Policy Briefing August 2014
Maternal Mental Health in Northern Ireland: a briefing
by the NI Maternal Mental Health Alliance, August 2014
Campaigning for Change: the UK Maternal Mental Health Alliance
Of the 25 273 births in 2011 in Northern Ireland, 2527 women developed antenatal depression, 3790
women developed postnatal depression, 50 mothers developed puerperal psychosis and 50 were
admitted as a result of relapsing (DHSSPS, 2013). A recent 32 week study found that 75 pregnant
women who were admitted to an acute psychiatric ward could have instead have benefited from
being treated in a mother and baby unit (Royal College of Psychiatrists, 2013). A woman may have a
pre-existing mental health condition, or mental ill-health can arise during pregnancy (DHSSPS, 2013).
Some women with pre-existing mental illness diagnosis may not become pregnant because they
have been (incorrectly) advised by health professionals that women with a psychiatric diagnosis
should, de facto, not to have a family.
This briefing has been produced by the Northern Ireland Maternal Mental Health Alliance whose
membership includes: professional bodies, clinicians, voluntary and community organisations, and
women and their families who have been directly impacted by these issues. We are part of the UK
Maternal Mental Health Campaign “Everyone’s Business” (funded for 3 years by Comic Relief until
September 2016). “Everyone’s Business” aims to: raise awareness of perinatal mental illness among
health and social care providers, stop the post code lottery of perinatal mental health provision and
highlight best practise in health and social care (www.everyonesbusiness.org.uk, 2014). Perinatal
mental health is concerned with the pregnancy and first year of a child’s life.
In Northern Ireland we are campaigning for best practise services using the stepped care approach
across all HSCT’s and the full implementation of policy commitments by May 2016, the end of this
Assembly mandate. We are seeking the following.
1. Health professionals to focus on early intervention and act quickly in order to prevent
adverse outcomes.
2. Mental health integrated within ante-natal classes in order to improve awareness about
potential challenges and available support
3. Having the same midwife/health professional throughout a pregnancy in order to provide
fully informed care, and build rapport/trust so that the woman feels that she can be open
about her feelings.
4. Health professionals, especially midwives, trained on maternal mental health in order to
recognise vulnerability, offer appropriate help and reduce stigma.
5. A care plan implemented throughout a pregnancy including an emphasis on maternal
mental health and a question about mental health at first contact in order to ensure help at
any stage of the pregnancy.
6. A mother and baby unit in order to allow the mother to receive specialist help and also bond
with her child in the same facility.
We have no mother and baby unit in Northern Ireland, and only one specialist mental perinatal
psychiatrist in the Belfast HSCT (Murray and Hamilton, 2005). We have signed up to the NICE
Guidelines on Antenatal and Postnatal Depression, which have 5 key themes: co-ordination of
service delivery, appropriate use of medication, effective communication, promotion, prediction and
detection, competencies of the multidisciplinary team (DHSSPS, 2011). The Executive has committed
to a policy framework, with leadership resting with the DHSSPS (health) and OFMDFM (human
rights); and published the Integrated Perinatal Mental Health Care Pathway (Public Health Agency,
2012). The Pathway recommends that women with a pre-existing mental illness should have: (i) a
health professional talk through potential issues; (ii) a medical support team throughout the
pregnancy; and (iii) a personalised care plan relevant to their needs. Women who become ill during
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Policy Briefing August 2014
or after pregnancy require emergency assessment if there is a high level of concern over declining
mental health. At first contact with obstetric services, women should be asked if they have a history
of mental ill health, this should be recorded and communicated with staff (Public Health Agency,
2012).
This briefing will cover the importance of positive maternal mental health, the Northern Ireland
policy framework, underfunding and the lack of provision, and regional differences across the UK.
Why Maternal Mental Health is important
Positive maternal mental health is vital not only for the mother’s outcomes but also those of her
baby, her partner and wider family.
"Success in this long term psychological process is associated with positive life-long
outcomes for both the parenting mother and the child and is essential for the normal
development of children and their maturation into competent adults" (Martin, 2012: 431).
