Maternal Mental Health During a Pandemic: A look at the rapid evidence review of the impact of Covid-19 and the subsequent recommendations made by the Maternal Mental Health Alliance

AIMS Journal, 2021, Vol 33, No 4

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By Frances Attenborough

I’m an NCT practitioner,^[1] supporting parents both before and after their babies are born. The last 18 months have been hard going. I’ve observed distressed mothers and fathers who have found birth to be not at all what they expected. I’ve spoken to parents who feel completely isolated, with no support from friends or family, and in some incidences with little support from health care professionals. I’ve heard stories of how pressurised pregnant people feel and how so many seem to be coerced into induction, without the support of a partner. NHS staff are overstretched and burnt out. But I’m also aware that I’m only seeing my little bit of the picture, supporting those that come to me. So, I read the rapid review of evidence by Papworth et al (2021)^[2] of the impact of the Covid-19 pandemic on maternal mental health with interest. Would my anecdotal viewpoint be confirmed, or was I seeing a small subsection of parents for whom Covid-19 had a particular negative impact? How would the recommendations fit into the existing checklist called for by AIMS in 2019?^[3]

The rapid review was published in early 2021, having been written in October and November 2020. It is therefore reporting on the impact of the first UK lockdown. It reviews both published research and papers that were still in pre-print^[4] in Autumn 2020 considering mental health and Covid-19. Papworth et al also looked at data sets on services and service users covering October 2019 – September 20 in England (the only nation where this data was available), undertook an online survey of voluntary and community-based services and asked for evidence submissions from institutes, professional bodies, commissioners and voluntary and community-based services. They are upfront in acknowledging the limitations of this evidence. For example, questions can be raised about the use of pre-print papers as they have not completed the peer review process and may be subject to changes, however, it can also be argued that, due to the very rapid time frame the review has been completed in, it would exclude much valuable data to only include published work. There are selection biases in those that fill in surveys, especially when the pressures that the last 18 months have brought are considered. Partners’ mental health was not considered because there was insufficient data. There are two main limitations. Firstly that the research is limited to the first lockdown, which in retrospect may have been different to subsequent lockdowns. Secondly, because this is a rapid review early on in a pandemic it is too soon to understand what the full impact may be.

My impressions of the review were that it was both thorough and valid in scope and methodology. The themes that came out from each of the data sets (i.e. the literature review, the numbers from the databases, the survey and the calls for evidence) confirmed each other, suggesting that these are indeed common themes, and that further investigation would not add anything new. The results and conclusions form interlocking themes, some of which are now being confirmed by other authors.

It was clear that there were already issues with perinatal mental health services and maternity services around the four nations before Covid-19 (AIMS, 2019). The authors describe how the pandemic has made this situation much worse, leading to mothers experiencing worsening perinatal mental health. This is caused in part by the anxieties around the pandemic itself, but also by the restrictions, adaptations and reduction in services. Parents were left unsure what services were available, whether it was safe to give birth, who would be able to support them, and what would happen if things didn’t go as planned. There was a dearth of information because this is a new disease and parents struggled with knowing how to make the right decisions. Choices were removed; home births were suspended in some areas^[5]. Choices for some birthing people might still change if Covid rates increase dramatically again, or if a woman in labour tests positive for Covid within 10 days of birth^{[6] [7]}. This has led to parents grieving the birth they had thought they were going to have as well as increasing anxiety. In addition, some parents were also grieving for lost family members or had family who were at risk or were ill.

Isolation came out as a very strong theme in the review. We know it takes a village to raise a child, but what happens when that village – including immediate close family and partners – is taken away, all a time of increased anxiety? One of the things that struck me through supporting people contacting the NCT infant feeding line throughout the pandemic is that parents were missing normalisation; the lack of peer and family members giving their perspective on things lead to parents concentrating on the negatives, and worrying about things being wrong even if they weren’t.

Up-to-date analysis by Public Health England^[8] shows that the mental health of the population as a whole declined and recovered to coincide with various lockdowns and easing of restrictions, however, this hid differences in subsections of the population. The authors describe how the response to Covid-19 has acted as an amplifier of risk; those people who were already at risk or were disadvantaged have been disproportionately affected by the pandemic response (confirmed by later research^{[9] [10] [11] [12]}). These risk factors included simply being pregnant^[13]. Worryingly, whilst it is clear that domestic abuse has increased during the first lockdown^[14], the review notes that safeguarding referrals went down. It is clear how the less confident mothers, or those less adept at navigating the systems, or those excluded from the systems put in place (e.g. because they have no private, safe space in which to talk, or they have no internet access) will get less support, even though these are the very people that might need the support the most. Research by the Mental Health Foundation^[15] has also shown that people with long-term conditions were also anxious about the shift towards taking personal responsibility for their own Covid-19 safety, which I’ve also heard pregnant people being concerned about.

