Owen, L., Nevin, H. (2008) A programme to improve perinatal emotional and mental health. This is an extended version of the article published in Nursing Times; 104: 8, 28-29.
Government reports consistently highlight the need to provide early support for emotional and mental health problems, with the antenatal and postnatal periods identified as important stages for women and their families. This article outlines the development, implementation and evaluation of a support programme for women with perinatal emotional and mental health problems. The project acts as a bridge between universal services offered by health visitors and the primary care mental health team’s specialist services. The article outlines positive outcomes from the programme, and also discusses issues around funding.
Lynne Owen, BSc, BA, DPSN, RGN, RHV, is health visitor and specialist practice teacher; Helen Nevin, BSc, DipHE, RGN, RHV, is health visitor; both at Knowsley PCT.
Knowsley is one of five metropolitan boroughs of Merseyside and has a population of over 150,500. Its population is relatively young, with nearly 41% within the childbearing age range of 16-44 (Office for National Statistics, 2001). There is considerable evidence to suggest that these years are a time when women are vulnerable to developing mood disorders.
Non-psychotic depression in the early postpartum period affects 10-15% of women (CPHVA, 2006), while anecdotal evidence suggests a prevalence of over 37%. A recent audit of health visitors’ work in Knowsley has shown over 14.2% of women are affected by postnatal depression, equating to the highest level suggested by research.
There is unequivocal evidence of the short- and long-term effects of postnatal emotional and mental health problems on women and their families. Research suggests that depression is detrimental to mother/infant and mother/partner relationships (Milgrom et al, 1999; Hoghughi, 1998). There is increasing evidence about the long-term effects of depression on: infant brain development; social, emotional and cognitive development; and the parenting process (Paulson et al, 2006; Robila and Krishnakumar, 2006; Gerhardt, 2004; Balbernie, 2001; Weinberg and Tronick, 1998).
Government reports have further reinforced the need for services that:
Are client centred (Department of Health, 2000);
Enable children to have a good start in life (Cabinet Office, 2006; Department of Health, 2004; 2001; Department for Education and Skills, 2003);
Address the promotion of good emotional and mental health (DH, 2006), with the ante- and postnatal periods specifically highlighted (DH, 2004; 2002a; 2001);
Address the prevention of and early support for emotional and mental health problems (DH, 2006; 2004);
Provide targeted support for clients with emotional or mental health concerns (DH, 2006; 2004; 1999a);
Endorse the importance of creating a seamless service through working partnerships and interagency, multi-professional collaboration (DH, 2002b; 1999b);
Provide staff with the knowledge, skills and empowerment to design and deliver services (DH, 2002a; 2002b).
As a result, service development focusing on postnatal support for women with emotional and/or mental health problems gained momentum in Knowsley PCT.
A postnatal depression integrated care pathway was launched in January 2006. The pathway was devised to reduce inconsistencies and to standardise care in this area, ensuring effective diagnosis, monitoring and support for clients with postnatal depression.
Health visitor assessment and subsequent planned support was then established and enhanced. Referrals to the local primary care mental health team (PCMHT) became more consistent and appropriate. The pathway also meant that clients’ needs were given a higher priority by the PCMHT.
However, demand for this service meant a waiting list remained and therefore support offered by health visitors to clients awaiting mental health assessments became inconsistent when planned support came to an end. Once again, there was a need to provide a service to fill the gap.
We needed to offer good-quality care in a seamless service, forming a bridge between the universal service offered by health visitors and the PCMHT’s specialist services.
Discussions took place with some healthcare professionals who had identified that inconsistencies in support for clients in their own caseloads were causing them concern.
An initial literature search on group support offered to women with postnatal depression in other areas was carried out. This enabled us to look at the types of programmes, their content, numbers in groups, length of sessions, what worked and what did not.
In addition, clients were asked what they would like from the health visiting service while they waited for counselling. A number of meetings were held to discuss and identify what kind of group was needed and what should be included. Following these meetings, a multi-professional/interagency team of nine was formed as a working party, including health visitors, nursery nurses and a midwife. The professionals involved were very motivated and each took on roles within the group very quickly. As some team members were already part of the wider postnatal depression strategic group, they took on strategic roles, such as coordinator and assistant coordinator.
When considering the programme to be delivered, we recognised it had to provide a supportive, empowering and educational environment in which clients could:
Develop strategies to communicate effectively their emotional and mental health needs;
Increase self-esteem and confidence;
Contribute to positive parenting;
Recognise the need for healthier lifestyles;
Devise achievable goals for change.
