1. Developing a Perinatal Mental Health Service across 2000² miles : is it prudent?
Title of Presentation:
Developing a Perinatal Mental Health service across 2000 square miles: is it prudent?
Abstract –
300 words max.
Powys is the largest county in Wales, covering a quarter of the nation. Providing specialist services equitably across the county is a challenge, particularly when wanting to provide services close to those who use them.
In 2016 funding was provided to all Health Boards to develop their specialist perinatal mental health services.
Mental ill health during pregnancy and post-birth is believed to affect up to 20% of women and 10% of men and can have lasting negative consequences for the family unit and the infant if not addressed. The majority of those experiencing problems will have mild to moderate poor mental health and will, if supported appropriately, recover without the need for specialist mental health services. However, a small minority will need referral to secondary mental health services.
Given the geography, the Powys approach to developing perinatal mental health services has been to focus on growing the knowledge, skills and confidence of our primary and community-based staff, namely Midwives, Health Visitors and Nursery Nurses. A direct referral pathway to secondary mental health services and perinatal mental health awareness training was developed. This enables staff to identify, assess and engage with those that they support who may be experiencing mild to moderate mental ill health and provide individualised support according to the needs and preferences of the woman.
Using our primary and community-based staff
means that women are being supported by a professional that they have already developed a trusting relationship with. It also means that support is provided in or near the woman’s local community, which in turn can help to increase local connections and social support. This early, local, support reduces the potential intrusiveness of services during this special time in a woman’s life, and, importantly, reduces the poor impact of mental illhealth on the mother, child and family.
Sophia Bird & Sharon Fernandez,
Powys Perinatal Mental Health Steering Group
Rural Health and Care Conference, Nov 2017

2. Background
1/5 women suffer from depression/ anxiety/ psychosis when pregnant or post-birth
1/10 men also experience MH problems during the perinatal period
12% experience depression
13% experience anxiety
20% suffer postnatal depression/anxiety
1-2 in 1000 suffer puerperal psychosis
Only 50% are currently diagnosed
Early diagnosis and treatment can mitigate the effects
Negative impact can be profound and long lasting on the family and infant
Many suffer both

3. Child birth – risk to mental health
Women are 23 x more likely to be admitted in the first few weeks after the birth of their first child than the general population.
Women are 23 x more likely to be admitted in the first few weeks after the birth of their first child than the general population.
You should refer to a specialist service in the following cases:
Where pre-conception and early pregnancy advice is necessary in women who have or have had severe mental illness, even if the woman is currently well
For women with severe mental illness in pregnancy
For women who have complex psychiatric morbidities, including personality disorders and drug and alcohol problems, post-traumatic stress disorder or OCD
Where the woman or her family express concerns
Where there is uncertainty about the diagnosis
Eliciting that a woman feels hopeless and pessimistic about the future for herself, her family and/or infant should trigger an urgent assessment of suicide risk. This involves asking her about:
Thoughts she may be having about wanting to die, not wanting to wake up, about wanting to end it all. The thoughts can be present for long periods or just fleeting
Images that may accompany thoughts, often violent, of seeing herself dead
Urges or impulses to harm herself or her infant
Plans to harm herself or her infant
If any violent thoughts, images, impulses or plans are elicited, they should be taken seriously and explored in detail; then a plan to keep the woman and her infant/children safe should be implemented. The risk to the infant must be fully recognised and local safeguarding procedures followed.
If there is any indication that the woman has suicidal or infanticidal thoughts, plans or fleeting ideas or impulses, she should not be left alone by her family or carers. This is because there is a grave risk to both her and the baby [4,22].
Admissions to a psychiatric unit in the weeks before and after delivery

4. (Welsh) Expected and actual rates for the Powys population
Female Perinatal Mental illness
Rates per 1000
Likely rate in Powys
Post puerperal psychosis 2
2.4
Chronic serious MI
Severe depression
PTSD 30 36
Mild to moderate depression and anxiety
Male Perinatal depression
100
110
1200 births per annum in Powys
As we can see, reported (to Midwives) rates are lower than the literature suggests they should be.
*** Work out % into numbers
Literature rates of risk: Powys Births per annum =1250
15% of pregnant women= Powys women
20% of pregnant women= 250 Powys women
35% =437.5
33% = 417
50% = 625
Implications for Powys:

5. Why does it matter? PNMH costs £8.1 billion in UK:
72% relates to learning difficulties or behavioural disorders in the child
Costs relating to the mother (28%)
The cost of PNMH problems is 5 x cost of improving services
Mental health starts in the womb
maternal mental ill health has significant and long lasting negative impacts on the woman affected, the child, family unit and the community”.
Existing situation was that if MW or HV was concerned about a woman’s MH they would advise her to see her GP. If they were concerned they would refer to the CMHS to PMHSS. Assessment target of 28 days, then on waiting list to be seen.
BUT, timeframes not appropriate if someone is pregnant – remember the chart re post-birth admissions?
The evidence shows that early intervention and support is vital to limit/ mitigate the effects.

