Clinical practice guidelines are fundamental to evidence-based practice. These are “statements that contain recommendations intended to optimize patient care informed by a systematic review of the evidence and an evaluation of the benefits and harms of alternative care options” (US Institute of Medicine, 2011).
There is evidence to support the importance of clinical practice guidelines in the perinatal period. For example, a 2014 NHS England guideline recommended that women with pre-existing (complex and severe) mental health problems should seek specialist mental health services during pregnancy and postpartum for early assessment and treatment (Howard et al., 2014). . In addition, NHS England has invested £365 million since 2016 to increase access to perinatal mental health services. this blogevaluated the implementation of community perinatal mental health groups and found a lower risk of relapse for women with a history of severe postpartum mental illness in areas with access to these groups (Gurol-Urganci et al., 2024).
Community perinatal mental health teams are now operating and it is essential that clinical practice guidelines are used to ensure equality of care across services in the NHS. This review helps summarize current guidelines for psychological and psychosocial assessment and intervention in the perinatal period.
With the proliferation of community perinatal mental health teams in the UK, clinical practice guidelines for the perinatal period are even more important.
Methods
This review was pre-registered, followed Johnston and colleagues' (2019) methodological guidelines for systematic reviews of clinical practice guidelines, and used the PRISMA checklist for the preparation of systematic reviews.
A systematic search was conducted in the databases of literature and guidelines, and a search was also conducted in relevant health institutions. Guidelines published between 2012 and 2022 were included. Search terms were adapted for each database and combined terms for the perinatal period were combined with the term “mental”. In database searches, filters were applied to guidelines when available.
Guidelines describing psychological assessment and/or intervention for perinatal mental health difficulties were included. Guidelines can be for women, mother-baby couples and/or partners.
Title and abstract screens were conducted by two reviewers. Data were extracted for each guideline to note whether it covered the target population (eg, women, mother-infant dyads, partners) and the four assessment and intervention phases (eg, antenatal and postnatal assessment and intervention). A narrative synthesis was conducted to describe recommendations, identify themes, and compare guidelines.
Instructional quality was assessed by two reviewers using the Appraisal of Instruction for Research and Evaluation (AGREE-II), an instrument specifically designed to assess instructional quality. The overall quality score was presented along with whether the authors recommended the guideline be used (“yes”, “yes with modifications” or “no”).
Results
Results were presented through 1) brief summaries of each guideline, 2) themes from all guidelines on evaluation/intervention recommendations, and 3) comparisons between guidelines.
Summary and quality of instruction
Included in the overview are seven guidelines, which are briefly summarized below:
Most guidelines covered all assessed domains of target populations (ie, women, mother-infant dyads, partners) and stages of assessment and intervention (ie, antenatal and postnatal assessment and intervention). However, SIGN did not cover mother-infant pairs or partners in the antenatal period or partners in the postnatal period, and RNAO did not cover partners in either period.
COPE received the highest quality rating with an average of 99% across AGREE-II domains. This guide was considered to be clearly presented, easy to follow, comprehensive, culturally sensitive and family oriented.
Topics from the guidelines
Three themes were identified among the guidelines:
- Specific therapeutic approaches in the perinatal context (e.g., CBT for mothers, video instruction for mother-infant dyads)
- Equal care considerations
- Individual and systemic considerations (eg safety planning, care planning).
Recommendations within the theme of equal care were divided into three categories:
- The therapeutic relationship
- Culture and diversity considerations
- Environmental considerations such as time.
Comparisons between instructions
Although guideline recommendations regarding psychological and/or psychosocial assessment and intervention during the perinatal period varied, the main recommendations remained consistent.
SIGN, COPE, and RNAO incorporated consensus-based recommendations based on the experience of guideline development groups in the absence of good quality evidence (eg, related to trauma-informed care). Of note, there were more consensus-based recommendations than evidence-based recommendations.
The COPE guidelines used in Australia were rated as the highest quality (99%). These guidelines are clearly presented, easy to follow, comprehensive, culturally sensitive, and family-centered.
