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Over Half of Perinatal Mental Illness Being Missed

Perinatal mental health support "is on the precipice", the Royal College of Midwives (RCM) warned, as it called for better support for women giving birth. 

Launching its own 'roadmap' for improving services, the College noted that perinatal mental ill-health is now the most common complication of childbirth", but that despite involvement of professionals, "more than half of perinatal anxiety and depression continues to go undiagnosed".

The report stated that one in five women experience mental health problems during pregnancy or in the first year after birth, and that more severe illness could prove fatal. Indeed, mental ill-health is now on "an equal footing with physical factors as a cause of maternal deaths in the UK", the College said. Between 2018 and 2020, suicide was the leading cause of death in new mothers up to the first year after giving birth. 

Yet very few of the women who died as a result of poor perinatal mental health had received a formal mental health diagnosis, despite symptoms suggestive 

of severe ill-health. Furthermore, one in three women had disclosed domestic abuse, which is known to be associated with mental health conditions, and half had multiple adversity, with a history of childhood and/or adult trauma.

Women Fear Their Baby Might Be Removed

Variations in availability of mental health services and the care offered were "often worsened by cultural stigma, previous trauma, deprivation, and discrimination", according to the report, which highlighted that 70% of women either hid or downplayed the severity of their mental health problems. Reasons were varied, but included concerns they would be judged unable to cope, and fears that their baby would be removed from their care, it said.

Compounding this was "the medical model of mental health acting as a barrier", with health professionals seeing domestic abuse as a social issue beyond the scope of mental health treatment. In contrast, a "trauma-informed approach", emphasising the value of trusted and non-judgemental relationships and listening to women's experiences, would place emphasis on linked-up compassionate care being available to everyone.

Importance of Mental Health "Not Reflected in Resources"

Birte Harlev-Lam, RCM executive director, said that while mental ill-health ranked with physical factors as a leading cause of maternal deaths, "this is not reflected in the resources allocated to it, whether in terms of staffing or other support".

She added: "Midwives need time to care and there need to be more midwives to share the workload." She estimated that fewer than 350 additional specialist perinatal mental health midwives could effect the changes needed. "We are not asking for the moon," she stressed. 

There was an "irrefutable economic and social case for more mental health resources", the RCM stated. As well as the emotional impact on women and families, undiagnosed mental illness cost the state an estimated additional £8.1 billion each year. "Investing in perinatal mental health and the training of more midwives now would be a fraction of that cost."

Awareness, Training, and Workforce Planning Needed

The report recommended:

  • All maternity professionals be concerned equally with mental and physical health, and have the appropriate understanding and knowledge of perinatal mental health which, at a minimum, should be updated annually
  • Baseline training of all midwives in perinatal mental health, with a review of professional standards through a perinatal mental health lens
  • A review of future planning for the midwifery workforce framework to include women's perinatal mental health needs, to inform local planners and maternity service commissioners
  • All maternity services should have at least one whole time equivalent perinatal mental health specialist midwife, with appropriate maternity and administrative support and a job plan incorporating clinical supervision and annual review of demand and capacity

The report noted that only 68% of RCM members currently received annual training on perinatal mental health. While 79% of trusts have a perinatal mental health specialist midwife, posts are not always full time and specialist midwives were sometimes used to cover other staff shortages, the report found. Some had no dedicated consulting space, and some worked solo, with little resilience to cover sickness, annual or maternity leave, which was "contributing to low morale".

"Midwives are enthusiastic about the need for perinatal mental health provision," according to the report, but "many factors" prevented them from improving care, and "staffing levels are a critical barrier". Overall, the RCM described the current state of perinatal mental health services as "bleak". 

Roadmap "Paves the Way" for Positive Change

Asked to comment by Medscape News UK, Professor Asma Khalil, consultant obstetrician and vice president of the Royal College of Obstetricians and Gynaecologists, welcomed the report and said the College supported the recommendations to ensure that perinatal mental health services had adequate resources. 

"This roadmap paves the way for positive changes at all levels, advocating for every maternity unit to be equipped with staff who can recognise women who may benefit from specialist care, and allowing specialist healthcare professionals the time to care for them."

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