recognise mental illness, compared with 22% of community midwives and 9% of hospital midwives. A total of 58% of health visitors described themselves as ‘somewhat confident’ in this regard. There was no difference in practitioners’ levels of confidence in recognition based on whether they had received training. However, there was a difference between practitioners with different lengths of service, with longer serving professionals reporting higher confidence in recognition.

The Northern Ireland care pathway for perinatal mental health requires health visitors and midwives to refer women to their general practitioner, who makes onward referrals to services (PHA, 2017). In total, 84% (n=92) of health visitors and 68% of community midwives (n=25) said they were very confident about referring a woman to their GP, compared to 31% of hospital midwives (n=43).

In terms of management and treatment of perinatal mental illness, only half of all respondents were ‘very’ or ‘somewhat confident’ that women’s illnesses would be managed appropriately in their own service (n=166), and less than half (48%, n=158) were confident women would receive the treatment they need. Health visitors expressed greater confidence than midwives. A total of 68% of health visitors were ‘very’ or ‘somewhat confident’ in the management of perinatal mental illness within their own service, compared to 35% of hospital midwives and 48% of community midwives within the context of their midwifery service.

Health visitors also expressed greater levels of confidence than midwives about whether women with a perinatal mental illness within their service would receive the overall treatment they need. A total of 72% of health visitors (n=79) were ‘very’ or ‘somewhat confident’ about this, compared with 31% of hospital midwives (n=44) and 38% of community midwives (n=14).

Screening tools and aids to identification

Professionals were asked about their use of two screening tools, the Whooley Questions, recommended for use by both health visitors and midwives under the Northern Ireland care pathway, and the Edinburgh Postnatal Depression Scale (EPDS), recommended for use by health visitors (PHA, 2017). Reported use of these screening tools by professionals indicated variation in policy and practice between the five health and social care trusts in Northern Ireland. For example, 54% of respondents in one trust reported ‘almost always’ using Whooley, compared with just 33% in another. However, it should be noted that this difference was not statistically significant.

The majority of health visitors (67%, n=73) said they used the EPDS ‘almost always’ or ‘quite often’. However, almost a quarter of health visitors reported using the EPDS only ‘sometimes’. Around one in 10 health visitors reported ‘never’ using it (n=10), stating that it was no longer standard practice, or not widely used within their trust. However, this conflicted with reports by other health visitors from the same trusts, who reported using the EPDS ‘sometimes’ or ‘quite often’. Follow-up statistical tests also showed that health visitors from two of the trusts used the EPDS significantly less than health visitors in the other three trusts.

The survey explored what health visitors and midwives in Northern Ireland find most useful to help identify a woman experiencing perinatal mental illness. Respondents were asked to rank a range of items in order of usefulness. Highest ranked overall was continuity of relationships. Home visiting was ranked second by health visitors, followed by screening tools. Similarly, respondents were asked their views about barriers to disclosure for women. Fear of the consequences was ranked highest overall by health visitors. Fear of labelling and a lack of confidence among women to recognise difficulties with their mental health, were ranked jointly in second place by health visitors. This was followed by a lack of relationship between professional and patient.

Challenges

Respondents were asked the following open question: ‘Looking to the future, in your opinion what is the greatest challenge(s) faced by your profession in seeking to improve the early identification of, and response to, women with perinatal mental illness in Northern Ireland?’ Across the occupational groupings, there was remarkable consistency in the emergent themes and their prioritisation. Overwhelmingly, the greatest challenges identified related to the systems in which professionals worked, namely lack of time to deliver woman-centred care, lack of capacity in the face of growing demands, and lack of funding for their service.

The systemic challenges reported by health visitors fell into three broad interrelated categories: time constraints, continuity of care, and workload pressures. Frequent references were made to health visitor shortages, sickness absence and retention difficulties leading to health visitors absorbing/providing cover for ‘vacant’ caseloads.

This appeared to have two main impacts: frequent changes to caseload, and subsequently a lack of continuity of care given to women. It also added to excessive caseload weight or size, which not only constrains the time available for each contact, but also affects the quality of that time – and relationships – with women, particularly when caseloads contain high numbers of women with additional vulnerabilities and needs. 

Time for action

Respondents expressed a general frustration with lack of funding, overwork and high levels of complexity of demand

The results reported in this survey research affirm that health visitors and midwives in Northern Ireland experience similar types of challenges in identifying and responding to perinatal mental illness as their counterparts in the rest of the UK. However, at the time of writing, Northern Ireland remains the only part of the UK which has not committed to the investment of funds.

The strong message from health visitors and midwives in Northern Ireland is that, when it comes to disclosure and identification of perinatal mental illness, relationships matter: time and continuity of care are essential. While the research focused on early detection and response, the respondents expressed a general frustration with lack of funding, overwork and high levels of complexity of demand. Overwhelmingly, there is a need to ensure these professions feel valued and that the issue of perinatal mental illness is invested in.

The report calls for action in five key areas: the development of a multidisciplinary training standard on perinatal mental illness, which sets out required competencies. Secondly, a review of ways of working within health visiting and midwifery services, with a view to improving continuity of care, and ensuring that, where possible, appointments allow parents and professionals sufficient time together. Thirdly, clarification on the use of screening tools and a review of training needs, including advanced practice skills around disclosure, to strengthen skill-sets and enhance how health visitors and midwives work with women. Fourthly, alignment of perinatal mental health with infant mental health in policy and practice, to address the dual role of professionals in detecting and responding to perinatal mental health needs, and also to support the parent-infant relationship and the infant’s mental health. Finally, the report calls for the development of specialist services in all five health and social care trusts in Northern Ireland and a mother and baby unit.

