Although pregnancy and birth are a positive time for most women, between 10 and 20% of women suffer from mental health problems during this period. Mental health problems can arise in pregnancy or after birth and most commonly consist of anxiety, depression, posttraumatic stress disorder (PTSD) following a difficult birth and stress-related conditions such as adjustment disorder. Severe postnatal mental illness, such as puerperal psychosis, is less common, but is one of the leading indirect causes of maternal death (Knight, Reference Knight, Kenyon, Brocklehurst, Neilson, Shakespeare and Kurinczuk2014). In the United Kingdom, there has been increased awareness of the importance of perinatal mental health in recent years, which has prompted a demand for change in prioritisation and health services. In this editorial, we consider some of the factors that contributed to this and the challenges we face if we are to implement change in primary care. In doing so, we do not provide an exhaustive list but focus on contributors that may be useful to consider. We also outline the argument for why perinatal mental health should be everyone’s business.
A significant factor in increasing awareness of perinatal mental health in the United Kingdom was the formation of the Maternal Mental Health Alliance (MMHA). This has over 60 member organisations, including many associated with primary health care such as the Royal College of General Practitioners, Institute of Health Visiting, Royal College of Midwives and NHS England. In 2014, the MMHA launched a campaign for perinatal mental health entitled ‘Everyone’s Business’, which included a map of perinatal mental health services produced by the Royal College of Psychiatrists. This showed significant variation in services across the United Kingdom, with 40% of the United Kingdom having no specialist perinatal mental health provision (www.everyonesbusiness.org.uk). Where services do exist, they range from one specialist mental health nurse or psychiatrist to complete specialist perinatal community teams and inpatient mother and baby units. However, full specialist community perinatal services are rare. This and other factors mean that approximately half of women with perinatal mental health problems are not identified or treated, despite regular contact with maternity services (Baur et al., Reference Bauer, Parsonage, Knapp, Iemmi and Adelaja2014).
So why should perinatal mental health be everyone’s business? The arguments for this are compelling. There is now substantial evidence that maternal mental health problems are associated with a variety of adverse outcomes for women and children. The impact on women and children varies according to the timing (pre- and/or postnatal) and type of mental illness, and there are still gaps in our knowledge, but the overall evidence is convincing. In this issue, Peter Cooper and colleagues outline the evidence that postnatal depression is associated with a poorer relationship between the mother and baby, and consequently with poor child development. Anxiety and PTSD in pregnancy are associated with increased risk of preterm birth (Ding et al., Reference Ding, Wu, Xu, Zhu, Jia, Zhang, Huang, Zhu, Hao and Tao2014). For example, a study of 2654 women in the Unites States found those with PTSD in pregnancy had a 2.5 greater risk of preterm birth (Yonkers et al., Reference Yonkers, Smith, Forray, Epperson, Costello, Lin and Belanger2014). There is also evidence that anxiety in pregnancy has an impact on the developing fetus. Studies of stress, anxiety and depression in pregnancy show that these are associated with altered patterns of fetal behaviour and heart rate responses (Kinsella and Monk, Reference Kinsella and Monk2009). Postnatal follow-up shows infants of women who are anxious are more likely to show fearful or anxious behaviour and are more at risk of poor development and adverse outcomes such as attention-deficit hyperactivity disorder (Talge et al., Reference Talge, Neal and Glover2007). Stress hormones and epigenetic mechanisms are thought to underlie the effect of women’s emotional state in pregnancy on the developing baby (Wadhwa, Reference Wadhwa2005).
The economic argument is also compelling. A recent economic analysis estimated that the cost to the UK society of not treating perinatal mental health problems is £8.1 billion per annual cohort of women giving birth. The majority of this cost (72%) was attributable to long-term adverse consequences for the child. The direct cost to National Health and Social Services was estimated as £1.2 billion. In contrast, the cost of providing perinatal mental health services as specified by national guidelines is £0.28 billion (Baur et al., Reference Bauer, Parsonage, Knapp, Iemmi and Adelaja2014). Thus from a public health perspective, a strategy for preventing perinatal mental health problems and treating them effectively has the potential to prevent significant long-term burden of ill health and problems in children. Evidence-based guidelines are available that outline effective treatments for the mother (Scottish Intercollegiate Guidelines Network, 2012; National Institute for Clinical Excellence, 2014).
