Research suggests 1 in 10 women develop a mental illness whilst pregnant or in the first year after giving birth (NHS 2018). In recent years, there has been an increase in awareness into the importance of emotional wellbeing assessments despite this, there are still gaps in the healthcare system that allow for women to be discharged from our care unnoticed (DOH 2014). Maternal suicide is the third leading cause of maternal deaths in the UK (MBRRACE-UK 2018). For almost 1/5 of women who died in 2016, there was no evidence that they had been asked about a history or mental health problems, despite the identification of this being a key recommendation in 2015 (Knight, Tufnell et al. 2015). Coordinated action across a wide range of health services is required to address this problem. Hence, this report will explore the importance of screening for mental health problems postnatally. Furthermore, it will include a poster which will aim to prompt midwives into implicating guidelines into the assessment of emotional wellbeing more strictly postnatally.
(WMMH 2016)
Health Issue
Postpartum mood disorders are a common form of maternal morbidity during the postpartum period. There is a large spectrum ranging in severity, from short-lived ‘baby-blues’ which is experienced by 50-80% of women, to postpartum psychosis; which affects <1% of mothers and usually results in hospital admission (VanderKruik et al 2017). One of these is Postnatal Depression (PND), this is a non-psychotic depressive episode that usually occurs within 1 or 2 months after giving birth, extending to a year after birth (RCOP 2010). The symptoms include; low mood (lasting over 2 weeks), irritability, difficulty bonding with baby, anhedonia, fatigue, anxiety, guilt and thoughts of suicide (NHS 2018). These symptoms are alleviated if the woman already has low self‐esteem or unrealistic expectations of motherhood (NICE 2014)
There are several other risk factors that make you more susceptible to PND. For example, sociodemographic (stressful living conditions, poverty) and a psychiatric history (familial and personal history)- which would indicate a biological predisposition; for example; there is a clear link between bipolar affective disorder and vulnerability to Postpartum psychosis (Jones et al 2007). Having a baby is a major life event and other recent life events such as major health illness or arguments with partner could also be triggering factors. (MIND 2016)
This morbidity has well documented public health consequences for the mother, child and the rest of the family. There’s an increased risk of future depression, relapses, thoughts of abusing their children as well as the father developing depression. There’s also a plethora of effects for the child. For example, research suggests that links between PND and delayed cognitive and language development as well as insecure attachment, more behavioural problems, and higher rates of depression in the children during the latter teen years (COCHRANE 2, Netsi et al 2018). Thus, the poster conveys the widespread knock on effects this can have if left untreated. It will remind midwives to spend a few extra minutes to make sure, as well as her physical health, the woman’s mental health is looked after.
The current NICE guidelines focus on tertiary prevention strategies; minimising relapse and reducing incapacity/injury (NICE 2014). At first point of contact, the Whooley questions are asked with the 2-item GAD scale used to enquire about anxiety, then further assessments and referrals ensue if positively answered (NICE 2014). If this isn’t the case then the woman is given a leaflet about postnatal depression and only asked again after she has given birth how well she is coping with the birth (RCOP 2011). See Appendix 1 for a reconstruction of the postnatal ward stickers that the midwives routinely use in a London trust. It is important to note that the space given to ‘psychological wellbeing’ is very small and anecdotally, midwives habitually write ‘generally well’ without a thorough screening done. Despite this, indirect maternal death rates remain high with no significant change in rate since 2003 (MBRRACE 2018).
The poster attached in Appendix 2 highlights these risk factors, reminding the midwife of the rapidity of change of mental health. As well as this, reinforcing the fact that all time periods after childbirth pose a greater risk for suicide when compared with the antenatal period (MBRRACE 2015).
In addition to the effect on the individual’s life, the implications of untreated perinatal mental health problems cost the NHS 8.1bn for every annual birth cohort (Bauer et al 2014). Despite this, more than 40% of England’s clinical commissioning groups don’t have access to specialist perinatal mental health services (Maternal mental health alliance (MMHA 2017). According to the MMHA, a local London trust which governs the area of Lambeth is currently operating at Level 5- meaning there’s perinatal community team that meets the standards for adequate 24-hour care. However, it’s border borough of Croydon is level 3 meaning women do not have 24-hour access to a specialist mental health team (MMHA 2017). The difference between the two, coupled with NSPCC reports, highlights the substantial gaps in specialist care offered across the UK as a result of inefficient funding (Hoggs 2013). Psychiatrists suggest that it would take £100 per birth, compared to £2800 spent on physical maternity care, to bring mental health care up to NICE standards (Gregoire 2017)
It is a RCM requirement that all women’s emotional wellbeing is assessed and that screening is routine, with tools such as the Edinburgh Postnatal depression scale (EPDS) and the GAD-2 Scale in-cooperated into national guidelines (NICE 2018). However, lack of training in perinatal mental health care means that there is still a real risk that women and families fail to access the right services (MMHA 2018)
Health Theory
The aim of the poster is to increase mental health awareness, in particular the importance of screening for PND. This is a primary prevention as it’s aimed at all women cared for in the postnatal period. Posters are effective at presenting health information as they have proven success in promoting knowledge transfer, changing attitudes and behaviours (Ilic + Rowe 2013). It will serve as a memory aid for midwives to take a little extra time to delve into emotional wellbeing on a busy postnatal ward. This is after many trials have found that both psychosocial and psychological interventions can help reduce symptoms of PND (Dennis and Hodnett 2007). “without the poster”
Health need assessments are crucial in shaping, planning and managing healthcare services and policies. Defining need is multifaceted but is the first element of any health promotion intervention (Bowden 2016). Bradshaw’s taxonomy of needs highlights 4 types; felt, normative, comparative, expressed (Bradshaw 1972). These can be applied to healthcare, specifically, routine screening for PND would be categorised as a normative need. It’s a good need as ‘it’s determined by experts’ and thus is based on scientific research, making it more reliable (Talbot & Verrinder 2005). However, this is a top-down approach and fails to acknowledge that definitions of needs can vary depending on whose perception, interpretation and values are in play (Bowden 2016). As a result, there’s a disparity between the felt needs of clients and normative needs defined by experts in pregnancy which is to be expected as there’s a range of healthcare professionals and pregnant women involved. Thus, no perception of need is sufficient on its own so the framework is a useful tool for planning appropriate services.