Caroline Cunningham and Susan Galloway are senior policy researchers in the NSPCC’s policy and public affairs teams. Caroline works in the Northern Ireland team, while Susan is based in the Scottish team.


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References:

Ban L, Gibson JE, West J, Fiaschi L., Oates MR, Tata LJ. (2012) Impact of socioeconomic deprivation on maternal perinatal mental illnesses presenting to UK general practice. British Journal of General Practice 62(603): e671-8. doi: 10.3399/bjgp12X656801. See https://www.ncbi.nlm.nih.gov/pubmed/23265226 (accessed on 31 May 2019).

Bauer A, Parsonage M, Knapp M, Iemmi V, Adelaja B. (2014) The costs of perinatal mental health problems. Centre for Mental Health and London School of Economics: London.  See https://www.nwcscnsenate.nhs.uk/files/3914/7030/1256/Costs_of_perinatal_... (accessed on 31 May 2019).

Department of Health and Northern Ireland Statistics and Research Agency. (2016) Northern Ireland Health and Social Care Workforce Census March 2016. Belfast: Department of Health and Northern Ireland Statistics and Research Agency. See https://www.health-ni.gov.uk/sites/default/files/publications/health/hsc... (accessed on 10 June 2019).

Health Education England. (2016) Specialist health visitors in perinatal and infant mental health. What they do and why they matter. See https://www.hee.nhs.uk/sites/default/files/documents/Specialist%20Health... (accessed on 31 May 2019).

Hearn G, Iliff A, Jones I, Kirby A, Ormiston P, Parr P, Rout J, Wardman L. (1998) Postnatal depression in the community. British Journal of General Practice 48(428): 1064–1066. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1410010/ (accessed on 31 May 2019).

Hogg S. (2013) Prevention in mind: All Babies Count: spotlight on perinatal mental health. NSPCC. https://library.nspcc.org.uk/HeritageScripts/Hapi.dll/search2?CookieChec... (accessed on 31 May 2019).

Khan L. (2015) Falling through the gaps: perinatal mental health and general practice. Centre for Mental Health. See https://maternalmentalhealthalliance.org/wp-content/uploads/RCGP-Report-... (accessed on 31 May 2019).

Leverton TJ, Elliott SA. (2000) Is the EPDS a magic wand? A comparison of the Edinburgh Postnatal Depression Scale and health visitor report as predictors of diagnosis on the Present State Examination. Journal of Reproductive and Infant Psychology 18(4): 279-296. doi.org/10.1080/713683048. See https://www.tandfonline.com/doi/abs/10.1080/713683048 (accessed on 31 May 2019).

Lovejoy MC, Graczyk PA, O'Hare E, Neuman G. (2000) Maternal depression and parenting behavior: a meta-analytic review. Clinical Psychology Review 20(5):561-92. See https://www.ncbi.nlm.nih.gov/pubmed/10860167 (accessed on 31 May 2019).

Maternal Mental Health Alliance. (2017) Northern Ireland Perinatal Mental Health is Everyone’s Business. Maternal Mental Health Alliance. See https://maternalmentalhealthalliance.org/wp-content/uploads/Northern-Ire... (accessed on 31 May 2019).

Oates M. (2003) Postnatal depression and screening: too broad a sweep? British Journal of General Practice 53(493): 596–597. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314671/ (accessed on 31 May 2019).

Pearson RM, Evans J, Kounali D, Lewis G, Heron J, Ramchandani PG, O’Connor TG, Stein A. (2013) Maternal depression during pregnancy and the postnatal period: risks and possible mechanisms for offspring depression at age 18 years. JAMA Psychiatry 70: 1312–1319. 

Public Health Agency (Northern Ireland). (2017) Regional Perinatal Mental Health Care Pathway: Revised July 2017. Public Health Agency. See https://www.publichealth.hscni.net/sites/default/files/July%202017%20PNMHP_1.pdf (accessed on 31 May 2019).

Regulation and Quality Improvement Authority. (2017) Review of Perinatal Mental Health Services in Northern Ireland. Regulation and Quality Improvement Authority. See https://www.rqia.org.uk/RQIA/files/28/28f4ee85-a5e9-4004-b922-525bc41ae5... (accessed on 31 May 2019).

Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, Howard LM, Pariante CM. (2014) Effects of perinatal mental disorders on the foetus and child. The Lancet 384(9956): 1800-1819 (accessed on 31 May 2019).

Milgrom J, Gemmill AW. (2014) Screening for perinatal depression. Best Practice & Research: Clinical Obstetrics & Gynaecology 28(1):13-23. doi:10.1016/j.bpobgyn.2013.08.014. See https://www.ncbi.nlm.nih.gov/pubmed/24095728 (accessed on 31 May 2019).

Austin MP, Priest SR, Sullivan EA. (2008) Antenatal psychosocial assessment for reducing perinatal mental health morbidity. (4):CD005124. doi: 10.1002/14651858.CD005124.pub2. See https://www.ncbi.nlm.nih.gov/pubmed/18843682 (accessed on 31 May 2019).

Cunningham C, Galloway S, Duggan M, Hamilton S. (2018) Time for action on perinatal mental health care in Northern Ireland A report on the perspectives of health visitors and midwives. NSPCC Northern Ireland. See https://learning.nspcc.org.uk/media/1584/time-for-action-perinatal-menta... (accessed on 31 May 2019).

 


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