Guest blog by Dr Hind Khalifeh, consultant perinatal psychiatrist
The pandemic has compounded the mental health problems experienced by pregnant and postnatal women, and at the same time limited their personal and professional support networks. This has put a significant strain on our perinatal mental health services.
The report commissioned by the Maternal Mental Health Alliance (MMHA), conducted by Centre for Mental Health, points to a national picture of services under strain and growing demand, and that’s certainly our experience in our specialist perinatal mental health service in London.
The things that influence how women experience our service are how quickly they are referred and seen, staffing levels and expertise, the range of interventions we can offer and the settings in which we work. Overall, the number of referrals to our service hasn’t changed for now, but what has changed is the complexity, and the fact that we’re seeing women later than normal. They may be more unwell at the point we first meet them.
Staffing levels have fluctuated at short notice. Some junior doctors were diverted to hospital wards during the peak of the pandemic, and the recent changes in shielding criteria meant members of staff suddenly need to work from home, with zero notice.
The report calls for a review of online treatments that became the norm during the pandemic, and I welcome that. Some women tell us they like the online group sessions with nursery nurses or occupational therapists – things like infant massage and mother and baby groups. Sometimes this is the only place they see other women with babies. Some women, with, for example, agoraphobia or anxiety, have not minded online sessions. We have actually seen a reduction in non-attendance for appointments.
On the other hand, we have concerns about such remote working. We are worried about the lack of privacy, for example for women experiencing domestic violence. Before Covid-19, one in three women using our services was experiencing domestic violence. We expect that to have increased. Often when we are on the phone with women, the partner is in the background and we are unable to have private, safe conversations. We are concerned that we have not been able to see mothers and babies together, so we can’t observe the mother-infant relationship. It’s hard on a screen. You can treat a woman for months and not see the mother and baby together in a meaningful way, which is a massive gap.
We are concerned too that it is harder to build enough of a rapport with women for them to be able to tell us difficult things, for example that they may be having thoughts of self-harm or that they do not feel connected to their baby. We can also miss important signs of early illness. With early psychosis, for example, there can be important non-verbal clues that are hard to detect online. Some women don’t like being on a screen, for example if they are very socially anxious. I have spoken to several women sitting in their cars – because that’s the only place they get privacy.
And as the MMHA commissioned report highlights, for women who don’t speak English, or have limited income, who don’t have data on their phone, refugees and asylum seekers with no technology, women with hearing impairments – it’s much harder to access services.
After the pandemic, the most important thing is to avoid knee-jerk reactions. We shouldn’t say ‘let’s move everything online’ nor ‘let’s only do face-to-face sessions’. We need to reflect on what worked, what was a helpful change, and what we need to keep. When it comes to resources, we need to get the basics right. For example, many perinatal mental health teams don’t have premises. We need a physical space to work in before we start the fancy things.
We work with a fantastic network of groups and organisations – midwives, obstetricians, health visitors, children’s services, GPs, voluntary sector, domestic violence charities. All of them need funding – for instance, there’s no point taking it away from health visitors to give to mental health services as it’s all connected. Women and families need this whole system of care.
The enormous impact of the pandemic on children and young people is being increasingly recognised. Yet, from our experience working in the perinatal period, we know that what happens in the early months of life, and in the womb, is an extremely important place to start. There will be an ongoing high demand for perinatal mental health services post-pandemic. Decision-makers need to understand the massive health, social and economic costs of not treating perinatal mental illness and how it needs a whole system approach.
Further reflections from parents with lived experience