Background
Pregnancy and the early postnatal period are critical and often stressful times in the lives of women and their families [
1]. At such a time of potential vulnerability a degree of worry, anxiety and low mood is normal [
2], particularly in primiparous women, especially if the pregnancy is unplanned. It is also a time when women are likely to be in more frequent contact with healthcare professionals than usual. There is thus increased opportunity for identification, diagnosis and treatment of problems. However, women with mental health problems may be less willing to access care and anxious about disclosing their situation or history due to fear of stigma, labelling, and losing custody of the child [
3]. Women with existing mental health conditions may also be socially isolated [
4].
Mental health problems during pregnancy and following birth include a wide range of disorders which vary in severity [
1]. Depression and anxiety, which may occur both antenatally and postnatally, occur in about 15 % of women [
5,
6], and are frequently co-morbid [
2]. Women with a previously existing mental health problem may require different medication during pregnancy or when breastfeeding, and for some conditions (e.g., bipolar disorder) there is an increased risk of an episode in the early postnatal period. Generalised anxiety disorder and adjustment disorder tend to be more severe during pregnancy and the early postnatal period [
1,
7].
There is an increased risk of adverse outcome for both the mother and baby associated with mental health problems. For example, rates of prematurity and low birth weight are increased in babies of depressed women, especially if untreated [
8]. Children of depressed mothers are also at increased risk of attachment difficulties, poor mother-infant relationships and developmental difficulties [
9]. At the extreme, rates of suicide are higher in women with mental health problems [
10] and mental health problems contributed to almost a quarter of maternal deaths in England between 2011 to 2013 [
11]. It is thus essential that emotional and mental health issues are discussed with all women both in pregnancy and in the postnatal period.
The association between mental health and adverse outcome is moderated by socioeconomic factors, adversity, education, smoking and domestic abuse [
12,
13]. Some of these factors may be amenable to intervention. Psychological and pharmacological treatments have been demonstrated to be effective [
1] although they are not always acceptable.
Despite frequent and universal contact during pregnancy and in the early postnatal period, identification of mental health problems is thought to be as low as 50 % [
1,
14,
15]. In 2014, the National Institute for Health and Care Excellence (NICE) recommended that a general discussion regarding mental health and wellbeing take place with all women both at the first contact in pregnancy and in the early postnatal period, and that questions about emotional and mental health are asked at each contact. NICE recommended that health professionals should consider asking the ‘Whooley’ questions [
1]. These are:
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’ and
‘During the last month have you often been bothered by having little interest or pleasure in doing things?’ [
16] If either of the Whooley questions elicits a positive response, it can be followed up with the Arroll question:
‘Is this something with which you would like help?’ [
17] This brief screening has been criticised for its low sensitivity and specificity [
18] although in that particular study the questions were asked in a self-completion format rather than being asked by a health professional. However, the Whooley-Arroll screening has the benefit of brevity, no additional resources are required, and it can be used both antenatally and postnatally.
It is not known how widely these or other screening tests are used or even what proportion of women have discussions with health professionals about their emotional and mental health. The aim of this study was to find out whether women are asked about their mood and mental health during pregnancy and in the postnatal period. Specifically, the research questions were:
-
Which women are asked about their emotional and mental health at these times?
-
Who is offered treatment?
-
Who takes up the offer and receives support, advice, and/or treatment?
Methods
This study involved secondary analysis of a national maternity survey carried out in 2014 [
19]. Women who gave birth in the first half of January 2014 were randomly selected from birth registration statistics by staff at the Office for National Statistics (ONS). Women were excluded if they were aged less than 16 years or their baby had died. The questionnaire, together with a letter, information leaflet and sheet in 18 non-English languages encouraged women to complete the questionnaire (by phone with the help of an interpreter if necessary) and return it in the Freepost envelope. The questionnaire could also be completed online. Using a tailored reminder system [
20] up to three reminders were sent as required.
Women were asked about events, care and experience of pregnancy, labour and birth and about the postnatal period, and questions about sociodemographic characteristics. They were asked if, at the time of pregnancy booking or a few weeks later, they had been asked about their current and past (including family history) emotional and mental health, and who asked them. If they had a mental health problem during pregnancy, they were asked whether they were offered treatment, and whether they received support, advice and/or treatment. Similarly, in the postnatal section, women were asked whether they had experienced a mental health problem since the birth and whether they had received support, advice and/or treatment.
ONS provided information about each woman’s age group, country of birth, marital status, and an area based measure, the Index of Multiple Deprivation (IMD) in quintiles, and whether or not she had responded to the questionnaire, which enabled comparison of responders and non-responders.