Results
The authors note that the content of key recommendations was generally consistent across the seven included guidelines, but the quality of the guidelines varied. Guidelines were generally broad (ie, not specific to psychiatric diagnoses). Most of the recommendations also considered mothers, partners, and mother-infant dyads, but the authors advocate for more research with these populations.
The content of key recommendations was consistent with perinatal mental health guidelines, but the quality of the guidelines varied widely.
Strengths and limitations
This review provides a useful summary of clinical practice guidelines for psychosocial and psychological assessment and intervention in the perinatal period. An overview of each guideline will be particularly useful for busy NHS clinicians working in perinatal services. As guidelines are generally broad, this may help clinicians to address the contextual needs of people with mental health problems in the perinatal period rather than the needs of specific mental health problems that may be found elsewhere.
Authors Recognize the need for all guidelines to include recommendations for working with modern family forms in the perinatal period. This review focused on mothers, and it is possible that the failure to use search terms such as 'persons who gave birth', 'paternal' or 'partner' meant that relevant guidelines for these populations were not found in the search.
A strength of the review is that it was pre-registered in PROSPERO and followed the methodological guidelines of Johnston and colleagues (2019) for systematic reviews of clinical practice guidelines. Although the review stated that the 2020 PRISMA checklist was used to prepare best-practice manuscripts, a copy of the checklist was not provided, which may be useful for other researchers to use when reading the systematic review. Note that while a process is declared for the title and abstract screens, a process is not declared for the full-text screen. In addition, it would be useful to report the inter-rater reliability of the title and abstract screens.
The authors acknowledge the limitation of including only manuals written in English, meaning that it is not surprising that all included manuals are from Australia (n=1), Great Britain (n=3) and Canada (n=3). Although this is an understandable limitation of the project, it may mean that the guidelines are not representative of the guidelines of other cultures.
The included instructions had a number of limitations. First, only SIGN and NICE included service users as guideline developers. Second, several guidelines did not explicitly provide evidence-based methods for developing their guidelines. This means that it is difficult to assess the methodological rigor of creating guidelines. In addition, the authors note that some guidelines use consensus-based rather than evidence-based recommendations, and therefore research is needed to provide evidence-based recommendations.
This review only covers manuals written in English, so it does not take into account manuals from other cultures.
Implications for practice
Guideline developers should use the AGREE-II Tool to develop their guidelines. At a minimum, guidelines should describe the methods used to gather the evidence on which the guidelines are based.
As it is used in NHS services, the NICE guideline has been 'recommended for use' through quality assessment. Clinicians working in perinatal services should familiarize themselves with this guideline and services should regularly assess themselves against it.
The review noted that the guidelines provided consensus, not evidence-based, recommendations for: trauma-informed care, provision of mother-infant interventions, and psychological approaches for borderline personality difficulties in the perinatal period. Therefore, this highlighted the need for research in these areas.
This review of clinical practice guidelines for psychosocial and psychological assessment and intervention in the perinatal period will be useful for busy NHS clinicians.
Statement of interest
None.
Connections
Primary paper
O'Brien, J., Gregg, L., & Wittkowski, A. (2023). A systematic review of clinical psychological guidance for perinatal mental health. BMC Psychiatry, 23(1), 790.
Other references
Gurol-Urganci, I., Langham, J., Tassie, E., Heslin, M., Byford, S., Davey, A., … & O'Mahen, HA (2024). Community perinatal mental health groups and associations with perinatal mental health and obstetric and neonatal outcomes in pregnant women attending secondary mental health care in England: a national population-based cohort study. Lancet Psychiatry, 11(3), 174-182.
Howard, LM, Megnin-Viggars, O., Symington, I., & Pilling, S. (2014). Antenatal and postnatal mental health: summary of updated NICE guidance. Bmj, 349.
Institute of Medicine (USA) Committee on Standards for the Development of Valid Clinical Practice Guidelines, Graham , R. , Mancher , M. , Miller Wolman , D. , Greenfield , S. , & Steinberg , E. (Eds.). (2011). Clinical Practice Guidelines We Can Trust. National Academies Press (USA).
NHS England. (2016). NHS England launches program to help 30,000 more new or expectant mothers with serious mental illness.