Think piece by Joanne Smith, Everyone’s Business Scotland Coordinator
On World Maternal Mental Health Day, the time is right to reflect on the progress made in Scotland to protect pregnant women, new mums and their babies during the perinatal period.
While there have been encouraging signs of progress following the establishment of the perinatal managed clinical network and the perinatal and infant mental health programme board, the levels of specialist provision still falls short in most parts of the country, meaning right now, women and families still face a postcode lottery.
As concern turns to social and economic recovery following COVID-19, there is a need to acknowledge and address the disproportionate impact of the pandemic on women and their babies. Stress and mental health needs were already high before the crisis, between 10% and 15% of women experience mental health difficulties during pregnancy, and the risks are likely to have increased with reduced access to care and the support networks women and families rely on.
Last week, the Scottish Government announced funding to help charities support families during pregnancy and the first year after birth. The Perinatal and Infant Mental Health fund will provide vital resource to key third sector perinatal services who have shown themselves to be agile, highly skilled and a lifeline to women and their families in a time of crisis.
It is encouraging to see the invaluable contribution of the third sector recognised in spending commitments. However, this is not new money but part of the £52 million previously pledged to transform perinatal mental health services in Scotland. The evidence is clear that short-term third sector funding, on its own, is not a strategic or sustainable solution to address the chronic and historic lack of investment into specialist perinatal mental health services in Scotland.
If the Government is serious about delivering on its commitment to human rights in its COVID-19 framework for decision making, then it must place a higher priority on perinatal and infant health within the national health budget. The level of investment must reflect the weight of evidence identifying spending on perinatal and infant mental health as the key to preventing poor mental health outcomes across the life course.
In December 2019, MBRRACE-UK published their latest Confidential Enquiry into Maternal Death. Once again, the statistics make for sobering reading. Maternal suicide is still the leading cause of direct deaths occurring within a year after the end of pregnancy. Lack of local, specialist support means that problems are not being identified early, often leading to tragic consequences. In order to save precious lives, we must urgently address the gaps in perinatal mental health care.
A range of measures have been introduced to achieve a transformational change in approach towards prevention and support for mothers and babies has been recognised as central to this process. The Scotland-wide clinical guideline on the management of perinatal mood disorders, published 7 years ago (SIGN 127) provides evidence-based recommendations to all health boards.3 The Perinatal Managed Clinical Network developed a detailed needs assessment and delivery plan to support implementation of the guideline.
The Delivering Effective Services report makes recommendations across all tiers of service delivery, with the aim of ensuring that Scotland has the best services for women with, or at risk of, mental ill health in pregnancy or the postnatal period, their infants, partners and families.
The problem is that practice in Scotland still lags behind the evidence base. This is underlined by the fact that the guideline is not being fully implemented. Mental health care for expectant and new mothers remains fragmented and specialist support in the community for mothers and babies is only available in some areas. Only 6 out of 14 health boards currently have a specialist community PMH service, and just one of these is comprehensive.
Critically, there is still neither sufficient knowledge nor expertise within primary or secondary care to ensure that every woman and her baby receive the best care in the perinatal period. Women with serious mental illness need specialised knowledge and skills on the part of the professionals who care for them.
While important investment has been made to expand acute inpatient care, to develop guidance to inform local planning and to bolster third sector support, in the short term, we have yet to see plans to develop the specialist skills required within psychiatry, psychology, nursing and social care in order to develop service provision to fully implement the SIGN guideline across the country.
Skills shortages in specialist nursing, psychiatry and psychology and the ongoing problem of recruiting outside of Scotland persist. Yet, without the appropriate skills mix and staffing levels, how do we ensure the recommendations in ‘Delivering Effective Services’ are realised locally?
There are a number of key actions required to ensure the committed £52m is spent in the most effective and transformative ways by health boards, taking into account both access and quality of provision. One measurement of success will be a sustained and significant increase in the number of specialist community PIMH teams offering well-integrated support for the mothers, and for the mother-infant relationship.
Identifying and addressing maternal mental illnesses requires there to be a range of high quality services in place in every area. Integrated Joint Boards and Health and Social Care Partnerships are central to this work. Tackling perinatal mental illnesses and mitigating their effects requires joint working between mental health services, psychiatry, midwifery, primary care, children’s services, obstetrics, paediatrics, adult services and the voluntary sector.
Strategic work has secured important advances, including steps to strengthen local accountability structures through the establishment of perinatal and infant mental health executive leads. Work is underway to inform the development of local strategies to secure sufficient, high quality, joined up services and clear care pathways in each place. Both statutory and voluntary organisations, and experts by experience must participate in the development of these strategies.
Taken together, these measures have the potential to drive the necessary shift towards prevention, but this must be supported by prescriptive national direction and resource. The Government must make explicit its renewed commitment to perinatal and infant mental health in a post COVID-19 context. The time is right to overhaul the Mental Health Strategy for Scotland 2017-27 to better reflect the evidence on prevention by placing perinatal and infant mental at the heart of the national approach.
The work of the MCN and the programme board have clearly identified what each board has and needs to have very comprehensively. The robust benchmarks have been commissioned by and reported back to the Scottish Government who have begun the momentum of encouraging boards to aim for the targets set. However, without recurring, sustained funding or policy commitment to hold boards to account the recommendations will remain only that.
The Scottish Government’s budget-setting and spending decisions following the pandemic must take account women’s right to access these services. It is important to recognise that women and babies have been hit harder than others by the pandemic. Many of whom already experience significant barriers to accessing their rights. Important lessons must be learned.
It is time-critical that specialist support for mothers and babies pre- and postpartum is embedded at the heart of our national decision making. This is not an add on or a burden to be shouldered by an insecurely funded third sector.
If we’re serious about honouring the memory of those women who have lost their lives following childbirth, we must urgently shift resources towards prevention. Investment in perinatal mental health services must be a priority aim across all national planning approaches. Decisions taken now will determine the future wellbeing and prosperity of our nation for generations to come.