Depression it is often found in the perinatal period (from conception to one year after birth). suicide remains the main cause of maternal death. Perinatal mental health conditions are more common in specific groups, including young women, migrant women and women with history traumaincluding intimate partner violence. A study of 2 million women in England also found increased obstetric (premature birth) and neonatal (small for gestational age) risks among women who had contact with secondary mental health care prior to pregnancy, risks were higher where the contact was more recent or more intensive (eg, crisis resolution/home treatment team access or inpatient admission). Women with mental health conditions are known to be at increased risk of relapse or worsening during the perinatal period.
In 2016, £365 million was invested in perinatal mental health services across the National Health Service (NHS) in England, followed by further funding in 2019. The authors of this recent research aims to determine whether the gradual rollout of community perinatal mental health teams is associated with increased access to secondary mental health care or reduced postnatal relapse.
NHS England invested £365 million in perinatal mental health services in 2016.
Methods
This cohort study analyzed data from the NHS England national secondary mental health data set. This includes all mental health “episodes” from 01/04/2006 to 31/03/2019 (excluding 12/15/31/03/16) with Hospital Episode Statistics (all total hospital contact) and Personal Demographics Linked to the service's birth notifications. .
The authors examined the records of women aged 18 years and older with a pregnancy that began on 04/01/2016 and a singleton baby up to 03/31/2018, with a gestational age of 24 weeks or more. Women with a pre-existing mental health condition (defined as contact with any secondary mental health service within 10 years prior to their current pregnancy) were included in this study.
They then determined whether the Clinical Commissioning Group (CCG) responsible for health in the region where the woman lived provided a community perinatal mental health team (defined as having at least one dedicated psychiatrist, psychologist and specialist nurse). post) from the date of conception.
The authors calculated adjusted odds ratios and 95% confidence intervals using logistic regression, first adjusting for monthly time trends and then for maternal demographic characteristics and regional differences in socioeconomic deprivation.
Results
Of 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 who gave birth in March 2018 became pregnant). Of the 70,323 women included, 31,276 (44.5%) lived in an area with a community perinatal mental health team, and 39,047 (55.5%) did not.
A smaller proportion of women had an acute postnatal relapse (hospital admission or crisis resolution/home treatment group) in the regions. with community perinatal group than regions without team (n=1117, 3.6% vs n=1,745, 4.5%; aOR=0.77, CI=0.64-0.92). There was no statistically significant difference in recurrences during pregnancy.
In the regions, a greater proportion of women received secondary mental health care (admission, crisis resolution/home treatment team or community mental health team) during the perinatal period (both during pregnancy and within one year after delivery). with community perinatal group than regions without team (n=9,888, 31.6% vs 10,033, 25.7%; aOR=1.35, CI=1.23 to 1.49).
The authors also found that women in the regions had a higher rate of stillbirth or neonatal death with community perinatal group than regions without team (n=165, 0.5% vs n=151, 0.4%, aOR=1.34, CI=1.09-1.66). 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=1.02–1.20). The opposite was true for preterm birth: regions have lower rates for women with the community perinatal group had more preterm infants than the regions without team (n=3,167, 10.1% vs 4,341, 11.1%; aOR=0.86, CI=0.74-0.99).
Differences in obstetric and neonatal outcomes were found in women with mental health conditions living in areas with and without community perinatal groups.
Results
As expected, the presence of community perinatal mental health teams was associated with increased access to secondary mental health care during the perinatal period. Encouragingly, they were also associated with reduced risk of postpartum relapse (requiring hospital admission or crisis resolution/home care team support) and preterm delivery..
unexpectedly, the authors found higher rates of stillbirth, neonatal death, and small-for-gestational-age infants in areas where community perinatal mental health teams were provided, despite controlling for potential confounders. Potential explanations for these unexpected results include:
- Focus on perinatal mental health, which overshadows the recognition of modifiable behavioral and obstetric risk factors by physical health professionals.
- Emphasizing mental health status can lead to discrimination (diagnostic overshadowing) when women seek physical health services.
- Increased use of psychotropic drugs. However, the authors note that there is currently no evidence that psychotropic drugs are associated with stillbirth.
The presence of community perinatal mental health teams was associated with higher access to secondary mental health care in 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 proxies to increase the number of women who could be included in their analysis.
- The use of regional provision of community perinatal teams avoided confounding by clinical indication, but may have reduced the estimated effect size (as not all women were included in the team).
- Because the authors did not have access to adolescent mental health records, less than 10 years of psychiatric history may be obtained for young women at higher risk of perinatal mental disorders.
- The authors are conducting a realist evaluation that will examine the mechanisms by which women engage with community perinatal groups, as well as changes in service use patterns and costs over time, which will illuminate some of these findings.
Taking an adolescent mental health history would be useful to identify women at risk for perinatal mental health problems.
Implications for practice
Clinicians and policy makers can be encouraged that the provision of community perinatal mental health teams is associated with increased access to mental health services and reduced postnatal relapse, as well as reduced preterm birth. However, the higher stillbirth and neonatal mortality rates in areas where such groups are served suggest that investment in mental health care alone cannot be assumed to affect pregnancy risks, which are known to be higher in women with mental health conditions. Clinicians in psychiatry, obstetrics, and general practice must be alert to the risk of diagnostic shadowing and work closely together to provide collaborative care throughout the perinatal period.
Specialists should work at a multidisciplinary level and provide high-quality care in the perinatal period to prevent pregnancy risks.
Statement of interest
My second PhD supervisor was Professor Louise Howard (one of the authors), but I had no involvement in this work.