New research reveals that already stretched mental health services for expectant and new mothers have been hugely impacted by Covid, precisely at a time when women need them most.
WH hears some of the stories behind the statistics and asks: where do we go from here?
This feature appears in the September issue of Women's Health UK. Subscribe now.
Leah’s legs buckled beneath her. The softly spoken words of her mindfulness app soothed her slightly, but it wasn’t enough to steady her breath. The walk had been her husband’s idea; he’d hoped getting out of the house would help.
But as the pins and needles pricked her legs, she knew she was having a panic attack. ‘I remember thinking: how far can I push this until it breaks me?’ Leah tells WH from her home in Ferndale in the South Wales Valleys.
‘The anxiety was constant and every day I wondered how long I was supposed to be able to manage until it took over my life. I knew that A&E had a crisis team, but I’d always thought it was only for people with suicidal thoughts. That night, though, I knew I couldn’t go on like this; I had to offload to a professional.’
Leah’s dad drove her to A&E. ‘I told the crisis team everything: that I’d had a baby at the start of the pandemic; that I was raising him without any professional support, adult interaction or baby groups. The women told me: “We’re not surprised you’re here.”
They gave me a card with a phone number for a 24-hour helpline. It doesn’t sound like much, but I went home feeling reassured.’ It was a sense of assurance that had been missing during the months of isolation as she grappled with how to access the help she so desperately needed.
How has the pandemic impacted maternal mental health?
The psychological wounds the pandemic has inflicted upon new mothers can’t be overstated. In January, the maternal mental health charity PND Awareness & Support reported that calls to its helpline had more than tripled in the past year.
More worrying still were the findings, published in the Journal Of Psychiatric Research in April, of a UK-wide study, conducted by the Maternal Mental Health Alliance (MMHA) and Centre for Mental Health (CMH) on the experiences of postnatal women since March 2020.
A staggering 43% of new mothers met the criteria for clinically relevant depression and 61% for anxiety; the usual rates in the UK are around 15% for both. But it was the publication of a report in March that really sounded the alarm. The conclusion of the 54-page document, titled Maternal Mental Health During A Pandemic, was unequivocal: the pandemic has created a maternal mental health crisis, the fallout of which will be felt for years to come.
Graham Durcan is associate director at CMH; a psychiatric nurse by training, he’s worked in the mental health field for 40 years and believes policymakers’ decision to prioritise the physical health of pregnant women and new mothers over their mental health failed them.
‘Pregnancy and early motherhood are high-risk times all round, but there’s a strong risk around mental wellbeing that wasn’t accounted for in the restrictions.’ He’s referring to the rules themselves – such as attendance limits on midwife appointments – as well as the way in which they were introduced.
By the end of April 2020, there were 14 different sets of guidance on the subject, varying by NHS trust. In a survey of 15,000 women by the campaign group Pregnant Then Screwed last November, 90% said hospital restrictions had a negative impact on their mental health, with almost all reporting increased anxiety around childbirth.
Thousands more shared their stories of difficult births and receiving bad news alone as part of the viral social media campaign #butnotmaternity.
The state of maternal mental health, before the pandemic
Sadly, this crisis isn’t wholly born of Covid. Pre-pandemic, the rate of perinatal (during pregnancy or within a baby’s first year) mental illness was more than one in 10, spanning everything from postnatal depression and anxiety to perinatal obsessive disorder, postpartum psychosis and post-traumatic stress disorder.
Untreated, conditions can become life-altering and – in extreme cases – life-threatening; suicide remains the leading cause of death for perinatal women. While researching this piece, WH heard from more than 30 women who’ve experienced firsthand the issues inherent in maternal mental health services. While some were effusive about the institution that cared for them, others struggled to navigate the complex web of services that make up the UK system.
How should a pregnant person with a pre-existing condition be helped?
Today, a pregnant woman with an existing serious mental illness should be referred to a specialist perinatal mental health team, as should those whose conditions have severely worsened, and women who develop a new condition, like postpartum psychosis.
