Mental illness during or after pregnancy is common. A project offering intensive support with befriending in the perinatal period was found to benefit mothers’ mental health
Family Action is a charity that helps more than 45,000 vulnerable families and children across England a year by offering emotional, practical and financial support. A pilot of a perinatal support project in Southwark, London was found to reduce mental health problems in vulnerable women and is now being extended. Such schemes complement the work of health visitors and other health professionals. Commissioners need to be aware of the long-term impact of such low-cost interventions in the early years.
Citation: McCaul A et al (2011) Perinatal support to protect maternal mental health. Nursing Times [online]; 107: 48, 16-18.
Authors: Anthony McCaul is senior media and campaigns officer; Jayne Stokes is director of business development; both at Family Action.
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A 2006 study by Mind, Out of the Blue? Motherhood and Depression, found that one in six women is affected by mental issues and stress during pregnancy or after birth (Oates and Rothera, 2006). These issues, if not dealt with properly, can negatively affect the relationship between mother and child (known as attachment), the child’s long-term development and the mother’s wellbeing (Hobcraft and Kiernan, 2010; Oates, 2008).
Frank Field’s 2010 report The Foundation Years: Preventing Poor Children Becoming Poor Adults, states that “a healthy pregnancy and a strong emotional bond between parents and the baby in the first few months can place a child on the road to successes”. The report also notes that there are a range of services to support parents in the early years, but that services provided by GPs, midwives, health visitors, children’s centres and voluntary organisations are fragmented and “are neither well understood nor easily accessed by those who might most benefit”.
Early intervention is crucial in mitigating the repercussions of perinatal depression, which can affect early healthy attachment and cause problems down the line. Family Action runs a wide range of services, all of which focus on the need to prevent families and children from developing or continuing down a path of mental, emotional or financial hardship.
The perinatal period refers to the time around a baby’s birth, including pregnancy and up to one year after birth. Studies surrounding attachment theories have found that the early years can profoundly affect behavioural development, and improving the quality of close relationships can have a positive impact (Howe et al, 1999). In addition, culturally sensitive, family-oriented interventions and support can prevent problems and are cost effective.
It is important to understand what types of intervention are most effective in ensuring mothers and babies achieve a healthy attachment. Numerous studies have been undertaken on services offering support to mothers in need.
A study by Lyons-Ruth et al (1990) examined the effect of a home support visiting service provided to mothers. The mothers were depressed, living in poverty and showed poor care-giving skills, including maltreatment. Interventions provided a trusting and accepting relationship in the form of a “befriender” and helped with meeting basic material needs.
Follow-up studies found that children were more securely attached at an early and later stage than children in similar conditions who had not received the services (Howe et al, 1999). The study found that the most effective and economic interventions measured over time are preventive practices with young children and their parents (Howe et al, 1999).
Managing maternal depression and working towards a healthy pregnancy increases the likelihood that children will develop with fewer long-term problems. This could reduce spending on health and social interventions later on in the lives of families and their children.
Health visitors: a key service
It has been suggested that primary care trusts have limited understanding of the incidence of postnatal depression and an inadequate strategic focus for the commissioning of perinatal mental health services (The Patients Association, 2011). Further research also suggests that opportunities may exist for enhancing health visitors’ knowledge in this area; they may have a limited understanding of, and ability to respond to, perinatal depression (Chew-Graham et al, 2008; McConnell et al, 2005; Naji et al, 2004).
A 2007 review of the role of health visitors (Department of Health, 2007) recommended that early intervention and prevention, proactive promotion and prevention of ill health, the promotion of mental health and cross-organisational working should remain core professional responsibilities. Recognising the need for continuing professional development, the review also acknowledged the need to update health visitors’ knowledge, particularly in the field of neurological development and mental health promotion.
While health visitors provide an essential role in supporting new mothers around mental health issues in the community, there are opportunities for enhancing the perinatal mental health support available to women in a way that complements health visitors’ roles.
Antenatal and postnatal depression
Between 1999 and 2003, a study of the antenatal and postnatal work at Family Action’s Newpin services for parents of young children was carried out (Harris et al, 2006). It assessed whether women who were either vulnerable to depression or depressed during pregnancy did better after having had a volunteer befriender in their first year of motherhood.
