Intervention Strategies for Post Partum Depression

More than 1 in 10 women in the United Kingdom develop a mental illness during pregnancy or in the first year after giving birth, according to research by the Centre for Mental Health and London School of Economics (Bauer et al, 2014). Alarmingly, the 2018 report of the Confidential Enquiries into Maternal Deaths (MBRRACE-UK, 2018) states that maternal suicide is the fifth most common cause of women’s death throughout pregnancy, and the leading cause of death over the first year after pregnancy in the UK.

On a global scale, post-partum depression is the most prevalent of all childbearing related illnesses, affecting 13 percent of women worldwide within the first 12 weeks of giving birth (O’Hara and Swain, 1996). Yet, despite these shocking statistics, common maternal mental health disorders (CMMHDs) are often stigmatized, belittled, and the severity of their ongoing impact on both the mother and her child, neglected.

The combined negative effects on the children of mothers with maternal mental illnesses can be astronomical. International and varied research has long signalled the detrimental outcomes these CMMHDs can have on all aspects of the child’s health and development, including cognitive ability (Sharp et al, 1995, Keim et al, 2011, Li et al, 2013, Kingston et al, 2015), developmental speed (Murray et al, 2010, Conroy et al, 2012, Bauer et al, 2014b), pre-term birth risk and growth restrictions (Orr et al, 2007, Grote et al, 2010, Nkansah-Amankra et al, 2010 ), physical health complications (Ramchandani et al 2006, Cookson et al, 2009, Wen et al 2017, Gould et al, 2015), behavioural problems (Murray, 1992), social and emotional difficulties (Guyon-Harris et al, 2016, O’Connor et al, 2002, Sinclair & Murray, 1998), psychological effects (Blair et al, 2011, Halogen et al, 2007, O’Donnell et al., 2014), an increased risk of sudden infant death syndrome (Sanderson et al, 2002, Howard et al, 2007), and – most recently – childhood injury (Deighton, 2018).

As this paper will examine, the evidence is not irrefutably tied solely to the presence of maternal mental illness, and there are many competing factors that have to be taken into account when determining the cause of many of these children’s health and development differences. However, by the sheer volume and variety of the research taking place around the globe, it stands to reason that this should be an issue of paramount importance for the public health sector, and an area in which significant change should be possible.

However, within the United Kingdom’s National Health System (NHS) the provisions and support offered to women remain hard to access, maintain, and most vitally, inconsistent across a range of factors including socioeconomic status and geographical location. Many women across the United Kingdom lack access to the appropriate screening, treatment and support needed to ensure they and their children are not neglected. This neglect not only places these children at increased risk of numerous developmental and health issues, but enhances an avoidable financial strain on the health system, as this assignment will investigate.

This paper will focus on the children of mother’s with CMMHDs as specified by the Maternal Health Alliance, which include anxiety, depression (antenatal and postnatal), psychosis and post-traumatic stress disorder (PTSD). Although this research is respectful of the nuances of these various disorders, it is beyond the scope of this paper to comprehensively assess the individual systems in place for each respective disorder. Instead, this assignment will seek to more broadly assess the general provisions available for any mother in need of maternal mental health assistance in the United Kingdom, and the universal improvements that need to be made.

At the close of the 20^st century, suicide ranked as the leading cause for maternal death (CEMD, 2001). In 2015, the government pledged £365 million to be spent over the next five years on specialist maternal mental health services in England. This was set out in The Five Year Forward View for Mental Health (Mental Health Taskforce, 2016). According to this report, the money is to place a “particular focus on tackling inequalities” (2016:3). Previously, research has stated that maternal suicide does not discriminate on the grounds of adversity or socioeconomic class (Oates, 2003) however; many recent findings suggest that the opposite is the case. As the government’s report suggests, clarifying this issue is key in providing a relevant public healthy strategy to combat maternal mental health.

