Perinatal mental health

Pregnancy and childbirth are normal life events, with a range of emotions throughout this journey, however these normal emotions can be complicated by disturbances in mental wellbeing.

A mental health condition is considered a disability if it has a long-term effect on normal day-to-day activity. This is defined under the Equality Act 2010. The condition is ‘long term’ if it lasts, or is likely to last, 12 months. ‘Normal day-to-day activity’ is defined as something that is done regularly in a normal day. This includes things like using a computer, working set times or interacting with people.

Perinatal mental health (PMH) is the overarching term for mental health during pregnancy and the first postnatal year (although some areas will continue to provide support beyond the 1st year). It can be characterised by either an existing mental health issue or a condition that arises during pregnancy, or related to pregnancy.

Evidence from the World Health Organisation (WHO) suggests that worldwide about 10 percent of pregnant women and 13 percent of women who have just given birth experience a mental disorder, primarily depression. In developing countries this is even higher, i.e. 15.6 percent during pregnancy and 19.8 percent after child birth. In severe cases mothers’ suffering might be so severe that they may die by suicide. See: Maternal mental health.

Mental health in pregnancy

This information is written for midwives, nurses and healthcare professionals caring for:

• any woman who has mental health problems during pregnancy
• any pregnant woman who has had a mental health problem in the past
• their partner, family and friends
• consideration should also be given to women planning pregnancy, in particular pre conception, who may be concerned about mental health issues, and require support.

Mental health in pregnancy, produced by the Royal College of Psychiatrists (2018) provides useful information on:

• mental health problems in pregnancy
• how to stay well during pregnancy and after the birth of your baby
• how to decide whether or not to take medication in pregnancy
• what help and support there is during pregnancy and have a mental health problem. 

Women and mental wellbeing

Women are twice as likely as men to be diagnosed with a mental health problem. 53 percent of women who have mental ill-health have experienced violence/abuse or post traumatic distress disorder (affects over 31 percent of the population).

Severe mental illness support during pregnancy

In 2021, the charity Tommy’s partnered with KCL, NHSE and PHE to produce a suite of resources to support women with a severe mental illness (SMI) to make informed decisions around when to get pregnant, what to watch out for and how to treat their condition during and after pregnancy.

The resources include a new online information and support hub for anyone with SMI planning a pregnancy, as well as practical guidance for the frontline healthcare professionals who support them. Tommy’s also updated their Planning for Pregnancy tool so that users with severe mental illness get specific tailored information and support. 

Factors that impact on mental well-being include:

Impacts include:

• feelings, thoughts and actions
• physical health, wellness and experiences
• education and employment
• social/family relationships
• economic and social circumstances
• lifestyle choices
• culture and ethnic background
• gender and sexuality
• use of drugs or alcohol
• past experiences
• any dependents e.g. a child or elderly relative.

Mental health issues during pregnancy and post birth could include:

1. Generalised anxiety disorder (GAD), social anxiety, panic disorder, obsessive-compulsive disorder (OCD)

2. Severe mental health issues such as:

• depression
• psychosis and bipolar disorders
• personality disorders

3. Some developmental conditions are more likely to have mental health problems including: 

• autistic spectrum disorders
• attention deficit hyperactivity disorder.

4. Suicide and self-harm

Perinatal mental health (PMH) is mental health during pregnancy and the first postnatal year. This could be characterised by an existing mental health issue or a condition that arises during pregnancy, including: antenatal depression and postpartum.

During pregnancy, women may also be subject to specific mental health issues, generally identified as antenatal depression.

Antenatal depression can occur at any stage during pregnancy. here is a range of support including self help, psychological therapy and medication to manage symptoms. The NHS provides information on this: Depression in Pregnancy. If antenatal depression is not treated symptoms can get worse and may continue after the baby is born (postnatal depression).

Postnatal (or puerperal) mental health issues include three main presentations:

• maternity blues, normally occurs around days three to four and affects 80 percent of women
• postnatal depression, affects 10 percent of women
• puerperal psychosis, rare but severe form of psychiatric illness.

MIND (2020) provides further information on:

• Perinatal depression
• Perinatal anxiety
• Perinatal Obsessive-Compulsive Disorder (OCD)
• Postpartum psychosis
• Postpartum Post Traumatic Syndrome Disorder (PTSD)

Key symptoms of depression

• emotional – sadness, irritability, anxiety, apathy, anhedonia
• cognitive – Inappropriate guilt, inattention, poor concentration, delusions, memory disturbances
• physical – disturbance in sleep, appetite, lethargy, fatigue, headaches or vague pains
• behavioural – tearful, withdrawn, irritable.

