For both mothers and fathers, pregnancy and the birth of a baby are periods of transition and changing roles, and it is a life-stage that is widely acknowledged as a time of heightened stress for new parents (Hock et al, 1995). Parental mental health difficulties during the perinatal period are a particular cause for concern because this is a sensitive time for children, when substantial neural, cognitive and socioemotional developments occur (Talge et al, 2007). Fortunately, the perinatal period is also a time when parents report being open to support and when expectant mothers receive a particularly high number of health-care appointments and professional contact, making it a key opportunity to identify difficulties and signpost families to early intervention programmes and support.
Prevalence of antenatal mental health difficulties
Antenatal mental health difficulties can include conditions which manifest during pregnancy as well as pre-existing conditions that may relapse or recur in the perinatal time-frame. Perinatal disorders can range from mild depression and anxiety, to florid psychosis, and everything in between. Mental health difficulties during the perinatal period affect between 10–20% of women (Bauer et al, 2014). While there is a tendency to associate mental health difficulties during this time with the period after birth, many women will also experience mental health difficulties during pregnancy. Research suggests that mental health difficulties may be more common in pregnancy than after birth (Heron et al, 2004).
The most common mental health difficulties experienced by women during pregnancy are stress, depression and anxiety, with around 12% of women having depression and 13% having anxiety at some point, with many living with both (O'Hara and Wisner, 2014). Perinatal mental health difficulties are thought to be of particular concern compared to other life stages as they represent some distinctive clinical features (Box 1; Heron et al, 2008; Oates and Cantwell, 2011).
The NSPCC recognised the importance of throwing a spotlight over fathers during pregnancy and the transition to parenthood, and in 2014, published All Babies Count: The Dad Project (Hogg, 2014). The report highlights that many expectant and new fathers also experience mental health difficulties in the perinatal period, with 5–10% of fathers describing symptoms of depression (Paulson and Bazemore, 2010), a large proportion report feelings of isolation as attention is focused on their partner and the new baby. Of those fathers with a depressed partner, between a quarter and a half reported being depressed themselves (Goodman, 2004).
Many children whose parents experience difficulties in pregnancy and after birth go on to have a normal development; however, a number of recent prospective studies indicate that parental antenatal mental health difficulties may pose a risk to infants. Research shows that maternal stress during pregnancy can have an impact on the development of the baby's brain and has been found to be associated with poorer physical, emotional, behavioural and cognitive outcomes for infants into their childhood and beyond (O'Connor et al, 2014; Sanger et al, 2015). Parents experiencing anxiety and depression in pregnancy often go on to have similar symptoms during the postnatal period (Austin et al, 2007), which may have an impact on their capacity to provide sensitive and attuned care for their baby.
Assessment, screening and identification
Parents who experience, or are at risk of experiencing antenatal mental health difficulties will require a range of support, depending on their needs. Midwives play a crucial role in this spectrum of support, particularly in identifying the need for intervention. However, we know that parents tend to be reticent about their mental health problems, and screening by maternity services is not always effective. Recent research has shown that 60% of cases of perinatal anxiety and depression go undetected, and this is particularly true for expectant fathers (Gavin et al, 2015). Therefore, high quality engagement (Box 2), assessment and screening processes are essential to identify parents experiencing difficulties.
Guidance for midwives and other health professionals around recognising and specifically assessing antenatal mental health difficulties in pregnancy is set out in the updated National Institute for Health and Care Excellence clinical guideline: Antenatal and postnatal mental health: clinical management and service guidance (NICE, 2014).
To complete a high-quality clinical assessment, midwives must be alert to the risks factors associated with mental heath difficulties in pregnancy. Research indicates that some women are at higher risk of mental health difficulties in pregnancy, particularly those who have a previous history of mental health problems, or those experience high levels of social disadvantage. The NSPCC conducted a literature review of risk factors associated with perinatal mental health difficulties as part of their Prevention in Mind report (Hogg, 2013), and Box 3 summarises the key findings.
Although there is an increased risk of mental health difficulties among some disadvantaged groups, women from all parts of society can be affected by psychological difficulties in pregnancy; over half of the women who committed suicide during pregnancy or shortly after birth in the UK between 2006 and 2008 were white, married, employed, living in comfortable circumstances and aged 30 years or older (Oates and Cantwell, 2011).
In order to screen for mental health difficulties, the NICE guidance recommends the use of two 2-item screening tools at a woman's first contact with primary care or her booking visit: the Whooley Questions to screen for depression, and GAD-2 to screen for anxiety (NICE, 2014).
As we know, it can be hard for parents to talk about their difficulties, it is important when asking these screening questions to think carefully about how they are framed, tone of voice, and speed of delivery. The quality with which questions are asked will influence how parents respond and whether they feel comfortable to raise any issues.
If the outcome of these measures causes concern, additional more detailed screening measures are recommended—the PHQ-9 or Edinburgh Postnatal Depression Scale for depression and the GAD-7 for anxiety—as well as a rapid referral to the GP and a specialist perinatal mental health service.
An update on the role of specialist midwives
The growing numbers of specialist mental health midwives in maternity services around the UK is a recent and exciting development towards the goal of ensuring all women have support for antenatal mental health difficulties. Following campaigning by the Maternal Mental Health Alliance and others, in 2014 the Government issued a mandate to Health Education England to ensure pre- and post-registration training in perinatal mental health in order that there are specialist midwives and doctors available for every birthing unit by 2017 (Department of Health, 2014). The Royal College of Midwives is currently developing a standards document, recommendations for training and an e-network for specialist mental health midwives. Specialist mental health midwives have such a pivotal role to act as champions and advocates for women with perinatal mental illness, developing local care pathways, providing training and advice and support for other maternity staff, and providing women with additional specialist support and treatment where required (Maternal Mental Health Alliance, 2013).