These multidisciplinary teams include psychiatrists, nurses, psychologists, occupational therapists and social workers, who collaborate to deliver the most suitable care.
‘The initial focus [in improving maternal mental health provision] was, rightly, on getting provision in place for the most at-risk, and in recent years there’s been significant investment in these specialist teams in England,’ says Durcan, who credits the MMHA’s Everyone’s Business campaign for this progress.
He cites the increased number of mother and baby units (MBUs), which provide inpatient care for seriously ill women and their babies, as one of the most positive developments.
Provision is still inequitable, though; while four fifths of England have services that meet current recommendations, that figure falls to 29% in Wales and 14% in Scotland, while Northern Ireland has no areas that fully meet standards.
If you live in an area without a perinatal mental health team, you may have to rely on mainstream community services, which could lack the training to identify or treat your needs. Likewise, women who live in an area without an MBU may have to travel far from home, or be admitted to a general psychiatric ward without their child.
The specialist teams also work with women in the planning stage. Currently, those with existing serious mental illness – such as bipolar disorder and schizophrenia – who are more at risk of developing a severe mental health issue, are entitled to a one-off consultation. Some mums we spoke to felt this doesn’t go far enough.
Louise has bipolar II disorder and knew through her own research that she was at high risk of postpartum psychosis. (According to the charity Action on Postpartum Psychosis, around one in four women will develop it, compared to one in 1,000 for women without bipolar.)
In Louise’s check, it was agreed she move onto a lower dose of antipsychotic medication and was told to come back when she was pregnant.
During her two-year fertility battle she suffered from severe depression and anxiety. When she did fall pregnant, she was wrongly told she couldn’t self-refer. In her struggle to get back in the system, her anxiety skyrocketed and she found herself wondering whether a more vulnerable mum-to-be would have given up.
Happily, Louise says she received ‘an avalanche' of support in the end. She gave birth to her daughter at the start of the pandemic in April 2020, with her care plan followed ‘to the letter’; her partner was able to stay overnight and she had regular check-ups with the team.
Durcan is clear that care for women with more severe mental health conditions, like Louise, is effective if they meet the threshold and have a local service. But ‘if you have a mild-to-moderate condition, the roadmap to treatment is less clear cut and you’re at the mercy of the expertise and provision available in your area,’ he explains.
If you disclose a mental health issue to your GP or midwife, you may be referred for free psychological therapy – known as Improving Access to Psychological Therapies (IAPTs) in England – which you can also self-refer to.
You might also be allocated a mental health midwife, who can offer more specialised support; there are health visitors with specialist mental health training, too, though this also varies by region.
But the system relies heavily on the self-reporting of symptoms and that disclosure being dealt with effectively. If any one of these channels of communication breaks down, symptoms can go unnoticed, and cases that could have been treated early are allowed to deteriorate.
How are the signs of a mental health condition picked up?
The intrusive thoughts that Sarah now recognises as the first symptom of perinatal OCD started around three months after the birth of her first son, in December 2015. Her GP referred her to IAPTs, after which she was diagnosed with health anxiety and taught techniques to help with anxiety-based conditions.
But it was only after having her second child, when the thoughts became more extreme, that her symptoms were picked up, serendipitously, by a friend. ‘I was in a really bad way – I remember thinking I didn’t want to be here,’ she recalls.
‘My friend invited me over, and when I told her about the intrusive thoughts, she burst into tears. She told me it sounded like OCD – she knew because she’d had it herself for 20 years.’
Sarah’s research led her to the website of the mental health charity Mind, and when she read the listed symptoms for maternal OCD, she ticked every box. She took them to her IAPTs therapist who, lacking experience in the condition, referred her to the specialist perinatal mental health team.
Under their care, she started exposure and response prevention (ERP) therapy – which encourages you to face your fears and let obsessive thoughts occur – and started taking fluoxetine, a drug known to be effective in managing OCD symptoms.