he use of Bradshaw’s tax- onomy of needs in a maternity setting may lead to health care which is more likely to address social determinants of health and ultimately improve health outcomes for pregnant women. (idk)
All midwives and MSWs should maximise their role and contribute to health and wellbeing through the ‘every contact counts’ approach at a population level of public health practice (REFERENCE). There are many different theoretical models been used in health promotion and by midwives to define the mode of care they give to women. One of these is Piper’s Health Promotion Practice Framework for Midwives (Piper, 2005).it incorporates both the top-down and bottom up approach. As seen in Appendix 2, the model introduces the idea that the midwife has four differing methods of health promotion. The model is split by a ‘power continuum’ and the methods can either be objective, with the midwife taking a traditional educational approach, or subjective, where a more woman centred approach is taken.
The model of the midwife as a ‘behaviour change agent’ is applicable to the screening of PND as a normative need (Piper 2005). This reflects a more conventional health promotion role. At a primary level, using the EPDS and GAD-2 questions allows the midwives to recognise and identify those at risk of developing PND. The aims of this approach include encouraging compliance with treatments and attendance to services they’re referred to. However, it is considered a two-directional approach as it creates a hierarchy between midwife and woman (Bowden 2016). Consequently, the social desirability bias may be seen through her answers due to stigma and fear attached to them.
Thus, this can be overlapped with the model of midwife as an ‘empowerment facilitator’ (Piper 2005). This uses non-authoritarian methods to allow the woman to become self-empowered. It allows for the woman’s care to be viewed on an individual level, giving her the freedom to speak about her experience and decide her own coping methods with guidance from the midwife. There is a lot of research to indicate that this is a very successful approach (NcLoughlin 2000, Donaldson + Scally 2009; Upton +Thirlaway 2014) as well as fitting the consumer culture within the NHS (Sturgeon 2014). However, this ‘bottom-up’ approach provides slow results. Some would argue that this would mean a strain is put on services and finances in order to achieve change (Bowden 2017). Despite this, PND is a complex health issue that cannot be identified and resolved with a leaflet. The midwife needs to empower the woman and allow her to become an agent in recognising her own changes in mood and when she is in need of support when she isn’t under the care of the midwife and she is able to seek out for medical help.
Discussion
National guidelines suggest the use of tools such as EPDS and GAD-2, however, most existing studies of the accuracy of the screening have been too small to determine precise accuracy (Howard et al 2013). For example, the Likert scale is used; this allows for some opinion to be expressed as opposed to closed questions. However, answers can be compromised by the social desirability bias (McLeod 2008). This is due to prevailing stigma surrounding PND, many women fear their child will be taken from them if they don’t live up to their own expectations of motherhood (RCM 2015).
Only one systematic Cochrane review observed the prevalence of PND in 4150 women in the UK was found. 9% had thoughts of harming themselves when sent the EPDS through the post, 6 weeks postnatally (Howard et al 2013). Despite this, there were many methodological limitations and in other studies relying on clinical records to obtain data regarding outcomes at 1 year postpartum was a limitation (Lancaster 2009). As a result, there isn’t enough data to prove its accuracy and there’s a risk that its regular use could lead to over-diagnosis of PND (MBRRACE 2018).
From a midwives’ perspective, the main barrier faced is the lack of time; this leads to a lack of training and services to give adequate care (Khan 2015). In a London trust, the unit has seen a 20% increase in the number of babies delivered since April 2017 so the ward is busy and understaffed. As a result, midwives have less time dedicated to the women and the proportion of women who were unhappy with the service; including staff attitudes rose (GSTT 2018). As well as this, multiparous women are expected to require less support postnatally (Parvin et al 2013) as they already have children and 94% of women who attend antenatal classes are primiparous (GSTT 2017b). This is despite in suicides due to mental health issues, over two-thirds were multiparous (Knight et al 2017). Therefore, there is a need for stronger implementation of national guidelines for screening as a minimum standard of care (RCM 2015).
The lack of implementation however could be explained by a lack of training, recent research revealed that 23% of maternity professionals had received no education on maternal mental health (Rowan C et al. 2010). Supporting research also indicated that midwives aren’t confident with the care and support they can offer women with mental health problems. Many were reluctant to ask women about their mental health, with fears they would uncover an issue that would be difficult to resolve (TOMMYS & RCM 2013). Hence, ensuring that high priority is given to mental health and midwives do not omit this aspect of care despite clinical time being short (MIDWIFERY 2020).
Services such as MAPPIM are available, however they cater towards women with severe mental illnesses (GSTT 2018). Thus, to combat this gap in care, more training days allow the midwives to effectively communicate with women to reduce anxiety (McNeil et al 2012) will help fill gaps and give care to those with mild/moderate mental health issues. A clear beneficial effect in the prevention of PND was found from psychosocial/psychological interventions such as group communication (Denis + Downsell 2013). In this London Trust, group ‘discharge talks’ are held before the women leaves where various health promotion topics are discussed. This group setting, paired with leaflets and appropriately trained staff would ensure >50% of information is retained by the women (Corcoran, 2013). 74% of women report feeling embarrassed about their feelings, so if they learn how to shamelessly identify symptoms, early pro-active care of women can be given (RCM).