The Royal College of Obstetricians and Gynaecologists (RCOG) works to improve health care for women everywhere, by setting standards for clinical practice, providing doctors with training and lifelong learning, and advocating for women’s health care worldwide.

We welcome the opportunity to submit our views to this inquiry.

Background

1. In February 2017, the RCOG published a report, Maternal Mental Health – Women’s Voices,exploring women’s experiences of perinatal mental health problems in an effort to break down the barriers to high-quality care. By surveying women with lived experience, the College aimed to understand the current provision of perinatal mental health care to identify gaps, to provide better training where necessary and to advocate for change.

2. The report was based on a survey of over 2,300 women from across the UK, who had given birth in the last five years. Regional data was collected to allow for better analysis with the survey receiving 59 responses from women in Wales.

Maternal Mental Health – Women’s Voices

3. The RCOG’s survey found that 81% of women who responded experienced at least one perinatal mental health condition during or after their pregnancy. Low mood was experienced by over two-thirds of the women, anxiety by around half and depression by just over one-third. In Wales, 91% of women who responded experienced at least one perinatal mental health condition, with 82% experiencing low mood, 59% experiencing anxiety and 55% experiencing depression.

The level of specialist community perinatal mental health provision that exists in Wales

4. The NICE clinical guideline on Antenatal and Postnatal Mental Health states that a pregnant woman should be asked about her emotional wellbeing at her first contact with primary care or at her booking visit, as well as during the early postnatal period. Healthcare professionals should also ask about a woman’s mental wellbeing with each subsequent contact, with the guideline suggesting standardised questions to use to identify possible depression or anxiety.

5. There were large variations in the proportion of women from each region who were not questioned by any healthcare professional about their mental wellbeing. However, in Wales 26% of women were not asked by any healthcare professional during or after their pregnancy, this compared with that national average of 15%.

6. Across the UK most regions had relatively similar rates of respondents who were comfortable talking to healthcare professionals about how they felt. In Wales 20% of respondents said that they did not talk to, or would not have felt comfortable talking to any healthcare professionals about their mental wellbeing during or after pregnancy (compared with 16% nationally). Most women who responded from Wales (63%) would have felt comfortable talking about how they were feeling with their midwife.

7. Nationally, the most common reason for respondents to the survey not feeling comfortable or not talking to a healthcare professional about their mental wellbeing was that they were concerned about it being noted in their medical records. In Wales, 50% of respondents highlighted it was because they thought healthcare professionals could or would not help, and 50% also said that they were simply not asked.

8. Across the UK 19% of women who experienced symptoms were referred onto further services, with 55% receiving no support or signposting. In Wales, 22% reported being referred with 54% having no further information about where to seek help.

9. There was also significant regional variation in the time it took women to be seen after being referred. In Wales 58% of respondents reported waiting over four weeks after referral to be seen, compared to 38% across the whole of the UK.

10. The majority of respondents in Wales who were referred reported being seen by a general outpatient mental health service (55%), with only 18% seeing a specialised perinatal mental health service (compared to 30% of women nationally). Perinatal mental health problems are unique and require specialised services that understand and can support the needs of women before, during and after childbirth. These services have the knowledge and skills to understand the risks and benefits of different treatments, including medication in pregnancy and during breastfeeding, and to care for the emotional needs of the women and their babies. It is vital that more women are not only referred on to services but that they receive care from the specialised services that are best placed to help them recover.

Inpatient care for mothers with severe mental illness who require admission to hospital

11. As Wales currently has no mother and baby units, one respondent from the RCOG’s survey in Wales reported being admitted to an in-patient psychiatric ward. Here they would have been separated from their babies at a critical time. This often causes huge distress for the mother, which can interfere with her treatment and recovery. Furthermore, this enforced separation at this critical time can have a serious impact on her bonding and relationship with her baby, and this in turn may have long-lasting effects for mother and child.

The Welsh Government’s approach to perinatal mental health

12. In 2015, the Welsh Government announced an extra £1.5m in funding to improve outcomes for women with perinatal illnesses, their babies and other children. Although this additional funding is welcome, further investment is urgently needed in Wales to address specialist community perinatal mental health services, including wider provision of mother and baby units.

The emotional well-being and mental health needs of partners and the wider family

13. Partners can also experience mental health problems during a woman’s pregnancy and after the birth, yet they are often forgotten about. 13% of respondents to the RCOG’s survey from Wales said that their partner had experienced mental health issues during or after their pregnancy.

14. The impact of mental health problems on the whole family unit can be overwhelming. A number of women reported feeling that their condition directly affected their partners’ mental health. Some felt that their and their partners’ mental health put a strain on their relationship that not only impacted their ability to support each other but, in some cases, led to the breakdown of the relationship. The effects that a relationship breakdown can have on the whole family unit are severe and wide ranging, and providing timely and specialised support for the mother will improve the wellbeing and health of the whole family.