Befrienders provided emotional and practical support on issues such as accommodation, baby care and finances. At the follow-up interview when the babies were nine months old, particular attention was given to the levels of emotional support received by women from their volunteer befriender. Those who received emotional support were half as likely as those in the control group to have experienced the onset of major depression, or a depression sufficiently severe to warrant antidepressants, or to have remained without recovery from major depression (Harris et al, 2006).
Pilot perinatal project in Southwark
The study discussed above formed the basis for Family Action’s perinatal support project, a volunteer befriending service targeting socially excluded women in Southwark, London. There were a high number of referrals from the immigrant community; the largest ethnic group was black African (37%), followed by black Caribbean (15%), with 48% having English as a second language.
The project aimed to provide intensive support to improve parental mental health during pregnancy and to ensure the development of a healthy bond after birth. Women were matched with a volunteer befriender who provided assistance with practical and emotional issues. All befrienders were mothers recruited from the local community, reflecting Southwark’s ethnic diversity. They were CRB cleared and attended a six-day training course as well as local safeguarding children training and other relevant courses, including first aid and basic drug awareness.
After the Southwark pilot, an independent evaluation of the programme revealed positive success rates (Lederer, 2009). Of the service users followed up, 88% showed reduced anxiety on a clinical score and 59% had a reduced score for depression, while 47% showed a higher level of social support.
When observed, 45% of service users were seen to have good communication and a close bond with their baby, and 55% had partly achieved this. In addition, 75% had achieved their target of joining activities at a children’s centre (Lederer, 2009).
Based on the success of the Southwark perinatal project, the Big Lottery Fund, the Monument Trust and the Henry Smith Charity have funded an expansion of the service. Family Action will extend the project to four other areas of England -Swaffham, Oxford, West Mansfield and Hackney in London. In these areas, up to 1,553 children are expected to be born to mothers who have depression or other mental health issues. These geographical areas were selected because there was an opportunity to build on existing Family Action outreach services that involve strong interorganisational networks.
The project is not aimed at replacing NHS services. Instead it is intended to add value to existing services provided by health visitors, midwives and community nurses by extending the emotional support available to vulnerable mothers.
Expectant or new mothers who stand to benefit from this expanded programme are likely to lack family and support networks nearby. They may be socially isolated, have depression or other mental health problems, be at risk of these mental health difficulties or be victims of domestic abuse.
Volunteer befrienders will offer emotional support before, during and after the birth of the baby. The volunteers, many of whom will be mothers, will have had previous experience of mental distress, and will be paired with mothers who are referred to the service.
Service users will receive:
- Practical support;
- Emotional support;
- Regular home visits;
- Weekly drop-in peer support for parents;
- Family play programme for children aged under one-year-old; and
- Grant applications for impoverished families.
Volunteer befrienders can expect:
- Full support from the project manager;
- Increased confidence and self-esteem; and
- Improved employment opportunities.
Barriers to access
It is important to consider the barriers to receiving help that individuals with anxiety or depression may face. It has been noted that the views, attitudes and behaviour of those with perinatal mental health problems may prevent them from receiving psychological therapies if they:
- Believe that the mental health problems are shameful and should be hidden;
- Use language to express their depression that fails to communicate its seriousness;
- Feel too hopeless to ask for help because they are depressed;
- Have physical health problems that distract them from recognising their problem.
Barriers to responding to these difficulties may exist for GPs, nurses or other care professionals who:
- Have time constraints that prevent them from diagnosing mental health problems;
- Recognise symptoms of depression or anxiety, but are unaware of all the treatment options;
- Are unable to identify and manage perinatal mental health problems;
- Decide to prioritise physical health over mental health, and do not refer patients to the appropriate mental health service (Oates, 2008).
In identifying women at risk of perinatal depression, nurses and health visitors need to consider:
- The ideal place to assess a woman for perinatal depression is likely to be in her own home where her surroundings and relationship can be assessed;
- Whether the mother has a history of depression, mental health issues or anxiety;
- Access to social networks. Does she have a partner or family in the house or is she living alone? Does she have friends or family nearby or does she seem isolated?