• recognising and understanding the woman’s mental wellbeing
• general support and understanding
• cognitive behavioural therapy or other talking therapies
• pharmacological/medication. 

Continuity of care is a key component of maternity care, and care for mental well being. These should include:

• identify that there is an issue
• diagnose
• early intervention
• appropriate care
• aftercare. 

NICE recommends asking Whooley questions which are:

• During the past month, have you often been bothered by feeling down, depressed or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?

Also consider asking about anxiety using the 2‑item Generalized Anxiety Disorder scale (GAD‑2):

• Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?
• Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?

If a woman responds positively to either of the depression identification questions, is at risk of developing a mental health problem, or there is clinical concern, consider:

• Using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ 9) as part of a full assessment or
• Referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional.

See further here: NICE recommendations

When asking a woman ‘how are you feeling?' consider asking supplementary questions such as:

• do you take time to look after yourself?
• how are you coping?
• do you feel low?
• are you sleeping poorly?
• are you not eating properly?
• are you tearful, angry and/or anxious?
• do you have concerns about your mental health?
• do you have anyone to talk to about your concerns and what impact is this having?

This should support a better holistic assessment for mental wellbeing as well as physical health.

View the resource: Guide for delivering preconception care to women with a serious mental illness.

“When a woman has a serious mental illness, thinking about having a baby can be both challenging and worrying for her. This excellent new guide brings together the latest evidence to support professionals and women in having conversations about properly planning a pregnancy and having a baby. It covers the importance of discussing fertility and sexual health, as well as considering physical health and mental health needs, including medication, and having a ‘think family’ approach.”

Resources for women with SMI (serious mental illness) planning pregnancies

• A website hub - Planning a pregnancy when you have a severe mental health illness 
  A pregnancy planning tool - Planning for Pregnancy
  Information animation - Planning a pregnancy with a serious mental health condition. 

The Maternal Mental Health Alliance (MMHA) is a coalition of over 90 UK organisations (including the RCN). This includes professional bodies such as Royal Colleges and organisations that represent, or provide care and support to, parents and families. The MMHA works across England, Scotland, Wales and Northern Ireland. Their vision is to see all women across the UK get consistent, accessible and quality care and support for their mental health during pregnancy and in the year after giving birth.

The MMHA has a wide range of contacts and resources on their website. 

Scotland

In Scotland, perinatal and infant mental health services are delivered by health boards, integrated authorities and the third sector. 

In the past few years it has been an area which has received increasing attention and funding from the Scottish Government. In March 2019, the Perinatal and Infant Mental Health Programme Board was established to oversee, provide strategic leadership and have overall management of the delivery of improved perinatal and infant mental health services, alongside a £50 million investment in services. The review focuses on improving support during pregnancy and birth, better training and awareness of people working with vulnerable families & delivering improved infant mental health support for families. RCN Scotland is a Board member and has engaged with this work throughout.

While the development of services was put on pause during the COVID-19 pandemic in 2020, this Programme Board continued to advice on the content of online support materials via the Parent Club website. The remobilisation of perinatal mental health services, along with other mental health services, is one of the priorities of the Scottish Government.] In September 2020 (as part of the 2020-21 Programme for Government), the Scottish Government announced a £1m Perinatal and Infant Mental Health Fund which will support 16 third sector organisations to deliver perinatal counselling and peer support."

Wales

The Wales Perinatal Mental Health Network is aimed at delivering high quality perinatal mental health care to individuals and their families across Wales. In 2016, the Children Young People & Education Committee (CYPE) undertook a review of perinatal mental health services (PNMH) across Wales and in September 2018, From Bumps to Babies: Perinatal Mental Health Care in Wales was published. This led to the development of a National Clinical Lead for Perinatal Mental Health role for Wales with a focus on providing national leadership, coordination and expertise for the further development of perinatal mental health services and workforce, including quality standards, care pathways, professional competencies and training resources.

The focus is on:

• Strengthening Partnership Working 
• Developing a Fully Integrated Care Pathway to provide the right care, at the right time and by the right people
• Providing high quality care that meets national standards
• Ensuring we have a workforce with the right skills, knowledge and supervision (NHS Wales Health Collaborative 2020)

Northern Ireland

In January 2021, Northern Ireland’s Health Minister, approved funding for the development of a new Perinatal Mental Health Delivery Model, including specialist multi-disciplinary perinatal mental health teams in each of the five trust areas. Further details are available here.