Maternal Mental Health Alliance - Written evidence (FFF0005)

 

Submitted by the Maternal Mental Health Alliance (MMHA) February 2022

 

House of Lords Public Services Committee: Designing a public services workforce fit for the future

_________________________________________________________________

  1. The Maternal Mental Health Alliance (MMHA) is a UK-wide charity and network of over 100 organisations, dedicated to ensuring women and families affected by perinatal mental health problems have access to high-quality comprehensive care and support. We bring the maternal mental health community together and make change happen by combining the power of real-life experience with clinical and professional expertise.

 

  1. We welcome this House of Lords Public Services Committee call for evidence re designing a public services workforce fit for the future.  We acknowledge that this Committee is considering public services in the broadest sense, for this submission we have focused on the role of services involved in the delivery of perinatal mental health (PMH) care.
     
  2. More than 1 in 10 women develop a mental health problem during pregnancy and the first year after having a baby.  Currently, not all pregnant women and new mothers can access the PMH care they need. Perinatal mental illnesses can be life threatening and suicide is the leading cause of death over the first year after pregnancy.  Although it is not inevitable, perinatal mental illness can also increase the risks for children having poor health, educational and social outcomes. Alongside the human costs of untreated PMH problems, there are huge economic costs. A report by the London School of Economics and the Centre for Mental Health (2014) showed that the costs of perinatal mental illness for every annual cohort of births were £8.1bn.   
     
  3. In summary our submission looks at what is needed to better ensure parity between mental and physical health care; what investing in the workforce, including maternity, health visiting, mental health practitioners GPs and the voluntary sector can deliver; includes new research highlighting how changing current practice and embedding mental health practitioners within maternity and health visiting settings could save costs and help provide integrated care to women and families; and presents evidence of the unequal impact the pandemic has had for women and their families experiencing maternal mental health problems.
       

RESPSONSE TO QUESTION 1:

  1. A confident, well-equipped workforce is a key element of ensuring all women and families across the UK have equitable access to comprehensive high-quality PMH care. Most mothers and pregnant women encounter a range of practitioners during the perinatal period. Maternal mental health training for GPs, midwives, health visitors and maternity services can improve early intervention and reduction in inpatient admission for PMH problems (Hogg, 2013). However, cuts to statutory services, for example health visiting and family services, have limited the extent to which services have the capacity and resources to address mental health as part of the maternity pathway (Papworth et al., 2021). The Royal College of Midwives (2021) warn that the NHS in England face a shortage of 2,000 midwives and rising. The Institute of Health Visiting (2021), estimate a national shortage of 5,000 health visitors. This may mean it is easy for mental health concerns to be missed. We know, for example, despite the change in terms of GP contract where all new mothers are required to be offered a 6-week postnatal check on their mental health, only 15% of mothers surveyed by NCT reported having an appointment that was focused on their own health and wellbeing.
  2. A system that supports the mental health of all women in the perinatal period must embed mental health competency and support in other relevant services: maternity services, health visiting, primary care, child and family social services, and public health approaches. These services are as vital to many women’s mental wellbeing as specifically targeted mental health provision, and are critical to early detection, intervention and ongoing wellbeing monitoring. Furthermore, an understanding of how trauma, domestic abuse, addiction, deprivation and discrimination impact on fear of child removal and therefore women's engagement with professionals are vital competencies for all services.
     
  3. Whilst there has been some investment in PMH care, especially in specialist services, this will not be appropriate for all women. Furthermore, there is evidence of cuts in recent years to some services for women and families during the perinatal period, meaning comprehensive PMH support is not always available.
  4. New independent research (February 2022) commissioned by the MMHA and conducted by the London School of Economics and Political Science (LSE) examined the economic viability of reforming current treatment for pregnant and postnatal women experiencing common maternal mental health problems such as depression and anxiety. This report found that an efficient model of care includes both specialist and general roles within maternity and health visiting services. Specialist PMH midwives and health visitors provide supervision, training and strategic support in setting up collaborative ways of working. Alongside addressing the known existing workforce shortages (paragraph 5) so there is a well-resourced general maternity and health visiting workforce, there needs to be specialist PMH midwives and health visitors within each local area.
     