15. Services should also explore mechanisms to diagnose and offer appropriate treatment to partners experiencing mental health problems before and after the child’s birth, as part of a wider approach to treating perinatal mental health problems and limiting the impact it can have on the whole family.

16. The importance of the whole family’s mental health needs during the perinatal period are currently overlooked. The Welsh Government should develop a strategy to support the mental health of partners, whether through digital platforms or community-based support.

Knowledge and understanding of perinatal mental health

17. One of the major recurring themes throughout the respondents’ answers to the RCOG’s survey was that of knowledge and understanding of perinatal mental health conditions. Apart from depression, healthcare professionals often failed to recognise or look for signs of other perinatal mental health conditions. This can lead to them missing many women whose symptoms do not fit in with their perceptions of perinatal mental health.

18. Many women also explained that they had heard of postnatal depression but did not know the symptoms to look out for, let alone having heard of other conditions that they might experience. Greater awareness is needed of the range of perinatal mental health problems that women may experience, especially in relation to lesser known anxiety conditions such as post-traumatic stress disorder, perinatal obsessive–compulsive disorder (OCD) as well as postpartum psychosis. Greater public knowledge and recognition will also lead to more acceptance and destigmatisation of perinatal mental health problems, allowing more women to feel comfortable in coming forward when they experience problems.

19. Women and their families need information on the effects that pregnancy and childbirth can have on mental wellbeing, including the signs of perinatal mental health problems to look out for. Services should review and update the information currently available to women and include discussions on perinatal mental health and on where to go for help in antenatal classes.

Third Sector support

20. Where respondents did access specialised perinatal mental health services, they often praised how effective they had been in helping them to recover. On the other hand, many women reported that they felt that non-specialised mental health care had inhibited their recoveries and in some cases made them worse. The generalised nature of these services often means that they do not take into account the unique needs that women with perinatal mental health conditions have.

21. Many women highlighted the help and support they had received from the voluntary sector. A number of women singled out charities that had helped them recover and, in some cases, they credited their full recovery to them. Commissioners should consider introducing clinically supervised and trained local peer support networks and groups in partnership with the community and voluntary sector, which many women find particularly helpful in their recoveries. These should include provisions to remove barriers for women to attend, such as on-site crèches, to allow women to bring their babies with them.

Access to support for a range of disorders

22. Respondents to the survey experienced a range of perinatal mental health conditions, as well as various circumstances and physical conditions that they felt impacted on their mental health and subsequent treatment.

23. A large number of women reported that they felt that the focus of perinatal mental health services, especially with regard to the knowledge of non-specialised healthcare professionals, was on depression. Many felt that their symptoms were ignored, or not treated seriously enough because they did not fit into the classification of postnatal depression (i.e. moderate to severe depression following childbirth that last longer than 2 weeks). This is of concern considering that, among the survey’s respondents, more women had experienced anxiety conditions than they had depression. A number of women mentioned that, when they were asked questions or asked to complete questionnaires, the focus of these were on moods rather than on anxiety symptoms such as flashbacks.

24. Some respondents to the survey had experienced miscarriages and stillbirths, and did not feel that there had been enough support following these events, or in subsequent pregnancies. Some women reported not being offered any bereavement support, despite asking for it, or receiving it a long time after the event. On occasions where women were being offered support, often their partners were denied it. Many reported feeling that there was an assumption that these events do not affect men in the same way they do women.

25. Women who had gone on to have further pregnancies following multiple miscarriages reported that they had been incredibly and understandably anxious during their pregnancy and for some time after giving birth. Despite this, they had felt that healthcare professionals were not acknowledging their concerns or offering support for the anxiety.

26. Bereavement support following a stillbirth should be automatically offered to a woman and her partner. Services should also take into account the impact that multiple miscarriages can have on a woman’s and her partner’s mental health, especially the effects that they will have on anxiety in subsequent pregnancies and births. Following a traumatic birth, recurrent miscarriages or a stillbirth, services should consider offering support for couples to attend together, such as couples therapy.

27. All labour wards should have a perinatal mental health lead who works in a team with a perinatal mental health specialist, a midwife and an obstetrician, and who can carry out quick assessments on a woman’s mental health following childbirth. Any woman who has had a traumatic birth should be seen and assessed before being discharged and given information on where to seek help should perinatal mental health symptoms develop.

28. Healthcare professionals involved in the care of women during and after pregnancy should pay special attention to the mental health of women who have had difficult pregnancies or births. The consequences these have on mental health should be treated as seriously as the physical impacts are.