Today brings the latest report and recommendations from the second MBRRACE -UK confidential enquiry into maternal deaths. The fact that a quarter of all late maternal deaths (between 6 weeks and a year following pregnancy) for the 2011-2013 period were down to mental health related causes shouldn’t come as a shock to those of us who have insight into perinatal mental health, because we know how prevalent it is. It comes as a shock because despite these figures there is still a shameful lack of provision for women who have a history or diagnosis of a mental health issue during pregnancy.
According to MBRRACE-UK one in seven women died by suicide and if those women who died were to become ill today, 40% of them would be unable to access any specialist perinatal mental health care and only 25% would be able to get the highest standard of care.
Women with a history or diagnosis of mental ill-health need to have access to specialist staff to ensure their care is planned effectively in partnership with them and their families because they are the experts in their condition. This will not be achievable unless women are asked the right questions early on in pregnancy. It astounds me how many women I hear from on social media who were not asked about their mental health at their initial booking appointment because it is every bit as important as recording a full medical history. It is ridiculous to think that recording a tonsillectomy at the age of seven would be somehow more important than the anxiety and depression the woman has suffered since age sixteen. Health care professionals also need to be asking the same questions to partners, and support should not be limited to the pregnant woman as mental ill health for either party will require increased support from professionals during the perinatal period and beyond.
Women and their partners need to be able to access information on mental health issues which may affect them during pregnancy or the postnatal period. The reason why so many parents do not even realise there is an issue until they have become very unwell can be down to a lack of insight and an inability to recognise when things “don’t feel right”. The fear of the unknown is also a huge factor and a perception that by admitting there is a problem their ability to parent may be called into question. A universal approach to providing information is a starting point and should include signposting to further information and support. Health care professionals have a responsibility to open a dialogue which can be ongoing throughout the perinatal period. What better health promotion than to begin to educate about perinatal mental health to the people who are most likely to benefit?
Women and their partners who have a history of mental ill health need a care plan, the intensity of which depends entirely on the individual needs of the person but at the very least should include a discussion around medication and expectations in regard to infant feeding. Most anti-depressant medication is completely safe during pregnancy and breastfeeding although some drugs are recommended over others. Psychotropic medication may be contra-indicated in some cases and this requires more of a discussion and the involvement of a perinatal psychiatrist. Women need to be able to chose the best option for them but need to be given the correct information to make an informed choice. In the inquest into the tragic death of Charlotte Bevan and her newborn baby last year, stopping her medication due to her desire to breastfeed and the lack of a care plan meaning she was not given the correct support and monitoring which may have kept them both safe were highlighted as two major contributory factors in her suicide.
Health care professionals can not work effectively in isolation. If other professionals, such as mental health services, are involved it is imperative they are included in planning care. Support is most effective when it is co-ordinated and each professional will have their own expertise to contribute to ensure the care is of the highest standard. Postnatally this is especially important as women need to feel supported but not overwhelmed with professionals one day with feelings of abandonment the next. A discharge planning meeting prior to going home can be invaluable in identifying need and offering a co-ordinated response and should include the parents, family members who will be offering support too when possible, as well as key professionals such as Health Visitors, Mental Health Services and Midwives.
This is of course not a complete insight into supporting parents where there may be a mental health issue, for some there may be many more complex factors to consider but is a baseline of the very least that should be offered. Not hugely difficult to achieve and not expensive, so why are so many areas getting it wrong?