Community-based perinatal teams associated with better access to care

Depression is common during the perinatal period (from conception to a year after delivery), while suicide remains a leading cause of maternal mortality. Perinatal mental illness is more common in certain groups, including younger women, migrant women and women with a history of trauma, including intimate partner violence. This was also evident from a survey among 2 million women in England increased obstetric (preterm birth) and neonatal (small for gestational age) risks among women who had contact with a secondary mental health service before pregnancy, with risks being greater when contacts were more recent or intensive (i.e. crisis resolution/input of a home treatment team or inpatient admission). It is known that women with mental health conditions are at increased risk of relapse or deterioration during the perinatal period.

Unique to the National Health Service (NHS) in England, £365 million was invested in perinatal mental health care in 2016, followed by further funding in 2019. The authors of this article recent research The aim was to determine whether the gradual rollout of community perinatal mental health teams was associated with better access to secondary mental health care or with fewer postnatal relapses.

NHS England invested £365 million in perinatal mental health care in 2016.

Methods

This cohort study analyzed data from the NHS England national secondary mental health data set. This linked all mental health ‘episodes’ from 01/04/2006 to 31/03/2019 (except 01/12/15 to 31/03/16) to hospital episode statistics (all general hospital contacts) and birth notifications from the Personal Demographic Employ .

The authors examined data from women aged 18 years and older with a pregnancy that started between April 1, 2016, who had one child until March 31, 2018 and a gestational age of 24 weeks or longer. Women with a pre-existing mental health condition (defined as contact with a secondary mental health service in the ten years before their current pregnancy) were included in this study.

They then determined whether or not the Clinical Commissioning Group (CCG), responsible for healthcare in the region where the woman lived, provided a community perinatal mental health team (defined as the presence of at least one dedicated psychiatrist, psychologist and specialist nurse in the region where the woman lived). post) from the date of her pregnancy.

The authors calculated adjusted odds ratios and 95% confidence intervals using logistic regression, adjusting first for monthly time trends and then for maternal demographic characteristics and regional differences in socioeconomic deprivation.

Results

Of the 780,026 eligible women, 70,323 (9.0%) had a pre-existing mental health condition. The availability of community perinatal mental health teams increased from 81 CCGs (39%) in April 2016 to 130 (63%) in June 2017 (when women who had given birth in March 2018 became pregnant). Of the 70,323 women included, 31,276 (44.5%) lived in a region with a community perinatal mental health team, and 39,047 (55.5%) did not.

In certain regions, a smaller proportion of women had an acute postnatal relapse (inpatient admission or crisis resolution/home treatment team). of a community perinatal team than in regions without a team (n=1117, 3.6% vs. n=1,745, 4.5%; aOR=0.77, CI=0.64 to 0.92). There was no statistically significant difference in recurrences during pregnancy.

A greater proportion of women received secondary mental health care (admission, crisis resolution/home treatment team or community mental health team) during the perinatal period (both during pregnancy and within a year of childbirth) in regions of a community perinatal team than in regions without a team (n=9,888, 31.6% vs. 10,033, 25.7%; aOR=1.35, CI=1.23 to 1.49).

The authors also found that in the regions a higher proportion of women had a stillbirth or neonatal death of a community perinatal team than in regions without a team (n=165, 0.5% vs. n=151, 0.4%, aOR=1.34, CI=1.09 to 1.66). They found the same pattern for babies born small for gestational age (n=2,777, 7.2% vs. n=2,542, 6.6%, aOR=1.1, CI=1.02 to 1.20) . The opposite was true for preterm birth: a lower proportion of women in the regions of a community perinatal team had a premature baby than in the regions without a team (n=3,167, 10.1% vs. 4,341, 11.1%; aOR=0.86, CI=0.74 to 0.99).

Differences in obstetric and neonatal outcomes were found in women with mental health problems living in regions with and without perinatal community teams.

Conclusions

As expected, the presence of community perinatal mental health teams was associated with better access to secondary mental health care in the perinatal period. Encouragingly, they were also associated with a reduced risk of postpartum relapse (requiring hospitalization or crisis resolution/support from the home treatment team) and preterm birth.

Unexpectedthe authors found higher rates of stillbirth, neonatal death, and small for gestational age infants in regions where perinatal community mental health teams were present, despite controlling for potential confounders. Possible explanations for these unexpected findings include:

• Focus on perinatal mental health, overshadowing the recognition of modifiable behavioral and obstetric risk factors by physical health care professionals.
• Highlighting mental health issues could lead to discrimination (diagnostic overshadowing) when women access physical health care.
• Increased use of psychotropic medications. However, the authors note that there is currently no evidence linking psychotropic medications to stillbirth.

The existence of community perinatal mental health teams was associated with better access to secondary mental health care in the perinatal period.

Strengths and limitations

• Due to significant missing data, the authors did not identify women with pre-existing mental health conditions from clinically recorded diagnoses. They used mental health contacts as a proxy, increasing the number of women who could be included in their analyses.
• The use of regional perinatal community team facilities avoided confounding by clinical indication, but may have reduced the estimated effect size (as not all women had access to the team).
• Because the authors did not have access to adolescent mental health records, less than ten years of psychiatric history could be captured for younger women, who may be at greater risk for perinatal mental health problems.
• The authors are conducting a real-world evaluation that will examine the mechanisms of women’s involvement in community-based perinatal teams, as well as changes in patterns of service use and costs over time, which will likely illuminate some of these findings.

It would be useful to record adolescent mental health histories to identify women at risk for perinatal mental health problems.

Implications for practice

Clinicians and policymakers can be encouraged by the fact that providing perinatal community mental health teams is associated with increased access to mental health care and reduced postpartum relapse, as well as a reduction in preterm birth. However, the higher rates of stillbirth and neonatal death in the regions where such teams are deployed indicate that investments in mental health care cannot be assumed to only impact pregnancy risks that are known to be higher in women with mental health conditions. Clinicians in psychiatry, obstetrics and general practice should be alert to the risk of diagnostic overshadowing and work closely together to provide collaborative care at all stages of the perinatal period.

Professionals must work multidisciplinary and provide high-quality care during the perinatal period to prevent pregnancy risks.

Declaration of interests

My second PhD supervisor was Professor Louise Howard (one of the authors), but I had no involvement in this research.

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