A child's development is mediated through its attachment to his or her mother. Poor maternal
mental health can impact a child’s development; and, conversely, intervention and secure
attachments improves the child’s emotional and educational outcomes as s/he grows older (Martin,
2012) and enhances the child’s longterm cognitive, behavioural and emotional outcomes. Early
intervention can help strengthen family relationships especially with their partner; ensure support
through continued social contact with friends; and develop a closer mother-baby bond. Early
intervention reduces the likelihood of financial pressures because the mother’s return to work is less
disrupted, and family members do not need to become carers (Robson and Waugh, 2013).
Investment in early intervention makes economic sense. Post natal depression can cost UK
healthcare £35.7 million every year; and this figure rises when we take into account the long term
health, education and employment costs for mother and child (NICE guidelines, 2007).
Northern Ireland Policy Framework
The policy framework within Northern Ireland is led primarily by DHSSPS. On maternal mental health
the following have addressed this issue: A Strategy for Maternity Care in Northern Ireland 20122018, Bamford Taskforce Annual Report 2011, the Evaluation of the 2009-2011 Bamford Action Plan,
Transforming your Care: a Review of Health and Social Care Services in Northern Ireland, Service
Framework for Mental Health and Wellbeing, and Strategic Framework for Adult Mental Health
Services.
OFMDFM is the lead Department with regard to the progressive realisation of human rights in
Northern Ireland. All UK jurisdictions have human rights obligations, which they must act on
including human rights to health and family life.
In 2005, a Strategic Framework for Adult Mental Health Services stated that maternal mental health
issues should be tackled through a regional strategy, which would emphasise the different service
levels that were required and ensured all workers were sufficiently trained. The following
recommendations were made.
• Regional specialist mental health services for help during the perinatal period.
• Inpatient mother and baby facilities based on a regional needs assessment.
• Assessment and care planning for the management of women with pre-existing mental illness
during pregnancy.
• Assessment of maternal health needs to include mental health. (DHSSPS)
In 2010, the Service Framework for Mental Health and Wellbeing stated that pregnant women
should be asked about previous or current mental health history at first contact, booking visit, final
trimester visit, 6- 10 weeks after childbirth and up to first year after childbirth. When needed they
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Policy Briefing August 2014
should have access to specialist mental health services with psychological interventions; and extra
help from health visitor and inpatient care in line with NICE guidelines. (DHSSPS)
One of Transforming Your Care: A Review of Health and Social Care in Northern Ireland’s main
proposals was a regional plan for women with severe mental conditions (DHSSPS, 2011).
The Evaluation of the 2009-2011 Bamford Action Plan Review stated its intention to improve
perinatal mental health services through improved identification and treatment of mental illness
during and after pregnancy. The NICE guidelines were to be implemented in all Health and Social
Care Trusts, particularly in primary care. Consultation on the Review was in 2009, and
implementation agreed by 2010. (DHSSPS, 2012)
The Bamford Taskforce Annual Report 2011 noted that the Bamford Review had led to the
establishment of a regional perinatal mental health group focussed on: early intervention,
prediction, integrated care pathway, service improvement and training and awareness. In addition
to the regional integrated pathway for perinatal mental health (published 2012), this group had roles
around the development of a training strategy for clinicians, and the promotion of public awareness
via campaigns (DHSSPS, 2011).
A Strategy for Maternity Care in Northern Ireland 2012-2018 recognised that some women require
inpatient mental health services and supported Transforming Your Care and the Bamford’s Action
Plan’s key proposals on this area. The Strategy’s recommendations included:
 follow up visits for newly delivered mothers who have had pregnancy complications due to
mental health issues in order to provide for early intervention and counselling for postnatal
depression;
 personalised information on impact of pregnancy on long term conditions such as
depression and usage in GP surgeries/specialist clinics; and
 implementation of the regional care pathway to manage mental health throughout
pregnancy. (DHSSPS)
Access to and provision of best practise health and social care requires a reduction in stigma
amongst professionals and the public. Northern Ireland is the only area of the UK without a regional
mental health anti-stigma campaign. The Equality Commission for Northern Ireland found that
mental health stigma is a significant and growing problem: 1 in 4 individuals would mind if an
individual experiencing mental health problems was their work colleague or neighbour; and 1 in
three would mind having them as an in- law (2011).