Sarah speaks positively about the care she’s received but remains convinced that a delay in diagnosis allowed her condition to deteriorate. Part of the problem, she believes, was that none of the professionals she spoke to recognised her symptoms.
For other women, the opportunity for such a conversation never arose. ‘In my health visiting appointments, I was asked questions like “are you staying hydrated?”,’ Leah recalls.
She later learned that her health visitor had been redeployed to another role during the peak of Covid; her case wasn’t picked up by anyone else until February this year, after she made a complaint.
Catherine spent two weeks on a psychiatric ward in the US after being diagnosed with postpartum psychosis following the birth of her first child. While pregnant with her second under the care of the NHS, she had to explain her history multiple times to different people because of a lack of cross-communication. While Cho has written about her experiences, this situation could be re-traumatising for many.
Improving the effectiveness of conversations between perinatal women and health professionals has been the focus of multiple campaigns during the past decade. But progress has been slow. While a 2015 report by the Royal College of Midwives (RCM) called for mental health midwives in every NHS trust, over a third of maternity services still didn’t employ any by 2019.
Calls for dedicated appointments to discuss physical and mental health were echoed by the National Childbirth Trust (NCT), after its 2017 report found that 50% of new mothers’ mental health problems weren’t picked up. It identified the six-week postnatal GP check as a missed opportunity.
The resulting ‘Hidden Half’ campaign was a success, on paper, in England. From April 2020, mothers became entitled to a solo GP check-up, with mental health now a focus.
And yet, NCT research one year on found that a quarter of new mums who’d given birth during that time had not been asked about their emotional wellbeing. The decision to redeploy health visitors, as Leah’s was, goes some way to explaining why.
Tackling the taboo of maternal mental health
In WH’s interviews, another obstacle emerged that’s harder to solve with policy. A fear of being ‘locked up’ initially kept Sarah from divulging the worst of her intrusive thoughts, which she thinks contributed to her initial misdiagnosis. Others told us they thought their child would be taken away.
If such fears sound extreme, they have roots in the not-too-distant past; 19th century mothers with severe depressive symptoms were sent to asylums. Catherine, who explored this reticence in her book Inferno: A Memoir Of Motherhood And Madness, believes this narrative has prevailed. ‘When you become a mother, you’re expected to set your identity aside. I think that’s why poor mental health is seen as selfish or self-indulgent.’
Catherine, who’s Korean American, believes this stigma is particularly pervasive for women of colour; her well-meaning in-laws still attribute the onset of her condition to the stress of travel, as she didn’t follow the Korean tradition of confinement for 21 days.
Sandra Igwe, founder of The Motherhood Group, a social enterprise that delivers events, peer support and programmes for Black mothers, agrees. ‘In many African and Caribbean cultures, conditions like depression aren’t acknowledged. This makes it difficult for Black women to know when to seek help and find the courage to do so.’
Much of Igwe’s work is focused on tackling this stigma, but she believes that mental health services need to work harder to deliver more culturally appropriate care. ‘Cultural beliefs can impact the way symptoms are interpreted.
For example, Black mothers tend not to say, “I’m feeling depressed,” but rather describe physical symptoms, like aches and pains or tiredness. Culturally appropriate care means recognising what disclosure looks like for different women.’
The Motherhood Group offers peer-to-peer support to thousands of women, and we spoke to groups throughout the UK offering similarly invaluable help, both in-person and online. Often, these voluntary and community sector organisations (VCS) are set up by women with lived experience who have identified a gap in support in their local area.
Organisations are at their most effective when they’re joined-up with professional services, who can refer vulnerable women, and likewise groups can sign-post members to clinical services. But crucially, the groups need to be findable and run safely.
The Hearts and Minds Partnership is working to make sure this happens; formed of three perinatal mental health charities from around the country, it shares best practice between organisations and is developing an England-wide map of to ensure all women can find high-quality groups in their area.
Encouragingly, one of the key findings of the CMH/MMHA report was to recognise the importance of VCS set-ups and it highlighted the need for better long-term funding, rather than them scrabbling to survive on short-term support.