6. The principles of prudent healthcare
Here’s reminder of the 4 principles of prudent health care
Public and professionals are equal partners through coproduction
Care for those with the greatest health need first
Do only what is needed and do no harm
Reduce inappropriate variation through evidence-based approaches

7. Multi-disciplinary Perinatal Mental Health steering group formed 2014
The Powys Approach
Multi-disciplinary Perinatal Mental Health steering group formed 2014
Early identification and intervention
Normalising asking about anxiety and depression form start of pregnancy
Reduce stigma of anxiety and depression
Powys have been looking at perinatal mental health since Powys believe that a multi disciplinary approach to perinatal metal health is needed given the geography of the county and scope of the issue. The perinatal mental health steering group was formed and consisted of midwives, health visitors, cpn, consultant psychiatrists, etc and importantly service users.
This meant:
Training for MWs and HVs
Supporting women to take a proactive approach to their mental health, eg Utilising the Boots family trust ‘my pregnancy and postbirth wellbeing plan
MWs and HVs wanted a clear referral pathway for women they had concerns about

8. Priorities for the steering group
Proactive approach to mental health in pregnancy and post-birth:
Multi disciplinary working
Education and training for health professionals
Early identification and early intervention
Clear Perinatal mental health referral pathway
Norm to ask about anxiety and depression in pregnancy
Reduce stigma of anxiety and depression
Raise awareness of mental illhealth during pregnancy and post-birth
Closer links with Adult mental health services
Audit of current caseloads and practice
Do more
Our midwives and healath visitors wanted a clear referral pathway for women they had concerns about. The focus of our service user was to normalise asking about anxiety and depression in pregnancy and raise awareness of antenatal depression. More is spoken of postnatal depression. Our health professionals wanted more training on PNMH. We also felt it is important for women to take a proactive approach to their mental health. Utilise the boots family trust ‘my pregnancy and postbirth wellbeing plan.
Closer links with primary mental health including primary mental health counsellors
Our focus was on Early identification and early intervention
Normalising asking about anxiety and depression form start of pregnancy
Reduce stigma of anxiety and depresssion

9. Steps taken in 2015
PTHB antenatal and postnatal MH guidelines developed and implemented
Joint clinical referral pathway for MW/HV developed and implemented with CMHTs
1 and 2 day training on Perinatal Mental Health delivered to MWs, HVs, NNs and A4C staff
Scenario based mental health training for midwives/HV/NN included listening visits delivered in partnership with CPNs
Feedback from the audit showed us that health professionals wanted more information on perinatal mental health. We put on 2 separate training for perinatal metal health. Funding was sourced for a 1 day and 2 day training, specific to PMH. The feedback was extremely positive.
When the revised guideline was launched , we made it mandatory for all midwives HV and nursery nurses to attend a PMH scenario based workshop . Again the feedback was extremely positive.CPN involvement increased the mw, hv and NN confidence in asking questions such as suicidal tendencies, intent, plans and what to do with that information.
Feedback from the training….
Use of scenarios/ case studies to make it more personal

10. 2016 developments
WG funding to develop specialist perinatal MH services
Development a community focused model of care:
Focus on mild to moderate anxiety and depression
Funding secured, which lead to ...
6month part time project lead secondment
All staff to be upskilled so they can provide support to those with mild-moderate mental ill health
Funding being used for additional nursery nurse hours to help families affected by parents with anxiety and depression.
NN model adds capacity to the system, they are supervised by HVs to provide additional support to universal services.
Band 7 post going to be advertised shortly. Specifically designed to NOT be profession-specific. Aim is to identify someone with expert knowledge and commitment who can provide guidance and support to professionals working with PNMH cases.