Furthermore, discriminatory attitudes among health professionals are a significant challenge for
people using health services and make them reluctant to disclose and seek support. A 2011 study
found that 30.4% of mental health service users felt discriminated against by health professionals
despite public campaigns aiming to remove stigma and negative attitudes around mental health
(Brindle, 2013). Many women report feeling patronised and dismissed by their doctor when they
disclose. One woman described postnatal depression symptoms including tiredness, crying, feeling
irritable:
"The doctor said that I was a working mother of four and my baby was only twelve weeks
old, of course you’re tired, I mean you don’t want valium, do you? I was devastated and left
the surgery feeling small” (Corry, 2008: 11).
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Policy Briefing August 2014
Underfunding/lack of provision
Maternal mental health provision is often regarded as having little priority for the NHS
"Mental health services, generally, are a Cinderella area of the health service and perinatal
mental health is a Cinderella of the mental health services" (Moorhead, 2013: 1).
In Northern Ireland the situation is stark and unacceptable. The policy framework has not delivered
an acceptable level and range of care and support, by public, voluntary and community sectors, for
women and their families across Northern Ireland. There is clear evidence of a postcode lottery
within the limited provision that is available.
New mothers requiring hospital based mental health care should not be admitted to a general
mental health ward; and should not be separated from their babies. This can have a detrimental
effect on the woman’s recovery from her illness and weaken her attachment to her child (Tickle,
2013). However, the absence of a mother and baby unit in Northern Ireland means that this is what
is happening. The Service Framework for Mental Health and Wellbeing document noted that women
are scared to ask for help for fear of being separated from their baby (DHSSPS, 2010).
In Northern Ireland, the mental health sector is underfunded proportionate to need. Although in
Northern Ireland women who are pregnant have higher rates of depression compared to their UK
counterparts, this isn’t reflected in current expenditure levels for the mental health sector (Children
and Youth Programme, 2011). In 2011 spending on mental health was just 7% of the whole health
budget and 10-30% lower than English spending on this sector. This is despite our need being 44%
greater compared to England. Only 3.7% was spent on maternity and child health (Appleby, 2011).
Regional differences
Northern Ireland has committed to following the NICE guidelines on antenatal and postnatal mental
health; and implementation of the Integrated Perinatal Mental Health Care Pathway. There are
currently 19 mother and baby units across the UK (2 in Scotland, 17 in England and none in Wales or
Northern Ireland. In terms of specialist perinatal mental health provision this varies considerably
between regions. The majority of Wales and Northern Ireland has no provision. There is only
adequate provision in the middle and South of England. Scotland is varied with the most provision in
the middle of the country (Maternal Mental Health Alliance, 2014).
UK specialist perinatal mental health provision
(MMHA, 2014)
UK mother and baby units
(MMHA, 2014)
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Policy Briefing August 2014
In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 mandates NHS Boards to
provide specialist facilities for newly admitted mothers and their babies where needed. The
Delivering for Mental Health report led to the first mother and baby unit in 2005. Health Boards
created care pathways to deliver perinatal services including community and inpatient services
(Scottish Government, 2006). A Refreshed Framework for Maternity Care in Scotland emphasises
maternal and infant mental health and wellbeing through effective assessment and support services
(Scottish Government, 2011).
In Wales the Strategy for Maternity Services recommended that pregnant women on their first
contact with a health professional be asked about any history of and treatment for mental health
problems. The Government committed to follow NICE guidelines on primary and secondary care and
a local care pathway delivered to each maternity area in Wales (Welsh Government, 2011). The
Wales Together for Mental Health Annual Report required the use of maternity records to identify
women at risk of developing postnatal depression/postpartum psychosis. A midwifery learning
programme module on symptom recognition and care planning was delivered to all maternity units.
The Wales Perinatal Mental Health Group oversees implementation (Welsh Government, 2013).
In England the Government has committed to follow NICE guidelines on antenatal and postnatal
mental health (Hogg, 2011). In 2013 Health Education England was tasked with ensuring sufficient
perinatal mental health training so that specialist staff are in all birthing units in England by 2017.
1300 new midwives have joined the NHS to offer support for all vulnerable women before, during
and after pregnancy; with 5000 being currently trained. (Department of Health, 2013)
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