Perinatal mental healthcare in Northern Ireland: challenges and opportunities

Perinatal mental health is a vital component of public mental health. The perinatal period represents the time in a woman’s life when she is at the highest risk of developing new-onset psychiatric disorders or relapse of an existing mental illness. Optimisation of maternal mental health in the perinatal period is associated with both short- and long-term benefits not only for the mother, but also for her infant and family. However, perinatal mental health service provision remains variable across the world. At present in Northern Ireland, 80% of women do not have access to specialist community perinatal mental health services, and without access to a mother and baby unit, mothers who require a psychiatric admission in the postnatal period are separated from their baby. However, following successful campaigns, funding for development of specialist perinatal mental health community teams has recently been approved. In this article, we discuss the importance of perinatal mental health from a public health perspective and explore challenges and opportunities in the ongoing journey of specialist service development in Northern Ireland.

The impact of COVID-19 on an inpatient mother and baby unit: a service evaluation

AimsUnique challenges have been faced by women in the perinatal period during the COVID-19 pandemic and the impact of this is compounded for women suffering from mental illness. This service evaluation looked at different aspects of the treatment pathway on a specialist inpatient psychiatric Mother and Baby Unit during the pandemic to identify what changes occurred.MethodData were collected for all admissions to the unit between January 2019 and October 2020, with the beginning of the pandemic being defined as on or after 1st March 2020. Information was collected retrospectively from electronic clinical notes on ethnicity, length of stay, diagnosis, mental health act use and restrictive practice, medication, psychology, occupational therapy and social services involvement.ResultThere were 114 admissions to the MBU during the study period. 4 were parenting assessments rather than acute psychiatric admissions and were excluded from the analysis, giving a sample of 110 women. 58% (62/110) were classed as “pre-pandemic” and 43.6% (48/110) were “during pandemic”. 95.45% (105/110) of women were postpartum 4.55% (5/110) were pregnant. Mean length of stay was shorter during the pandemic at 44 days, compared to 61 pre-pandemic. There was greater use of the mental health act during the pandemic: only 43.75% of patients were informal throughout admission, compared to 70.97% pre-pandemic. Mean duration of detention was shorter at 25 days (32 pre-pandemic). Psychotic illness made up a greater proportion of diagnoses during the pandemic: 56% (27/48) compared to 44% (27/62) pre-pandemic. The next most common diagnostic group was mood and anxiety disorders, which made up 29% (14/48) of diagnoses during the pandemic, but 43% (27/62) pre-pandemic. Outcomes as measured using the Health of the Nation Outcome Scale showed a mean improvement between admission and discharge of 6.65, compared to 5.15 pre-pandemic. HONOS scores were higher on admission during the pandemic (12.83, vs 10.88), suggesting a higher level of acuity.ConclusionDuring the COVID-19 pandemic on this Mother and Baby Unit, length of stay was shorter, a greater proportion of patients were detained under the mental health act (although length of detention was shorter) and psychotic illness was more prevalent. This study demonstrates that there were differences in this perinatal inpatient population during the pandemic and this may be a reflection on the wider impact of COVID-19 on perinatal mental health.

Perinatal mental health outcome measures in a mother and baby unit

AimsTo Audit Perinatal outcome measures and understand better the population served in order to improve care and understand risks. Our audit standards inculded: paired HoNOS and PBQ recorded on admission and discharge as well as ASQ scores prior to admission.MethodHealth of the Nation Outcome Scales (HoNOS), Postpartum Bonding Questionnaire (PBQ) and Ages and Stages Questionnaires (ASQ) were recorded on Lorenzo and SystmOne. Scores were collected over 20 months within the same MBU and these were analyzed.ResultOur audit standards had an overall audit compliancy of 73% with paired HoNOS better than PBQ. Mental health severity mitigated and maternal bonding improved to a significant degree. Depression was the principal presentation as were patients from deprived areas. Only 55% of babies had ASQ scores completed appropriately pre- admission.ConclusionAs the newest MBU in the country, this an initial foray of perinatal outcomes. Gratifyingly, benefits of MBU admission for mother and baby is evidenced in this snapshot.