The involvement of the whole team in the programme’s planning enabled members to take responsibility for and ownership of the work. Each person identified their own areas of knowledge and skills within the topics, so the sessions could be planned and written.
Steps Forward programme
The programme’s name came about after discussion – we felt it had to portray the initial positive stage to help clients and colleagues to engage with the project. Hence the name Steps Forward (STEPS - Support Towards Enabling Positive Smiles) was developed.
By the end of 2006, the Steps Forward programme had been developed into a 10-week support programme for women with moderate perinatal emotional and mental health problems. Once each session was written and endorsed by the senior therapist in the PCMHT, the team had a training day in which condensed versions of each session were carried out as if team members were clients. This enabled the team to consider the possible barriers and issues that may impede clients’ ability to engage fully in the programme, as well as possible solutions. It also enabled each member to take on the facilitator role, as would be needed when the programme started its pilot phase.
Discussions then took place with other agencies to secure support for the provision of rooms and crèche places for women attending the programme. This was positive given government considerations in the Making a Difference document (DH, 1999b), which stated that effective care and treatment are the products of team effort. We received maximum support from a number of agencies including Sure Start children’s centres, Home-Start and a local family centre.
Early on in the project’s development, we recognised that Steps Forward may be seen as a way of placing clients in a support network when health visitor caseloads meant that care within the pathway was difficult. As a result, a robust referral system was set up containing criteria to reduce risk. These include:
Evidence in health visitor family records of clients being offered the universal service according to the integrated care pathway.
Clients must have been referred for primary care mental health assessment according to the care pathway.
Following discussions with the PCMHT, it has also been decided that clients can be accepted if they are leaving counselling but where the client and her mental health professional feel she needs additional support before returning to universal services. However, clients will not be accepted if there is involvement with secondary care services, as the episode of care needed is acute and the programme facilitators are not specifically trained in mental health.
The referrer must visit the client with the group facilitator.
This lessens the chance of clients not engaging with facilitators and aims to ease the transition between services and into a group situation. It also provides the opportunity to ensure that the equality and diversity policy is adhered to so, for example, any language barriers, literacy difficulties or disabilities can then be dealt with or planned for within the group. The visit also provides an environment in which any family stresses or life events that can exacerbate clients’ conditions can be discussed. In addition, a risk assessment can be carried out for both clients and facilitators.
During this joint visit, clients are given a welcome pack which provides:
An outline of the programme’s content;
Information and contact names and numbers for Steps Forward facilitators;
An overview of the signs and symptoms experienced by clients with emotional and mental health problems in the postnatal period, to illustrate the wide-ranging effects - this enables clients to relate to others in the sessions who may have different symptoms;
A self-help guide;
A carers’ information sheet to give an insight into how their relative or friend may be feeling and how they can help - this can help to open up lines of communication between clients and those closest to them.
A maximum number of between six and eight is accepted for each group as evidence suggests that smaller groups lead to better engagement, involvement and dynamics. Smaller numbers also stop the group splitting into cliques that prevent full group bonding.
A pilot project was launched in three PCT areas from January-March 2007. A total of 11 women started the programme - 10 were fully supported; one dropped out.
The second programme started in May, this time consisting of four groups in three areas. This decision was taken as one locality is large, which meant clients without transport could potentially become isolated from the programme. A total of 16 women started – 15 were fully supported, again with only one dropping out.
The third programme started in September in two PCT areas due to lower referral rates. Ten women started the programme but only seven were fully supported. This drop-out rate of three is the largest yet. However, as it has only occurred in one area, it can be partially attributed to sick leave and maternity leave that led to a lack of consistent facilitators; this appeared to destabilise the more fragile group members.
Evaluation is carried out through a range of process, impact and outcome methods from facilitators, clients and clients’ family members/friends. It takes the form of:
Facilitators - attendance sheets, observations, supervision;
Clients - questionnaires, evidence of impact;
Clients’ relatives/friends - questionnaires;
Other feedback - PCMHT, GPs, generic health visitors and Sure Start personnel.
Positive outcomes from the project include the following:
Most clients are attending more mainstream services;
Clients report better relationships with their partners and families;
Clients’ partners have acknowledged the difference that group attendance has made to family life;
Other clients report going out for activities together and joining children’s centre activities;
Clients in one area are attending their own weekly coffee morning for peer support and all have attended a number of social functions together;
Four of these have gone on to:
o Plan a future business strategy;
o Lobby children's centre management and council officials to secure support for the coffee morning to become a post-Steps Forward peer support group;
Two group members have discussed their feelings and experiences with an inspector for the local joint area review;
Two clients have gone on to train to become peer breastfeeding supporters;
A number of clients have returned to their original jobs;
One client has returned to a managerial post at work;
One client is now receiving secondary care services - although this does not appear to be positive, she is getting appropriate help and support.
