It is often forgotten that mental illness is by far the most common major health complication of having a baby, and suicide is always in the top 3 causes of maternal deaths, yet mental health is the only area of NHS maternity care without dedicated services. (Dr. Alain Gregoire, Chair Maternal Mental Health Alliance, November 2017).
The Children, Young People and Education Committee began an inquiry into perinatal mental health in March 2017 in recognition of the impact parental mental health can have on children's health and development. The Committee published its report, Perinatal Mental Health in Wales in October 2017. The report makes 27 recommendations to the Welsh Government.
The Cabinet Secretary for Health and Social Services responded formally to the Committee's report in November 2017. He accepted 23 of the 27 recommendations, albeit four only in principle, and rejected four.
The Committee's report has been widely welcomed. Stakeholders have been particularly pleased with the way in which the report, and its recommendations, incorporated professionals' views and those of service users.
The Committee's Report
The Committee's Report makes a number of recommendations to improve perinatal mental health care across Wales, including the re-opening of a Mother and Baby unit.
During the inquiry, the Committee heard evidence from a range of organisations and individuals, including the Maternal Mental Health Alliance, members of the third sector such as NSPCC and Action on Postpartum Psychosis (APP), healthcare professionals and women who have experienced perinatal mental illnesses in the past.
Managed Clinical Network
The Committee's first recommendation called for a clinician-led Managed Clinical Network (MCN). This network, it is envisaged, will provide strategic leadership to drive forward further development of perinatal mental health services in Wales. Importantly, this recommendation was accepted by the Cabinet Secretary. The establishment of the MCN underpins and supports many of the other recommendations made.
The Cabinet Secretary assures the Committee in his response that work to put the MCN in place will begin immediately, with plans to recruit to the leadership role this financial year.
Investment in specialist community services
The Committee's report welcomed the Welsh Government's investment of £1.5million in specialist community services as a significant step forward, but expressed the need to see this as a starting point, with more investment required to bring services in-line with national quality standards.
The Committee highlighted its concerns about the disparity in services between health board areas in Wales.
While the Cabinet Secretary accepted 'in principle' the Committee's recommendation for additional funding for specialist community services, Health Boards will be expected to ensure that the gaps in service provision are addressed from within the additional £20million each year (included in this year’s budget 2017-18) for mental health services more broadly.
The Committee's report is clear - it should not be down to the third sector to fill gaps in service provision.
Mother and Baby Unit
The Committee's recommendation to re-establish a Mother and Baby unit in South Wales attracted headlines - campaigners had been calling for this for some time as there is currently no Mother and Baby unit in Wales after the service, which was based at Cardiff University Hospital of Wales, was closed in November 2013.
It was reported that the closure of the Mother and Baby unit was due to an insufficient number of women using the service; but the Committee heard evidence contrary to that. The Committee's report is clear that the current evidence base demonstrates a need for inpatient care in Wales.
The Committee's report recognises that wherever possible, a community based specialist service is the preferred option of care for women and their families. However, there are occasions where, due to the extent of risk and the acuteness of the illness being experienced, this is not possible.
At the time of the Committee's Inquiry, the Welsh Health Specialised Services Committee (WHSSC) Joint Committee were considering an options paper on the future configuration of Tier 4 specialised perinatal mental health services in Wales. Yet, despite the Committee calling for work to be completed on identifying the level of demand for inpatient care within 6 weeks of publishing its report, a decision on the overall development of inpatient care across Wales has still not been made.
The Cabinet Secretary's response refers to the October budget agreement which commits the Welsh Government to developing specialist inpatient perinatal mental health support for mothers and babies in Wales. And while the Cabinet Secretary has accepted the Committee's recommendations, it remains unclear what the model of inpatient care in Wales will be.
Further, the report highlights the problem of poor data collection; the Health Boards and WHSSC struggled to provide the Committee with robust evidence relating to the admission of women within the perinatal period.
Other recommendations included ensuring timely access to psychological support for pregnant and postnatal women, working with relevant bodies to ensure perinatal mental health is included in training and continuing professional development for health professionals, and improving antenatal patient information and classes to include information about postnatal illnesses.
Recommendations that were rejected
The Committee's report notes that awareness of perinatal mental health remains poor among the public and health professionals. It recommends that frontline staff – including midwives, health visitors and GPs – need to be better equipped to identify and treat perinatal mental illness. It recognises that improving capacity to detect and treat perinatal mental health at an early stage will deliver the best possible outcomes for mothers and their babies.
The Cabinet Secretary didn’t agree that a public awareness campaign to improve understanding of perinatal mental health conditions and their symptoms was needed in Wales: he rejected this recommendation, stating that this would not be the most effective way of awareness raising and ‘could cause unintended adverse effects such as anxiety’.
The Cabinet Secretary also rejected the evidence put forward by the Committee on the need for Specialist Health Visitors in Perinatal and Infant Mental Health; and despite accepting 'in principle' the need for Specialist Midwives, there was no guarantee that Specialist Midwives would be available in all Health Board areas.
Perhaps, most disappointing, is the limited response from the Cabinet Secretary to look in further detail at the impact of breastfeeding on perinatal mental health; and what seems to be a reluctance to address the conflicting information that women and their families are given about medication during pregnancy and/or when breastfeeding.
The Assembly will debate the Children, Young People and Education Committee's report on Perinatal Mental Health in plenary on 31 January 2018.
Further, the Committee have agreed to undertake follow-up scrutiny of the implementation of its recommendations in the Autumn term 2018; one year on from the publication of its report.
The Committee will be keen to ensure momentum is not lost. Watch the plenary debate on the Committee's report, Wednesday 31 January on Senedd TV here.
Article by Sarah Hatherley, National Assembly for Wales Research Service