Perinatal Mental Health
Perinatal mental illness refers to new and recurrent mental illness that occurs during pregnancy and the first postnatal year. It includes all mental health conditions that may emerge or relapse during this time in a woman’s life. People immediately think of Postnatal Depression as the most common concern for new mothers, but Antenatal Depression is at least as common. Antenatal and Postnatal Anxiety are also both common. Perinatal mental illness includes mental illness specific to mothers, such as Birth Trauma, and the uncommon cases of Puerperal Psychosis. But any condition can occur or relapse during the perinatal period, including PTSD, Eating Disorders, OCD, Personality Disorder, Schizophrenia and Bipolar Affective Disorder.
Perinatal Mental Illness can have a significant impact on those affected, impairing relationships, quality of life and physical health. There is a substantial body of evidence demonstrating the risks of perinatal mental illness to both mothers and their infants. Perinatal mental illness is associated with a higher risk of pre-term birth, low birth weight, impaired bonding, and long-term emotional, cognitive and psychological problems for the child.
Perinatal Mental Illness is common. 20% of women experience diagnosable mental illness during pregnancy or the first year postpartum. This has been compounded in recent years, by the global impact of the Covid-19 pandemic. Studies in Ireland and the UK have highlighted the impact of the pandemic on women during the peripartum period with higher levels of Antenatal Anxiety and depression noted. SPMH services have faced substantial increasing demand since their inception, through increased awareness of perinatal mental illness, higher disease burden and also as the profile of the services has become more apparent.
Specialist Perinatal Mental Health services have been developed globally in the context of the recognition of the importance of prioritising women’s perinatal mental health. It is well recognised that the perinatal period provides a unique opportunity to improve perinatal mental health by early intervention and treatment as well as promotion of perinatal mental health and prevention of illness. There is a clear economic argument for specialist perinatal mental health services. UK research in 2014 estimated the financial cost of perinatal mental illness at £8.1billion, with 72% of this cost relating to adverse impact on the child rather than the parent.
Over the past five years, Specialist Perinatal Mental Health Services (SPMHS) have been established across Ireland to provide specialist care to all women, according to the Model of Care (2017). All six multidisciplinary hub services are now fully staffed, and offer a range of medical, psychological and other interventions to women in the major metropolitan areas. These services have allowed for more varied psychological interventions to be offered, with more nuanced, individualised mental health care. The spoke services are based in smaller hospitals with lower birth rates in more rural areas. In these settings perinatal mental health midwives attached to the maternity units see women with mild-moderate illness. They are supported by the liaison psychiatry teams (where they exist) who provide the support for women with moderate to severe illness. In the absence of Liaison Psychiatry services, community adult mental health teams provide care.
Treatment and interventions
Treatment options include talking therapy, lifestyle advice and accessing support with baby care, and also psychotropic medication. Antidepressants are an effective treatment for anxiety and depression, and a range of other perinatal mental illness. While there are some risks of using antidepressants in pregnancy and breastfeeding, medication may be an important part of treatment. Treating perinatal mental illness effectively will have benefits for the mother and her baby in the short and long term.
A large part of perinatal mental healthcare is provided in the Primary Care setting, by general practitioners, public health nurses, and community midwives. Some referrals to SPMHS services, which are mild-moderate in severity, are redirected to Primary Care where appropriate.
SPMHS offer assessment and case management of women suffering with perinatal mental illness. Perinatal Psychiatrists also offer preconception counselling to women with severe mental illness who are planning a pregnancy.
All care is delivered with a trauma-informed approach. A range of evidence-based interventions are offered, including attachment therapy, CBT, birth trauma support, group therapy for antenatal and postnatal depression and anxiety, and other specialist interventions. Women are assessed with their babies, to assess bonding and attachment, and support them both as a mother-infant dyad. We also support partners and fathers, as part of the family unit.
Women with severe or complex mental illness are offered pre-birth planning meetings, where a Perinatal Mental Health Care Plan is produced. This plan allows a woman and her carers to discuss her early warning signs of relapse, treatment preferences, and breastfeeding preferences. It provides guidance on mental health support during the pregnancy, birth and postnatal period, including the identification of relevant healthcare clinicians, the range of appropriate treatments and support services and a discussion about key family members that need to be involved.
Mother and Baby Unit
Ireland desperately needs a specialist, in-patient unit for perinatal women with severe mental health problems who require acute inpatient mental health care. There is currently no inpatient provision for specialist perinatal mental healthcare in the whole of Ireland. The gold standard for inpatient care for postnatal women up to the first year of the baby’s life, is to be admitted to a specialist mother and baby unit, staffed by specialist perinatal mental health staff, providing appropriate care to babies, and offering the full range of therapeutic services. Unfortunately, despite being a key recommendation in the Model of Care (2017), no such unit has been built to date with plans at a very preliminary stage of development.
Mother and Baby Units (MBUs) have been established in many European countries, Australia, New Zealand, Sri Lanka, India and the United States. Women living in countries or regions without access to an MBU have to be admitted to general psychiatric wards and separated from their babies. This is distressing for women, impairs bonding and attachment with their babies at a crucial stage in the baby’s development, and makes it more likely that formal care arrangements will have to made for the baby where a partner is not available. When mothers and babies are not separated, and positive relationships can continue, mothers tend to retain and enhance their role as primary care-giver.
An MBU service needs to be established in Ireland as a priority. Given such a project will take time, there is a need for interim training of adult inpatient psychiatrists in specialist management of perinatal mental illness.
What next?
Watch this space for a new revision of the Model of Care for Perinatal Mental Health Services in Ireland. The revision will lay out plans to expand SPMH services to meet the increasing demands, and in particular to provide multidisciplinary teams in the spoke areas to provide equity of access to all women in Ireland. The campaign for the MBU is gaining momentum, to provide this much needed inpatient service for women and babies in Ireland.
Written by Dr Catherine Hinds, Consultant Perinatal Psychiatrist, The National Maternity Hospital
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