Evaluation of staff knowledge; attitudes and experience of breastfeeding on a mother and baby unit

AimsTo evaluate the knowledge and experience of breastfeeding of staff working on a Mother and Baby Unit (MBU).To assess the level of breastfeeding education of Staff on the MBU.To identify any area of concern around breastfeeding on the MBU.MethodA fourteen question questionnaire was designed with assistance of the medical team, midwife, and health visitor on the unit. The questionnaire was comprised of questions requiring “yes/no” and free text responses alongside Likert scales. The questionnaire focused on staff experience on breastfeeding, education levels and whether they felt Mothers were sufficiently supported. This questionnaire was distributed to all staff groups within the team to ascertain the level of expertise. 29 questionnaires were returned from a staff team of 31.ResultStaff on this unit is made up of Multi-disciplinary professionals. Most respondents were Nursery Nurses (15%). 79% of staff had a lived experience of breastfeeding. Only 5 out of 29 respondents have had any breastfeeding training which was mainly in-house training, and these were the Health Visitor; Midwife and Nursery nurses. Of the respondents, 21% felt mothers who choose breastfeeding as their preferred mode of infant feeding were not adequately supported on the MBU. Seven percent were unsure and 72% felt women were adequately supported. 54% of staff were not aware of breastfeeding initiatives. 63% were able to list contraindications including names of psychotropic medications as well as personal choice and past medical history. The median rating in relation to confidence in skills on Likert scale of 1-10 was 5.Conclusion23 out of 29 professionals felt that Training would increase their confidence and skills in breast feeding support for women admitted to the unit. There is clear indication from the Staff Members that mothers on the MBU who choose breastfeeding as their preferred mode of infant feeding require further support. There is lack of confidence in staff's breastfeeding support in the MBU. An evaluation of patient's own experience of breastfeeding support they receive from staff is being undertaken alongside this, but data will be analysed later.

Mother-to-Infant Bonding in Women with Postpartum Psychosis and Severe Postpartum Depression: A Clinical Cohort Study

Mother-to-infant bonding is important for long-term child development. The aim of this study was to investigate bonding in women admitted to a Mother and Baby Unit with postpartum depression (PD, n = 64) and postpartum psychosis (PP, n = 91). Participants completed the Postpartum Bonding Questionnaire (PBQ), the Edinburgh Postnatal Depression Scale (EPDS) and the Young Mania Rating Scale (YMRS) weekly during admission. At admission, 57.1% of women with PD had impaired bonding, compared to only 17.6% of women with PP (p-value < 0.001). At discharge, only 18.2% of women with PD and 5.9% of women with PP still experienced impaired bonding (p-value = 0.02). There was a strong association between decrease of depressive and manic symptoms and improved bonding over an eight-week admission period. In a small group of women (5.7%) impaired bonding persisted despite being in remission of their psychiatric disorder. The results from our study show that impaired bonding is a more present and evidently severe problem in postpartum depression but not so much in postpartum psychosis. Treatment of depressive symptoms will improve bonding in almost all women, but clinicians should assess if impaired bonding is still present after remission because for a small group special care and treatment focused on bonding might be required.

Perinatal mental health

This chapter covers perinatal mental health problems, both those that develop in pregnancy and those that may be encountered as pre-existing when a patient becomes pregnant. Specific phobias relating to the state of being pregnant (tocophobia) or issues encountered in pregnancy (blood, injury, and injection phobia), as well as depression, schizophrenia, eating disorders, self-harm, and substance abuse are covered. Treatment without consent and the role of the mother and baby unit are discussed.

A retrospective audit of joint mother–baby admissions to the Werribee Mercy mother and baby unit (MBU) and of the severity of maternal depression over the course of admission

Objectives: This study examined (i) the demographic and illness profiles of mothers admitted to Werribee Mercy MBU in Victoria, Australia and (ii) the severity of maternal depressive symptoms over the course of admission. Method: A retrospective audit was conducted on consecutively admitted mother–baby dyads between January 2011 and June 2015. Routinely collected maternal Beck Depression Inventory, second edition (BDI-II) scores were analysed for severity and change. Results: A total of 307 mother–baby dyads were admitted during the study period. The majority of mothers was partnered and educated young adults. The average length of stay was 4.4 weeks. The mean age of babies was 3.3 months. One-third of mothers met International Classification of Diseases, 10th edition criteria for two or more psychiatric diagnoses. Unipolar major depression was the commonest diagnosis. Of the 307 mothers, 125 mothers completed BDI-II on admission and on discharge, which showed a mean reduction of 16 points ( p < 0.001) on discharge. Conclusions: This study notes the similarities between the clinical profiles of the study population with mother–baby admissions to MBUs worldwide. Maternal depressive symptoms improved by 16 points on the BDI-II over the course of MBU admission, which shows the utility of MBU admission on maternal depressive symptoms.