The positive change that has happened, so far
Since work began on this report, there have been some positive developments: Wales has opened its first long-promised MBU and NHS England has announced the creation of mental health ‘hubs’ to bring together maternity services, reproductive health and psychological therapies. Further progress is promised via the NHS Long Term Plan, which aims to continue the transformation of specialist services across England.
Catherine urges women to do their own homework. ‘I had no idea these resources existed,’ she recalls. ‘I didn’t know about MBUs, the perinatal team, the mental health crisis team. I was amazed by the care I received from these services during my second pregnancy, but I was never aware of this infrastructure.’
Louise also believes the system must be more joined up, with all professionals plugged into the specialist services. She wants those with severe conditions supported from the fertility process onwards.
What treatments might help people who need it?
Sarah credits both therapy (both ERP and EMDR – eye movement desensitisation reprogramming) and medication with helping her to manage her intrusive thoughts; she’s particularly vocal about the benefits of the latter, since many women believe they can’t take antidepressants while breastfeeding, as Sarah is now (the advice varies by drug, so it’s important to discuss this with your GP).
As for Leah, after leaving A&E that evening, she was referred to the specialist perinatal team, who put her in touch with Mothers Matter– a Wales-based voluntary organisation, whose one-to-one counselling and home visits help her to manage her anxiety as she adjusts to a world in which restrictions are easing.
Remember, what works for someone else might not work for you. But wherever you are on your journey, know that you don’t have to make it alone.
Your maternal mental health questions, answered
Dr Joanne Black, chair of the perinatal faculty at the Royal College of Psychiatrists, answers some of the most common mental health questions from pregnant women and new mothers.
I’m pregnant and I’ve previously had mental health issues that I sought help for. What should I do?
Tell your GP and midwife your history, even if you’re not currently having treatment. If they feel you may benefit from additional support, they’ll recommend the right care. If you’ve had a severe mental illness, you’ll be referred to a perinatal mental health team, who will build a plan for your care throughout your pregnancy. They might help with a birth plan, advise on medication or enable quick access to condition-appropriate therapy.
I take antidepressants – can I keep taking them during pregnancy?
Most antidepressants are safe in the vast majority of pregnancies, but you should always speak to your GP if you take medication and you’re pregnant or planning a family. Remember, stopping abruptly isn’t recommended; it can cause withdrawal symptoms and make relapse more likely.
Many women feel guilty about taking antidepressants in pregnancy or postnatally, but if you need to stay on medication to help maintain – or regain – good mental health, you’re doing what’s best for you and your baby.
I’ve recently had a baby and I’m struggling with my mental health. What should I do?
First, remember that perinatal mental illness can happen to anyone and it isn’t your fault. You should speak to your GP and health visitor (or midwife, if you’re still under their care) about how you’re feeling as soon as possible so they can advise you on getting help. Even if you’ve been struggling for a while, you can get better. Tell trusted family and friends so they can support you, too.
Recently had a baby? Get the help you need
Your midwife, GP and health visitor should all be asking you about your mental wellbeing at every appointment and recording in your notes. If you see a different midwife each time, check they’re aware of the issues you’ve raised before.
You should be offered a six to eight-week check after your baby’s been born, in which you should be asked about how you’re feeling mentally. If you haven’t been offered one, you can request an appointment.
There are some brilliant community-led groups and charities that can provide support, be that directing you to services, connecting you with other mums or offering counselling.
Ask your GP or health visitor about local organisations and search online for groups in your area. Your GP can refer you to free psychological therapies on the NHS and you can also self-refer in some areas.
Do your research
To ensure you’re treated quickly, it helps to know the signs to look out for. You’ll find resources from specialists for different maternal mental health conditions via the following charities:
Action on Postpartum Psychosis (app-network.org)
PND Awareness & Support (pandasfoundation.org.uk)
Maternal OCD (maternalocd.org)
Perinatal Anxiety & Worry Support (openpaws.co.uk)
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