- If she has a partner, does their presence seem positive? Is the father available and supportive?
- Is she living in accommodation suitable for a mother and new baby? Is the home properly furnished, with items such as a fridge, a cooker and washing machine? Is there adequate food in the house?
Perinatal depression, if not treated, has been proven to contribute to social, mental and financial hardships for mothers, fathers and children. If these mental health issues are not tackled in the beginning, they directly result in children’s cognitive and psychological development being hindered and new cycles of disadvantage being created.
It is in the interest of commissioners to understand the value of perinatal services as an investment in low-cost, high-value services in the early years. These can reduce the cost of intervening in the health and wellbeing of families when children are older and interventions are more expensive.
GPs, nurses and health visitors can enhance their support of expectant and new mothers who are experiencing, or are at risk of experiencing, anxiety and depression through increased awareness and identification of perinatal depression. In addition, they can develop links with, and refer vulnerable women to, services such as Family Action’s perinatal support projects, which can complement the work of health visitors.
BOX 1. CASE STUDY
Beatrice Carter* was referred to the project by her midwife because she was socially isolated and unsupported in her first pregnancy, having suffered severe domestic abuse. Her midwife noted:
When I first met Ms Carter, she had a low mood and often stayed in her room. She was matched with a volunteer befriender who visited her at home, and also supported her as a birth partner when her baby was born in May 2008. Ms Carter attended the drop-in for mothers and babies at the Newpin Centre and started getting to know other mothers.
With support from the befriender in the early postnatal period, she went on to establish successful breastfeeding. She also attended counselling with domestic violence services to help her understand the cycles of abuse and help avoid such relationships in the future.
The change in Ms Carter is remarkable. She is full of laughter and is making plans for her future, including going to college. She successfully enrolled on a hospitality course at the local college, but was unable to fund the childcare for a small baby, so had to drop out. Instead, she enrolled on a free parenting course with a supporting crèche run by the children’s centre. She is now making plans for college in September when her baby will be over one year and eligible for care in the college crèche.
*The client’s name has been changed
- One in six mothers is affected by perinatal mental health issues and stress
- Early intervention is crucial to better relationships and child development
- The Family Action perinatal support project complements the health visitor role
- Volunteer befrienders can reduce anxiety and depression and improve mother-baby bonding
- This approach is a cost-effective way to improve perinatal mental health
Chew-Graham C et al (2008) GPs’ and health visitors’ views on the diagnosis and management of postnatal depression: a qualitative study. British Journal of General Practice; 58: 548, 169-176.
Department of Health (2007) Facing the Future: a Review of The Role of Health Visitors.
Field F (2010) The Foundation Years: Preventing Poor Children Becoming Poor Adults.
Harris T et al (2006) The Newpin Antenatal and Postnatal Project: a Randomised Controlled Trial of an Intervention for Perinatal Depression. Poster prepared for the HSR Open Day, Institute of Psychiatry, King’s College London. 6 July 2006.
Hobcraft J, Kiernan K (2010) Predictive Factors from Age 3 and Infancy for Poor Child Outcomes at Age 5 relating to Children’s Development, Behaviour and Health: Evidence from the Millennium Cohort Study. York: University of York.
Howe D et al (1999) Attachment Theory, Child Maltreatment and Family Support. Basingstoke: Palgrave Macmillan.
Lederer J (2009) Southwark Newpin - Perinatal Support Project Evaluation Report.
Lyons-Ruth K et al (1990) Infants at social risk: maternal depression and family support services as mediators of infant development and security of attachment. Child Development; 61: 1, 85-98.
McConnell J et al (2005) Experiencing a dilemma - accounts of working with PND. Community Practice; 78: 7, 251-254.
Naji SA et al (2004) How ready are practice nurses to participate in the identification and management of depressed patients in primary care? Primary Care Mental Health; 2: 1, 47-54.
Oates M (2008) Managing perinatal mental health disorders effectively: identifying the necessary components of service provision and delivery. Psychiatric Bulletin; 32: 131-133.
Oates M, Rothera I (2006) Out of the Blue? Motherhood and Depression.
The Patients Association (2011) Postnatal Depression Services: an investigation into NHS Service Provision.