NICE guidelines are evidence-based recommendations for health and care in England. According to NICE (2018), the £365 million invested in perinatal mental health has been ring-fenced within the NHS budget, meaning it has to be spent specifically on this purpose, so that by 2021 an additional 30,000 women each year should be able to receive maternal mental health treatment. Despite this optimism, “it is widely acknowledged that the current provision of care for perinatal mental health problems is highly variable around the country, both in coverage and in quality” (Bauer et al 2014a)

At the time the plans were highly criticised, with many believing that more national funding would not necessarily guarantee more physical services for women – or the certainty that the money would be spent where it is most vitally needed (The Maternal Mental Health Alliance, 2014, Bauer et al, 2014).

It is because of these concerns that The Maternal Mental Health Alliance launched the awareness campaign “Everyone’s Business” in 2014. Since starting the campaign, MMHA has regularly produced maps highlighting the level of perinatal mental health care provided across the United Kingdom. The United Kingdom and Northern Ireland consists of 235 Clinical Commissioning Groups (CCGs), that were recognised as “the cornerstones of the new NHS health system” (NHS, 2012), and are responsible for the planning and commissioning of health care services for their local area. Despite the introduction of CCGs aiming to better address specific localised care needs, the division of the NHS funding in this way has garnered criticism, and is often blamed for widening health inequalities across the United Kingdom (Pearce, 2018.) According to Williams et al (2007 WHERE IS THIS FROM), the UK could learn a thing or two from other European countries, for studies have shown it is not the richest but the most egalitarian societies which boast the best public health statistics.

Despite the many merits of the National Health System in the United Kingdom, the “postcode lottery” that now exists further polarizes society, increasing the gap between rich and poor. As the Everyone’s Business Campaign highlights,

The pillars of the campaign are accountability, community and training, and draw attention to certain critiques of the government’s policies.

The research of Bauer et al (2014a) has been fundamental in campaigning for change in the maternal mental health sector. Unlike previous academic research, the report steers its focus towards the economic benefits of bringing the pathway of perinatal mental healthcare up to the level and standards recommend in national guidelines. This is arguably vital in persuading the government to invest further in perinatal mental health policies. This research was commissioned by the Maternal Health Alliance, and it is therefore important to note the internal bias that can come with this kind of data collection. Nonetheless, the report concisely collates a number of independent pieces of research that demonstrate the scope of perinatal mental illnesses in the UK, and why it should be regarded as a “major public health issue that must be taken seriously.” (Dr Alain Gregoire in Bauer et al, 2014:3).

According to the report, “perinatal mental illnesses cost the NHS around £1.2 billion for each annual cohort of births.” In comparison, it would cost “only an extra £280 million a year” to support all women across the UK at a level deemed adequate by the NHS. Despite the phrasing used here, this is still a significant sum of money, however the long term benefits would arguably outweigh the short-term pay-out. 

The report also analyses the financial cost to society for perinatal depression, anxiety and psychosis for each one-year cohort of births in the UK. According to the data, 72% of this cost relates to adverse impacts on the child, rather than the mother.

These calculations on the impact of maternal perinatal illness on children were based on studies analysing data from the Avon Longitudinal Study of Parents and Children (ALSPAC) (found in the aforementioned O’Connor et al. 2002; O’Donnell et al. 2014). Although these articles established correlations between maternal mental illness and adverse child development and cognitive outcomes, not all variables could be controlled for. For example, the research could not control for the impact of possible additional factors that might affect a child’s confidence, self-esteem, ability to learn or behaviour – notably domestic abuse, or violence in the home. This is a factor later noted in the research of Bauer el al (2014b), when analysing the effects of perinatal depression on child development outcomes of children in a South London borough. The research admits it is hard to take into account the effect of other factors in the children’s lives, but this is perhaps one of the key reasons why research of this kind has not been taken seriously before.

Bauer et al (2014a) also admit that they could not find studies from the UK that quantified the impact of anxiety during pregnancy on preterm birth, and so instead calculated this cost using data from a study in the USA (Orr et al.2007). This, however, points to a fault in national mental health data collection in the UK, another critique supported by further studies (Hope et al 2018, 

Pearce et al 2018, Sambrook et al, 2019).

Conclusion

A holistic screening process is needed as part of diagnosis, and treatment requires support for the mother, and a system promoting attachment and support for the mother-child relationship. Awareness campaigns from the start to end of pregnancy.

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