  5. In addition to addressing staffing shortages, ongoing training in PMH care, including trauma-informed care, should be delivered to all professionals involved in the care of women during pregnancy and the first years after birth.

 

RESPSONSE TO QUESTION 7:

  1. Covid-19 has brought about significant changes in the way mental health support is delivered. The use of remote support and digital technologies became more prominent in a several health and care contexts. This is an emerging area, with scope for research and robust evaluation of what works.
  2. We do not yet know the full extent or long-term consequences of the pandemic. It has undoubtedly had a profound impact on the risk and protective factors for mental health, especially for mothers and pregnant women. We know that women from some population groups, for example women and families of colour, have been disproportionately affected. Their experiences must feature in any research or data collected in this area.
  3. We need to understand the impact of ‘remote’ mental health care. Where face-to-face services have been replaced by remote services, we must understand how they work and whether there is an impact on quality, choice, patient satisfaction and most of all whether they help people with their mental health. There may be a real risk of indicators of PMH issues and other pressures on women and families being missed by 'remote' care
  4. Research should develop the evidence base so that women who have no access to digital technology get the support they need, and so that digital options are not implemented to save money at the expense of face-to-face consultations and therapies.
  5. As more services adopt remote/online interventions, the impact of ‘remote’ mental health care on mothers must be better understood. We must explore how they work and whether there is an impact on quality, choice, patient satisfaction and most of all whether they help people with their mental health. Women who do not have access to digital technology must get the support they need, and digital options must not be seen as a way to save money at the expense of effective face-to-face consultations and therapies.
  6. NHS Digital should collect and publish routine data on the mental and physical health of women during the perinatal period. This should include data on the uptake of PMH services, on deaths from all causes, and hospital admissions. Data must include robust monitoring across equality groups to identify inequalities in prevalence, experience and outcomes.

RESPSONSE TO QUESTION 10:

  1. There is a growing body of evidence on the disproportionate impact of the pandemic on mothers and pregnant women. MMHA and Centre for Mental Health published a review of Covid-19’s impact. It found that an increase in maternal anxiety during the pandemic was associated with several issues, including anxiety of new mothers about catching the virus; worries over their baby’s wellbeing and that of other family members; concerns about being able to cope without normal support being available; fears over partners being able to be present in hospital for labour and birth; worries over lack and clarity of information on maternity services; worries about being penalised if seeking support that falls outside of government guidance; and concern over job security for expectant mothers, new mothers and their partners (seemingly an even greater concern for women of colour) (Papworth et al., 2021).
  2. The review found that some women were disproportionately impacted by the pandemic and restrictions. This includes women from diverse ethnic communities, including South Asian and travelling communities; refugees and asylum-seekers; single parent families; women and families with limited access to the internet and online services; women with poor mental health or a history or mental health problems; women with a history of severe postnatal mental illness; and women who might ordinarily be anxious about pregnancy, for example those who have lost one or more previous pregnancies (Papworth et al., 2021).
  3. We also know that the workforce supporting women and families in the perinatal period has endured significant wellbeing challenges due to the pandemic. Some have experienced infection, illness, and bereavements. Contributors to our recent review shared concerns that virtual appointments might make mental health monitoring more difficult, and that redeployment of health visitors and other professionals in some area resulted in larger caseloads (i.e., less time to meet the needs of more women) and less experienced staff (Papworth et al., 2021).
  4. Some MMHA members expressed their views on how the pandemic has hit PMH services, the workforce and the needs of women and families.
  5. A minimum high standard of mental health care and support for pregnant women and mothers of young infants is required. PMH staff numbers should be maintained, and where staff redeployment proves necessary in a crisis, mental health services must be maintained.
  6. In addition, the mental health and emotional wellbeing of staff working with women and families during the perinatal period needs to be supported. There needs to be recognition of the risk of exhaustion, anxiety, depression and post-traumatic stress disorder (PTSD) for the workforce created during the pandemic and trauma informed approaches to good HR practice are required.

RESPSONSE TO QUESTION 11:

  1. To provide effective and integrated public services for women and families requires joint strategic working at the national and local levels. This is not currently happening consistently across the country. Better integration between services would help ensure women are not having to tell their story time and time again to different professionals. Given the stigma around PMH and the fear of looking like an ‘incompetent’ mother or having their baby ‘taken away’, creating space where women feel safe to talk about their mental health is key. A survey by the NCT found that, despite changes to the GP contract, the vast majority of women are not asked about their mental health during health checks.
     