In the early stages, the programme’s cost implications were obscured by the amount of initial support we received from partner agencies. However, as the financial year progressed, the actual costs became apparent and it has taken a vast amount of work to secure ongoing funding.
Throughout the past year, funding has come from several different sources. It has mainly come as a result of team members lobbying managers/budget holders and commissioners from different PCT services and integrated agencies such as the local Sure Start children’s centres. This has proved to be problematic, in that funding has been short term and from different budgets with varying means of access.
In hindsight, the team should have engaged a manager and/or commissioner at the original planning stage. Not only would this person have had a full understanding of the programme’s structure and process, but also she or he could have advised us on long-term budgetary matters. In addition, costs could have been considered in a much more robust manner and funds secured from more stable sources early on.
However, as already shown, the evaluations have been extremely positive. As a result, the programme has generated much interest from both within the PCT and other agencies.
Since the programme was presented at the talk shop sessions at last year’s CPHVA conference in Torquay and was a finalist in the NT Awards 2007, it has generated interest among PCT management and commissioners. As a result, a business plan is being produced so that the programme can be considered for mainstream funding from April 2008. Mainstream funding would secure the project and enable it to be offered in four centres across the three localities three times a year, subject to referrals. This would also enable current facilitators to train new professionals, ensuring adequate staff levels to run the programme and act as support in areas affected by staff absence.
Steps Forward aims to prevent the short- and long-term effects of postnatal emotional and mental health problems. The project can be acknowledged as good practice as it:
Promotes good emotional and mental health;
Applies national and local guidance, using a coherent approach to providing better support for mental and emotional well-being;
Creates a seamless service through working partnerships and interagency, multi-professional collaboration;
Embraces a partnership approach by optimising mainstream resources to provide staff and facilities;
Applies equity and equality in service provision and standardises inconsistencies;
Provides targeted support for clients;
The development of Steps Forward has not only benefited clients but also provided staff with the knowledge, skills and empowerment to design and deliver services. In particular, it has helped develop staff who may have previously felt unable to make a major impact on practice, especially in relation to service development.
This project was shortlisted in the maternity category of the NT Awards 2007.
Balbernie, R. (2001) Circuits and circumstances: the neurobiological consequences of early relationship experiences and how they shape later behaviour. Journal of Child Psychotherapy; 27: 3, 237-255.
Cabinet Office (2006) Reaching Out – An Action Plan on Social Exclusion. London: The Stationery Office.
CPHVA (2006) Support for Parents: Best Start for Children (2005) HV Forum/CPHVA. London: CPHVA.
Department for Education and Skills (2003) Every Child Matters. London: The Stationery Office
Department of Health (2006) Our Health, Our Care, Our Say: A New Direction for Community Services. London: The Stationery Office.
Department of Health (2004) Choosing Health: Making Healthy Choices Easier. London: The Stationery Office.
Department of Health (2002a) Liberating the Talents. London: The Stationery Office.
Department of Health (2002b) Shifting the Balance of Power: The Next Steps. London: The Stationery Office.
Department of Health (2001) Tackling Health Inequalities: A Consultation on a Plan for Delivery. London: The Stationery Office.
Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. London: The Stationery Office.
Department of Health (1999a) The National Service Framework for Mental Health. London: The Stationery Office.
Department of Health (1999b) Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. London: The Stationery Office.
Gerhardt, S. (2004) Why Love Matters: How Affection Shapes a Baby's Brain. East Sussex: Brunner-Routledge.
Hoghughi, M. (1998) The importance of parenting in child health. British Medical Journal; 316; 1545-1550.
Milgrom, J. et al (1999) Treating Postnatal Depression - A Psychological Approach for Health Care Practitioners. New Jersey: Wiley & Son.
Office for National Statistics (2001) Census 2001. www.statistics.gov.uk/census2001/census2001.asp
Paulson, J.F. et al (2006) Individual and combined effects of postpartum depression in mothers and fathers on parenting behaviour. Pediatrics; 118: 2, 659-668.
Robila, M., Krishnakumar, A. (2006) The impact of maternal depression and parenting behaviours on adolescents' psychological functioning in Romania. Journal of Child and Family Studies; 15: 1, 70-81.
Weinberg, K.M., Tronick, E.Z. (1998) The impact of maternal psychiatric illness on infant development. Journal of Clinical Psychiatry; 59: 53-61.