Perinatal mental health: A preventative approach

AIMS Journal, 2023, Vol 35, No 4

By Mary Nolan

Some Inconvenient Truths

Here are some uncomfortable facts that you may well be familiar with:

In the UK, in any given week,

• 8 in 100 people are living with mixed anxiety and depression
• 4 in 100 people are living with post-traumatic stress disorder (PTSD)
• 3 in 100 people are living with depression^[1]

If we look at statistics for Black or Black British people, we find that:

23% of Black or Black British people will experience a common mental health problem in any given week. This compares to 17% of White British people.^[2]

Statistics specifically for young women are as follows:

Over a quarter (26%) of young women aged between 16–24 years old report having a common mental health problem in any given week.^[2]

This figure is likely to be higher in 2023 than in 2016 given the impact of COVID on mental health, and especially on young people’s. In a 2021 survey of 12,000 adults across England and Wales, MIND^[3] found that around a third of adults and young people reported that their mental health has got much worse since March 2020, the start of Lockdown 1.

If we turn to statistics for perinatal mental illness, we find that antenatal and/or postnatal depression, anxiety, obsessive compulsive disorder, postpartum psychosis, eating disorders and post-traumatic stress disorder (PTSD) affect up to 27% of new and expectant mums.^[4]

Data for fathers’ perinatal mental health is neither as robust or as available as for mothers, but in 2017, the Born and Bred in Yorkshire (BaBY) team^[5] reported that:

The prevalence of fathers’ depression and anxiety in the perinatal period (i.e. from conception to 1 year after birth) is approximately 5–10%, and 5–15%, respectively.

(Abstract)

What can we deduce from these figures?

Well, we can certainly say that mental health problems are widespread among the British population. In particular, young people and Black or Black British people are too often struggling with loneliness, depression, anxiety and suicidal thoughts. If you are a young woman, you are more likely to be living with mental ill health than if you are an older woman, and if you are a young Black woman, you are even more likely to be living with mental distress. All of this equates to a huge amount of human suffering, and an enormous burden on the NHS.

A significant proportion of people living with mental illness are in the group of those likely to become parents for the first time or to add to their existing family. That is, they are the future mothers and fathers of the next generation of citizens. Parents who are depressed before they become pregnant are likely to be depressed during and after pregnancy. And this matters hugely because their mental health will significantly affect the wellbeing of their babies:

If parents experience mental health problems in pregnancy or the first year of a baby’s life, this can affect the way they are able to bond with and care for their child. This can have an impact on the child’s intellectual, emotional, social and psychological development.^[6]

Maternal mental health difficulties can have serious and lasting effects on the health and wellbeing of their baby.^[7]

Interestingly, and importantly, Public Health England^[8] acknowledged that parental perinatal mental health affects children beyond babyhood when it named its 2015 Report, ‘Mental health in pregnancy, the postnatal period and babies and toddlers’.

All of us working in the field of the transition to parenthood would agree that our aim is to ensure that every baby has the best possible start in life. To achieve this, I think that we have to adjust our sights to before pregnancy and explore what can be done to ensure that future mothers and fathers are as prepared as possible, in body and mind, to embark on their parenthood journey.

Pre-conception health, education and care

In 2018, researchers^[9] found that, worldwide, up to 50% of pregnancies are unplanned. That is, there has been no opportunity to address lifestyle factors such as smoking, overweight, relationship and mental health problems which increase the risk of adverse perinatal outcomes for mother and baby, including traumatic birth experiences and less likelihood of initiating breastfeeding.^[10]

Many of the women and childbearing people who are depressed and anxious during pregnancy have a history of mental ill health prior to pregnancy as is evident from the figures quoted in the introduction to this article. In a study from the Institute of Psychiatry in London,^[11] the authors examined how to improve outcomes for mothers and babies and concluded that the preconception window is the golden opportunity to address the physical and mental health of women thinking of having a baby, and of their partners, and that by so doing, health outcomes could be improved ‘across the whole life course’ for babies.

Spending money to address serious problems once pregnancy has occurred may well be a case of bolting the proverbial stable door….. Perhaps antenatal classes come far too late in the day; what we should be doing is running pre-pregnancy ‘Preparation for Parenthood’ courses and making it mandatory for every person between the ages of 16 and 25 who has not yet had a baby to attend (and, yes, I did say mandatory. Please send your comments via social media or email; I’d love to hear).

The Netherlands

I should be clear that the idea of a preconception programme is not my idea! Other countries such as the USA (some states) and The Netherlands have already thought about this. The Netherlands started its ‘Ready for a Baby’ program in 2008 and now has two online preconception programmes - ZwangerWijzer (Preparing for Pregnancy) and ‘Smarter Pregnancy’ which is a six months’ programme tailored to the needs of prospective parents who are finding it difficult to conceive. Zwangerwijzer invites prospective parents to assess their readiness for pregnancy. The home page^[12] asks:

Do you want to get pregnant?

Then it is important to prepare well…… It helps to give your child a healthy start. Sometimes also to get pregnant faster. With Zwangerwijzer you can test whether there are risks for the pregnancy and your baby.

Completing the questionnaire takes approximately 15 minutes. If you have a partner, you can complete it together with him or her.

If there are risks, you will receive immediate information and advice. At the end you will get an overview of all your answers. You can take it with you to your doctor or midwife. At the end of the questionnaire, you will also receive information about a coaching program to improve your lifestyle.