Politically, members of parliament have been important in highlighting that perinatal mental health should be a national priority. An All-Party Parliamentary Group (APPG) with representatives from all main political parties has looked at how to optimise the health of women and children from conception to age 2. This group made recommendations about the need to prioritise perinatal mental health and ensure services are available for women and families in their manifesto 1001 critical days (APPG for Conception to Age 2, 2013) and later inquiry report Building Great Britons (APPG for Conception to Age 2, 2015). The UK government subsequently allocated £75 million to perinatal mental health in the 2015 budget.
A variety of factors also enable women with perinatal mental health problems to have influence. Social media enables women with perinatal mental health problems to lobby politicians and health care organisations directly. For example, Kathryn Grant who blogs about her experiences (www.bumpsandgrind.blogspot.co.uk) and Rosey Wren who runs a twitter support group (@PNDandme). Families of women who have died from perinatal mental illness are also active such as Lucie Holland’s petition on behalf of her sister Emma, and Chris Bingley’s campaign on behalf of his wife Joanna (www.joebingleymemorialfoundation.org.uk). Social media helps people join forces with each other and relevant organisations to raise awareness and become a frequent and powerful reminder of the need for services. At the same time, it has become increasingly common for funders of health research in the United Kingdom to specify that research projects should involve members of the public and patients in all aspects of research – from setting research questions to conducting studies.
The evidence base, economic argument, political and social drivers have therefore combined to increase awareness in the United Kingdom of the importance of women’s perinatal mental health and provide impetus for change. However, implementing change is complex and there are barriers. Primary care in the United Kingdom has a potential conflict of interest, as primary care practitioners act as commissioners of specialist services and they also provide a service for women in their practices. If they do not understand the importance of perinatal mental health for their patients, they are unlikely to see the need for a specialist service. This is also a time of financial constraints to developing new services, although some new resources have been made available. A key barrier in the United Kingdom is that perinatal mental health is not yet prioritised at a local level, with only 3% of clinical commissioning groups having a strategy for perinatal mental health (APPG for Conception to Age 2, 2015). There is also little universal agreement on which types of services or pathways should be implemented and how they should be funded, structured or organised. This has led to different initiatives being implemented by public, private or third-sector organisations; often with little evidence they are effective (Fontein-Kuipers et al., Reference Fontein-Kuipers, Nieuwenhuijze, Ausems, Bude and de Vries2014). Various recommendations for the types of services and the way they should be structured have been put forward (eg, Royal College of Psychiatrists, 2001; APPG for Conception to Age 2, 2015), but again evidence for the effectiveness of different approaches is limited (Glover, Reference Glover2014).
Professional organisations are working to address this. The Royal College of General Practitioners made perinatal mental health a clinical priority with the aim of developing and implementing a strategy for perinatal mental health in primary care. The Institute of Health Visiting has trained perinatal mental health champions across the United Kingdom to raise awareness and expertise in nationwide public health services. A report commissioned by the Royal College of General Practitioners entitled Falling through the gaps identified a number of patient, physician and organisational barriers for identification and treatment of perinatal mental health problems (Khan, Reference Khan2015). The biggest barrier was lack of identification of women with problems. Other barriers included lack of training for general practitioners (GPs) on perinatal mental health, GPs not feeling confident about managing perinatal mental health problems, time pressure, stigma preventing women asking for help and women feeling dismissed or overly reassured by GPs when they did ask for help. When perinatal mental health problems were identified, the treatment most commonly provided was pharmacotherapy, which may partly reflect the lack of specialist services for practitioners to refer onto (Khan, Reference Khan2015). Research evidence on diagnosis and treatment of perinatal mental health problems in primary care is notably sparse and focuses almost entirely on postnatal depression. As primary care practitioners are often the first line of care for women with perinatal mental health problems, more research is needed on how to effectively identify and treat women with perinatal mental health problems in this context.
In conclusion, this is an exciting time for perinatal mental health in the United Kingdom because of the increased momentum for change. However, we still have a long way to go in terms of effecting change. We need to be careful that we are not implementing change without evidence that such change is effective. Research is needed on how to improve the identification and treatment of women with perinatal mental health problems in primary care and other services. It is important that policy makers, commissioners, researchers, clinicians, and women and families who have experienced perinatal mental illness continue to work together to ensure appropriate and effective care pathways and services are provided.