11. Steps taken in 2016 6 month p/t project lead development post:
Re-audit of staff and service users
Audit of perinatal caseloads in primary and secondary MH services
PNMH awareness training for MH practitioners developed and delivered
Communications plan developed and implemented:Press releases/Display boards/ bump talk , HV facebook page- key messages
Awareness raising amongst other health professionals
Clinical Supervisor (developing the nursery nurse role within PNMH)
Antenatal poster produced for waiting rooms, guided by Service user
Nursery Nurse Pathway developed
Additional nursery nurse hours
Additional nursery nurse training
Presentation to GP Clusters to raise awareness, & GP information sheet, resulted in a GP joining the steering group
PNMH Awareness training devised and trialled with Ystrad PMHSS, with good feedback
Press releases drafted to tie in with national campaign days, eg, Maternal MH day, Infant MH day, World MH day.

12. Developments in 2017 GAD questions EPDS now used antenatally
PNMH Sub-groups formed
Further development of nursery nurse role
Perinatal mental health awareness training
Working to support fathers
Working with primary care counsellors
Mums matter programme delivered by Mid and South Powys Mind
GAD questions are being asked as per NICE quidance. Gad is specific to anxiety. whooley are specific to depression. asked at booking and throughout pregnancy and by health visitors at first visit etc. if positive responses we ask the EPDs.

13. Snapshot of what MWs, HVs & NNs do in Powys
Booking :Past history of mental health/Family history
Whooley /GAD
Boots wellbeing plan
Antenatal: ask GAD and Whooley at each antenatal visit
If positive responses to Whooley/GAD an EPDS is undertaken
Outcome of EPDS: universal support
10-12 repeat in 2 weeks/NN
Listening visits/NN
GP / Primary care counselling/NN
Referral to CMHT/CPN
GAD questions are being asked as per NICE quidance. Gad is specific to anxiety. whooley are specific to depression. asked at booking and throughout pregnancy and by health visitors at first visit etc. if positive responses we ask the EPDs.
Sharon is doing some work on fathers and perinatal mental health.
Awareness training with the mental health teams. We continue to aim to raise awareness amongst the community. The sub groups will link in with the community to talk about perinatal mental health.i.e WI; farmers markets.
Sharon can tell you about the nursery nurses.

14. Still more to do……. More training & communication
Continue awareness training to mental health service providers across Powys
Continue to work closely with primary mental health services (counsellors)
Preconceptual advice
Continue to reduce stigma of anxiety/depression
Continue to evolve role of nursery nurse
Improve communication
Specific CPN training on PNMH
Better communication between all health professionals
Explore role of specialist midwives and health visitors
Exploration of development of infant mental health service
Nursery nurse role commenced. It is a starting point. This service will be shaped and evolve as feedback is received from staff, parents and colleagues.

15. Powys strengths….. Great working relationships between colleagues
Smaller workforce
Multi Disciplinary approach
Great working relationships between colleagues
CMHT/CPN
Pick up phone for advice
Named MW/HV
Continuity of care

16. Is our service prudent?
Public and professionals are equal partners through coproduction
Service user key member of steering group
Professionals work WITH parent to identify most appropriate support needed
Care for those with the greatest health need first
Primary care pathway ensures that those in need are referred directly by their midwife or health visitor to CMHT services without having to go back to their GP.
Do only what is needed and do no harm
Midwives and Health visitors in Powys confident and competent to provide early assessment and input
Reduce inappropriate variation through evidence-based approaches
Identification, assessment and intervention now happening earlier and systematically.

17. Summary Community focused model of care
Focus on mild to moderate depression
Service user input from the beginning
Robust clinical referral Pathway
Multi disciplinary approach
Raise awareness and reduce stigma
Focus on prevention and early intervention
Additional nursery nurse hours
Introduced additional screening tools
Working with fathers
And the steering group now sits under the Powys Public Service board mental health sub-group.
But, still lots more to do
Service user input helped gain engagement across MW & HVs & CPNS
Helped shaped pathway
Adult MH services in Powys have been complicated which hasn’t helped with pathway development, some were employed by other HBs
Need to ensure Primary MH services link in fully and that their National targets don’t override the NICE guidance re assessment and treatment timeframes
Still lots more to do to raise awareness and reduce stigma
This a picture of the display at the royal welsh this summer. Also had display boards in all birth centres on AN and PN depression and Infant mental health to tie in with Adult and Infant mental health week

18. Further reading
Children, Young People and Education Committee Perinatal mental health in Wales NAW, October 2017
NICE guidance (CG192) Antenatal and postnatal mental health : Clinical management and service guidance, revised 2014