These online programmes are part of a nationwide targeted programme called ‘Solid Start’ which was initiated in 2018 and aims to ensure that more vulnerable parents-to-be are well prepared when they start their pregnancy, and that fewer unplanned and unintended pregnancies occur. Solid Start has been described as ‘social obstetrics’ which moves maternal mental health beyond the medical sphere and places it at the centre of a complex of issues - poor housing, debt, job insecurity, domestic violence and substance abuse - which require the attention and cooperation of multiple groups because the challenges prospective parents face cannot be dealt with by one agency or professional group alone. A cross-sectoral approach is the most appropriate, involving local coalitions of medical and social professionals, including debt assistance services, youth healthcare services, social welfare teams, general practitioners and midwives.

The United States

In the United States, Michele Stranger Hunter has devised the One Key Question® approach to pre-pregnancy education, health and care. The idea is that every occasion on which a woman or childbearing person presents for medical care, or visits the pharmacist, or sees the occupational health nurse at work, is an opportunity for preconception advice and counselling. The ‘key question’ is, ‘Are you thinking of becoming pregnant in the next year?’ Researchers^[13] have noted that:

Asking about people’s reproductive goals and desires can be a powerful tool to learn more about the context of their lives and build a stronger relationship between practitioner and patient/client.

Women and childbearing people may answer the one key question with ‘yes’, ‘no’, ‘I’m not sure’ or ‘I don’t mind’. If they answer ‘no’, they are asked whether they are happy with their current contraception or would like to review it. If they give any of the other possible answers, they are offered information, advice and services to help them embark on a future pregnancy in the best possible mental and physical health.

Running a preconception course

Preconception courses could be run by antenatal teachers, midwives, health visitors, social workers or family support workers, and might cover:

• When is the right time for me to have a baby?
• What lifestyle issues do I need to address before conceiving a baby? (Thinking about diet, exercise, alcohol, smoking, drugs - prescribed, non-prescribed and illegal)
• Do I need some help with my mental health? Where can I get help?
• Are the key relationships in my life supportive?
• What special measures do I need to take before trying to conceive a baby (e.g. starting folic acid supplements)
• Where will my support come from if I have a baby?
• How much does it cost to have a baby? Where can I find financial support?
• Do I have the right contraception in place if I don’t want to have a baby in the immediate future?

Where might such courses be delivered? Should they be delivered online or face-to-face?

During the COVID pandemic, many prospective parents were grateful to be able to access antenatal education online, but in the post COVID era, I am regularly told by midwives and health visitors, and by pregnant parents themselves, that they would ideally prefer for antenatal classes to be face to face. It seems to me that the obvious place to offer preconception health, care and education in the UK is in Children’s Centres. Unfortunately, the number of these has declined steeply from the heady days of the late 1990s when the Sure Start programme was launched to target parents and children living in the most disadvantaged areas. The worth of Children’s Centres as a locus of education, counselling, advice and support was quickly recognised and Children’s Centres spread across the country to serve all parents, whatever their circumstances. However, in recent years, more than 1000 Centres have been closed. While there are plans to replace some of these with Family Hubs, it is not clear what exactly these hubs will provide and for whom. Writing only a few months ago, Sally Hogg,^[14] Senior Policy Fellow at the University of Cambridge, argued that the new Hubs and Family Centres appear to be ‘very different from the ‘welcoming, non-stigmatising progressive universal provision which is key to improving outcomes for all children in the earliest years’.

There is also scope for running ‘Preparation for Parenthood’ courses at colleges and universities, and in the workplace. Let’s not forget that another opportunity to maximise positive outcomes occurs between pregnancies – before the next baby is conceived. Such an inter-conception programme would enable women, birthing people and couples to reflect on their birth experience and on their experience of caring for a young child. Birth trauma resolution which many NHS Trusts now offer^[15] could be incorporated into or added onto a more general ‘Preparation for the Next Pregnancy’ programme.

A Broad Preventive Focus to Improve Parental Mental Health and Outcomes for Babies

The NHS Long Term Plan,^[16] which built on the Five Year Forward View for Mental Health, aimed to transform specialist perinatal mental health services across England so that by 2023/24, at least 66,000 women with moderate to severe difficulties would be able to access care and support in the community. This was an admirable aspiration and specialised mental health services for severely mentally ill childbearing people have improved in many areas.^[17] However, there is still very little for women and childbearing people with mental health issues which are sub-clinical or mild to moderate and these are the majority of parents who are struggling. There will never be enough money to fund services for all of these and while waiting for services, or being considered not sufficiently unwell to receive any, babies’ well-being is at stake. How much better – for parents and babies - if we could support people before they start a family.

Reviewing progress in perinatal mental health in 2020 and the challenges facing us, an article¹⁷ in ‘World Psychiatry’ argues for:

An extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality (p313).

For many years, those of us working in the early years were arguing for government and services to see ‘early years’ as commencing before children reached the age of three and started attending pre-school or nursery. Now the effort must be to push the moment of intervention back further and recognise that if we are to have an impact on children in the early years, we need to start by supporting the people who are planning on becoming their parents.

Author Bio: Mary Nolan worked as a birth and early parenting educator for 28 years before spending 13 years as Professor of Perinatal Education at the University of Worcester. She has published extensively in academic journals on birth-related issues and is the author of eight books. The most recent, 'Birth and Parent Education for the Critical 1000 Days', was published in 2020.