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Depression is common in the postpartum period (pregnancy to one year after delivery), but suicide is the leading cause of maternal mortality. Perinatal mental health conditions are more common in special groups, including young women, immigrant women, and women with a history of trauma, including intimate partner violence. A study of 2 million women in England found that maternal (preterm birth) and neonatal (small for gestational age) risks were also higher among women with secondary mental health service contact before pregnancy, where contacts were more frequent or more intensive (ie crisis resolution/home treatment). team input or inpatient admission). Women with mental health conditions are known to be at increased risk of relapse or worsening during the perinatal period.
Unique to the National Health Service (NHS) in England, £365 million was invested in perinatal mental health services in 2016, followed by further funding in 2019. The authors of this recent study determined whether the community would roll-out gradually. Perinatal mental health teams were associated with greater access to secondary mental health care or reduced postnatal readmissions.
NHS England invested £365 million in perinatal mental health services in 2016.
methods
This cohort study analyzed data from the NHS England National Dataset of Secondary Mental Healthcare. This links to all mental health care ‘episodes’ from 01/04/2006 to 31/03/2019 (01/12/15 to 31/03/16), hospital episode statistics (all general hospital contacts) and Personal Population Service birth notifications. did
The authors reviewed the records of women aged 18 years and older, with pregnancies beginning between 01/04/2016, and 31/03/2018, at or above 24 weeks’ gestation. Women with a pre-existing mental health condition (defined as contact with any secondary mental health service in the 10 years before the current pregnancy) were included in the study.
They ascertain whether the Clinical Commissioning Group (CCG) responsible for health care in the woman’s area of residence has a Community Perinatal Mental Health Team (defined as the existence or provision of at least one dedicated psychiatrist, psychologist and specialist nurse. Post) from the date of her pregnancy.
The authors calculated adjusted odds ratios and 95% confidence intervals using logistic regression, first adjusting for monthly time trends and then for regional differences in maternal demographic characteristics and socio-economic deprivation.
Results
Of the 780,026 eligible women, 70,323 (9.0%) had a preexisting mental health condition. The availability of community perinatal mental health teams increased from 81 CCGs (39%) in April 2016 to 130 (63%) in June 2017 (when women in labor became pregnant in March 2018). Of the 70,323 women, 31,276 (44.5%) lived in an area with a community perinatal mental health team and 39,047 (55.5%) did not.
A small number of women had an acute postpartum relapse (inpatient admission or crisis resolution/home treatment team) in the areas. with Community perinatal team rather than regions without A cohort (n=1117, 3.6% vs. n=1,745, 4.5%; aOR=0.77, CI=0.64 to 0.92). There was no statistically significant difference in relapse during pregnancy.
A higher proportion of women received secondary mental health care (admission, crisis resolution/home treatment team or community mental health team) during the perinatal period (during pregnancy and within one year postpartum). with Community perinatal team rather than areas without A cohort (n=9,888, 31.6% vs. 10,033, 25.7%; aOR=1.35, CI=1.23 to 1.49).
The authors found that women had a higher incidence of stillbirth or neonatal death in the regions with Community perinatal team rather than areas without A cohort (n=165, 0.5% vs. n=151, 0.4%, aOR=1.34, CI=1.09 to 1.66). They found the same pattern for infants born small for gestational age (n=2,777, 7.2% vs. n=2,542, 6.6%, aOR=1.1, CI=1.02 to 1.20). The opposite is true for pre-term birth: fewer women in regions with A community perinatal team has more preterm babies than regions without A cohort (n=3,167, 10.1% vs 4,341, 11.1%; aOR=0.86, CI=0.74 to 0.99).
Differences in maternal and neonatal outcomes were found among women with mental health conditions living in areas with and without community perinatal teams.
Conclusions
As expected, The presence of community perinatal mental health teams is associated with increased access to secondary mental health care during the perinatal periodencouragingly, they are Also associated with postpartum readmission (requiring hospitalization or crisis resolution/home treatment team support) and pre-term birth,
Unexpectedly, the authors found that even after controlling for potential confounders, areas served by community perinatal mental health teams had higher rates of stillbirth, neonatal death, and smaller children for gestational age. Possible explanations for these unexpected findings include:
- Focus on perinatal mental health covering the identification of modifiable behavioral and maternal risk factors by physical health care professionals.
- Highlighting mental health conditions can lead to discrimination (diagnostic overshadowing) when women access physical health care.
- The use of psychotropic drugs has increased. However, the authors note that there is no current evidence linking psychotropic medications to childbirth.
The presence of community perinatal mental health teams is associated with greater access to secondary mental health care during the perinatal period.
Strengths and limitations
- Due to substantial missing data, the authors did not identify women with pre-existing mental health conditions using clinically recorded diagnoses. They used mental health service contacts as a proxy, increasing the number of women to be included in their analyses.
- The use of regional provision of community perinatal teams may have avoided confounding by clinical referrals, but may have reduced the estimated effect size (because not all women accessed the team).
- Because the authors were unable to access adolescent mental health records, less than 10 years of psychiatric history could be captured for young women at high risk for perinatal mental illness.
- The authors are conducting an empirical evaluation that explores the mechanisms of women’s engagement with community perinatal teams and explores changes in service utilization and spending patterns over time that may illuminate some of these findings.
Summarizing an adolescent’s mental health history is helpful in identifying women at risk for perinatal mental health problems.
Implications for practice
Clinicians and policymakers may be encouraged to find that the provision of community perinatal mental health teams is associated with increased mental health service access and reduced postpartum readmissions, as well as reductions in pre-term birth. However, such cohorts show that investment in mental health care alone cannot be assumed to influence the increased pregnancy risks among women with mental health conditions, with higher rates of stillbirth and neonatal mortality in the regions served. Physicians in psychiatry, obstetrics, and general practice must pay attention to the risk of diagnostic overshadowing and work together to provide joined-up care at all stages of the perinatal period.
To prevent pregnancy risks, professionals should work in a multidisciplinary capacity and provide high quality care in the perinatal period.
Declaration of Interests
My PhD second supervisor was Professor Louise Howard (one of the authors), but I had no involvement with this study.