As mentioned above, service provision was not adequate prior to Covid. The authors commend that pregnant women and new mothers were recognised early on in the pandemic as being vulnerable and a priority group, yet in many areas (including my own) midwives and health visitors were redeployed elsewhere in the NHS. Services switched online, but took a little time to get up and running. Services were also reduced as staff became ill with Covid-19 themselves or had increased caring responsibilities. It is clear that the redeployment of health visitors and midwives was a mistake. Papworth et al (2021) state quite clearly 'it turns out that what was deemed "unessential" was, in fact, essential'. In other words, highly skilled staff such as health visitors and midwives were moved from supporting mothers and new families (considered less important) to supporting the Covid crisis (considered more important). The assumption that maternity and postnatal care was less important than treating Covid patients has since been shown to be incorrect. We know services were already stretched with shortages in the numbers of midwives and health visitors pre-pandemic. Those left have worked through unprecedented pressure and are burning out. They have gone through the pandemic the same as the rest of us with merely a few minutes clapping as a reward. I know from my own practice that those that support others must be supported in turn.

The result of this reduction was that the third sector^[16] was put under increased pressure to pick up the slack at a time when their own funding stream may have been at risk, staff were furloughed, sick or had childcare issues. Some third sector services supported mothers with more severe illness than they expected or were commissioned to support.

One of the concerns that I frequently came across in my own work was that more women and birthing people were experiencing a traumatic birth. I was fascinated to read in the review that, whilst health visitors were also reporting this, midwives were not. To my mind this is unsurprising because it takes time for people to process their experiences of birth and with many new families receiving fewer, or online, midwifery visits, this may be something that midwives are not seeing. However, as time goes by, I suspect that the numbers of families who report a traumatic birth may well increase. We know the risk factors for traumatic birth^[17] and it is clear how these could well be amplified at a time when the pandemic caused a reduction in staff and as the pressures on the staff (such as infection control) increased. Isolated mothers may have felt less in control at a time when they had no advocate in the form of a birth partner or doula.

The review describes several ‘silver linings’ of the pandemic. These could indicate ways that the situation of families might be improved as we return to a more normal life. Mothers reported that having a partner around more (possibly due to furlough, possibly due to working from home) was beneficial, as was the reduction in pressure and expectations from families and friends. Fewer visitors meant that new parents and babies could bond in their own bubble. There may be positives to consider around moving services online too, especially if it helps people to access services. However, the potential negatives, such as making access harder for some or the risks around missing important information, must also be fully explored. Whilst the picture is bleak, it is not unremittingly so.

The authors remind us that the crisis is not yet over, and at the time of writing (August 2021), with increasing Covid rates due to the Delta variant, I would concur that we are not yet through this. Furthermore, it is too soon to know what any long-term outcomes might be.

In the light of the evidence discussed, Papworth et al make a list of eight recommendations. These are:

1. To assess the true level of demand for perinatal mental health services
2. To future-proof perinatal mental health services against future pandemics or similar public health crises
3. To have up-to-date data to understand the changing picture
4. To tackle racial discrimination within health systems and adverse outcomes for people of colour
5. To have better research
6. To understand the impact of ‘remote’ mental health care
7. Government and NHS must recognise the importance of voluntary and community organisations
8. To support the mental health of all health and care staff.

It is somewhat disheartening to see that concerns raised before the pandemic do not seem to have led to lasting change. AIMS clearly reiterates the need to prevent traumatic birth, and to support perinatal mental health much more effectively. If staff had already been trained to provide culturally safe care to all women and families, if staff had not been redeployed, if services had been appropriately funded pre-pandemic and then not been suspended or disrupted – might we be in a different position now, without the increases in demand and the increases in complexity of cases? The long-term impact is not yet known, and resources need to be allocated to fully understand what this new level of demand really is. The true levels may never be known if mothers are not listened to properly or if they can’t access timely support. This needs to include removing any time barriers on receiving care or making a complaint. Lessons do need to be learnt in order to future-proof services. It will take time for everyone, including NHS staff, to recover from the pandemic and some issues may only come out when parents realise that what they have been through is not normal.

We need more, high-quality research, because without understanding what happened, why, and what the effects are we can’t make decisions about the future. This is especially true in the area of remote support, which might look very attractive to commissioners, but for which the effectiveness is not yet known. As Patel^[18] states, ‘People aren’t hard to reach, they are just easy to ignore’. We must ensure that no one is ignored no matter what their background is, where they live, where they give birth or whatever care they have received. The Maternal Mental Health Alliance (MMHA)^[19]has started a new campaign calling for all women and families to have access to high-quality, comprehensive care which, if implemented, could make a massive difference to families in the UK.

Despite the limitations of the report, it reads as a blunt wake-up call showing that mistakes were made, the repercussions of which are not yet fully understood. It is important to support mental health, especially during a pandemic; the long-term impacts of getting this wrong may be felt for some time to come.

One year on, the picture is not rosy. We are, as a population, ground down by ongoing stress, and whilst some people seem to be coping, for others the situation is no better one year on, or is worse^[20].

I can conclude by saying that what I was seeing and hearing was not from a unique subsection of the population. There is a clear need for more research into the long-term effects of the multiple lockdowns, and a clear need for more funding to be dedicated to support mental health across the board.

Author Bio: Frances Attenborough lives in the North West of England and originally pursued a career in Materials Science before having children and realising that supporting mothers was much more worthwhile.