A descriptive analysis was carried out using raw percentages to establish how guidelines were being followed and to support service planning. As there was likely to be overlap between different sociodemographic factors, binary logistic regression was used to estimate the extent of this and to determine the main drivers for any differences seen. The results of the logistic regressions are shown in the Additional file
1. Ethical approval for the survey was obtained from the NRES committee for Yorkshire and The Humber – Humber Bridge (REC reference 14/YH/0065).
Discussion
Childbirth is a major life event and women are potentially more vulnerable to mental health problems, particularly during the postnatal period. During pregnancy and postnatally there are opportunities to ask about mental health, to check and intervene if appropriate. While the results of this study suggest that more than four in five women were asked about their emotional and mental health – 82 % in pregnancy and 90 % in the postnatal period, the converse indicates that around one in five women were not asked about their emotional health antenatally and 1 in 10 postnatally. The concern about maternal mental health is reflected in the NICE guidelines and in the annual report of the Chief Medical Officer [
21] which focused on the health of women and in which a responsibility for health professionals to ask all women about their mental health is emphasised.
During their pregnancy, a similar proportion of women, 84 %, were also asked about their past emotional and mental health and whether there was a family history of mental health problems. Women who described themselves as Asian were significantly less likely to be asked about their current or past mental health during pregnancy, and much less likely to be offered treatment. This is consistent with the results of a recent secondary analysis of the Born in Bradford data [
22] which found that minority ethnic women were half as likely to have screening, and twice as likely to have a mental health problem missed as White British women.
In the postnatal period there was more marked variation. The findings clearly indicate that following birth White women, those living in less deprived areas and those who had received more education were more likely to be asked about their mental health, more likely to be offered treatment, and more likely to receive support than other women.
This is unfortunate as mental health problems tend to be most prevalent in disadvantaged parts of society [
1]. It is also consistent with the Inverse Care law, that the availability of care tends to vary inversely with the needs of the population served [
23]. This has been reported in many areas of health care including coronary surgery [
24], management of depression [
25], and overall service provision [
26]. In the context of maternity services, the Inverse Care law has also been shown to operate in high income countries, for example, Canada where rural areas were disadvantaged [
7], in the UK regarding choice of caesarean delivery without clinical indication [
27], and in Australia regarding satisfaction and choice of antenatal care provider [
28].
The disadvantage and, sometimes, discrimination faced by ethnic minority women has been highlighted in previous maternity care research [
29‐
32] and may relate to unconscious bias and a lack of cultural awareness, but also stereotyping, and the practical difficulties of communicating with women who do not speak English. Muslim women may feel particularly inhibited from discussing such issues with male healthcare professionals [
33].
Specifically regarding questioning women about their mental health, NICE has highlighted that there is a lack of information available to women prior to being asked about their mental health, regarding the consequences of particular responses, which may affect the honesty of answers [
1]. There is also an unmet need for culturally appropriate information and support especially following diagnosis of a mental health problem, for the partner as well as for the women, and a lack of awareness of the different treatment options available [
1]. This is reinforced by a qualitative study of women’s views of screening which reported that, although they were positive about being asked in general, they did not know what help might be available [
34].
Limitations of this work include the 47 % response rate to the survey with under-representation of young and single women, those born outside the UK, and those living in areas of deprivation [
19]. This is likely to have resulted in under-estimation of the proportions of women from disadvantaged groups not being asked about their mental health in the perinatal period. However, the questionnaires were well completed with missing values generally less than 3 %. The data relating to discussions of mental health are based on self-report, and may not agree with staff records. However, other research [
35‐
37] indicates that salient events in childbearing are well-remembered. This study is strengthened by being population-based and by the large number of women who did respond.
Barriers to midwives in asking questions about mental health include the many tasks that have to be completed during a booking appointment, the lack of specific training, a lack of knowledge about referral for women needing additional help, and fragmented care [
34].
This policy relevant study has demonstrated a lack of equity in assessment of and access to mental health support. Health professionals should endeavour to discuss emotional and mental health issues with
all women both in pregnancy and the postnatal period. This could be facilitated by better training and more continuity of
care and continuity of
carer. In the NICE recommendations little distinction is made between these two concepts. Both are clearly important, for example, it is essential that specialist perinatal mental health services are integrated with the community to ensure continuity of care, but equally important to the women was having a known health professional to facilitate access, identification and treatment [
1,
21,
38].
Acknowledgements
Our grateful thanks to the women who participated in the survey. The Office for National Statistics provided data for the sampling frame but bear no responsibility for its analyses and interpretation.