  2. New research by LSE (February 2022) identified ways in which the integration of public services could help address unmet maternal mental health needs. The report, ‘The economic case for increasing access to treatment for women with common mental health problems during the perinatal period’, evaluated the economic viability of reforming current treatment for pregnant and postnatal women experiencing common maternal mental health problems, such as depression and anxiety.

 

  1. Researchers found that changing current practice to a more integrated model of working, could have a net economic benefit of half a billion pounds over ten years; £52 million in NHS savings and quality of life improvements worth £437 million. 
     
  2. The proposed ‘integrated model of care’ would see mental health care for common mental health problems integrated into maternity and health visiting services. This would allow for women’s mental wellbeing to be accurately assessed at every routine contact and suitable treatments to be offered – in a similar way to physical conditions such as diabetes or high blood pressure. In contrast, the report finds that current practice leaves many women without access to evidence-based treatment when and where they need it.

 

  1. Policy analysis by MMHA member, Centre for Mental Health, determines that integrated service provision is the logical and economical next step in the evolution of PMH care in the UK. It would close a major gap and ensure women get timely access to help for their mental health needs.
     
  2. For the suggested integrated model to be effective, indeed for better integration of public services to deliver, services must be developed in an equitable way, actively seeking to meet the needs of all women, including those who are less well-served by current arrangements. We know that there are significant inequalities in how women from different backgrounds experience services. For example, research by the MMHA and Centre for Mental Health (2021) identified that PMH needs increased across the board during the pandemic. However, the impact has not been equal, women and families of colour and poorer families have been amongst the most adversely affected. We also know that incidence and severity of domestic abuse increased during the pandemic and is particularly prevalent during pregnancy. 
     
  3. MBRRACE-UK’s report ‘Saving Lives, Improving Mothers’ Care‘ (2021) found that maternal mortality is more than four times higher for Black women, two times higher for mixed ethnicity women and almost twice as high for Asian women compared with white women. A statement by the Royal College of Obstetricians & Gynaecologists describes how racial bias plays a part in poorer outcomes: “it can negatively influence diagnosis and treatment options made by clinicians, including pain management, and indirectly affects medical interactions through loss of patient-centeredness in treatment plans and removal of patient autonomy” (RCOG, 2020). This can lead to a ‘feedback cycle’ where people from Black, Asian and Minority Ethnic backgrounds might be less likely to interact with healthcare professionals through fear of potential prejudice and discrimination following poor experiences, or a perception of poorer care.
     
  4. Furthermore, the needs of other traditionally seldom heard voices including women in the criminal justice system, asylum seeking women and those who have had or are at risk of having children removed must be addressed. MMBRACE 2022 also highlights that many of the women who die from suicide or substance misuse face multiple adversity, again highlighting the need for an understanding of more complex social problems for maternal mental health care and support.

 

  1. Having the voice of lived experience involved in co-designing services is essential and we would encourage this way of working is used consistently. The involvement of women and families, proactively engage women from diverse backgrounds, sharing their own experiences can help to create services, which recognise and respond to their mental health needs, and support ALL families getting the best start in life.

 

RESPSONSE TO QUESTION 12:

  1. The voluntary and community sector (VCS) plays a crucial role within the PMH sector. During the pandemic, this has been even more the case, research by MMHA and Centre for Mental Health reported that the VCS had seen a huge rise in demand for their services and for PMH support and also a rise in the level of need among people accessing their services. Families are experiencing more complex, nuanced, and intense issues, existing mental health issues are worsening, and providers reported an increase in suicide attempts.

 

  1. The vital role of the VCS needs to be recognised and valued as equal partners, including by NHS organisations commissioning mental health services. In particular, the VCS can be especially important for women who have experienced gaps in support in their communities and face barriers to getting the care they need, for example women of colour or women within the criminal justice system and those facing multiple adversities. Sustainable funding for the VCS will help provide organisations working women and families in the perinatal period to provide stable long-term support.

 

Thank you for the opportunity to submit evidence.   

 

February 2022

 

 

References