Specifying antenatal and postnatal mental health services
The key components of antenatal and postnatal mental health services are:
- detection and referral of women with a mental disorder
- care and treatment of women with a mental disorder
- developing a high-quality service.
Detection and referral of women with a mental disorder
Commissioners and provider trusts should ensure that practitioners are trained to discuss contraception and explore the risks of pregnancy with all women of child-bearing potential who have an existing mental disorder and/or who are taking psychotropic medication. Training should include information on mental disorders, assessment and the effective use of referral routes and care pathways as recommended in NICE clinical guideline CG45 on antenatal and postnatal mental health. To identify women with or at risk of developing a mental disorder, healthcare professionals should be competent in using assessment tools, including key detection questions to identify possible depression (‘Whooley questions'), and should refer women appropriately.
Pregnant women who have experienced a previous episode of depression and/or anxiety and who present with mild or subthreshold symptoms of depression and/or anxiety can be offered individual brief psychological interventions, for example, four to six sessions of interpersonal psychotherapy or cognitive behavioural therapy. PCTs and practice-based commissioners (PbCs) need to ensure that sufficient capacity is available to allow prompt access to targeted psychosocial interventions. Commissioning a brighter future: improving access to psychological therapies - positive practice guide describes the key stages that PCTs need to consider when commissioning an appropriate range of psychological therapies to meet the mental health needs of the local community. It includes an example of how training in evidenced-based approaches and improving access to psychological therapies can help women with mental disorders who have recently given birth.
Social support, which may take the form of regular, informal individual or group-based sessions during pregnancy and the postnatal period, should be available for women who present with mild or subthreshold symptoms of depression and/or anxiety but have not had a previous episode of depression or anxiety. PCTs and PbCs need to be aware of the range of support services that are available, such as Sure Start children's centres, maternity and child welfare services, social services and services provided by voluntary sector organisations.
Commissioners and those responsible for perinatal networks should ensure that adequate systems are in place to guarantee continuity of care and effective transfer of information to reduce the need for multiple assessments. The Map of medicine obstetrics and gynaecology pathway provides an information resource that visually organises the care pathway.
Care and treatment of women with a mental disorder
The recommendations for the care and treatment of women with mental disorders during pregnancy and the postnatal period are highlighted in NICE clinical guideline CG45 on antenatal and postnatal mental health. For information on specific conditions go to the relevant clinical guideline listed in the benefits section of this guide. The care of women with a mental disorder during pregnancy and the postnatal period should be the same as for anyone with a mental disorder. However, treatment decisions are complicated by the presence of the developing fetus, breastfeeding and the timescales imposed by pregnancy and birth. To minimise the risk of harm to the fetus or breastfed baby, drugs should be prescribed cautiously. As a result, the thresholds for non-drug treatments, particularly psychological treatments, are likely to be lower than those set in NICE clinical guidelines on specific mental disorders, and prompt access to these treatments should be ensured if they are to be of benefit.
PCT and PbCs may need to increase resources within their existing psychological therapies service or consider the need for an additional service specifically for women with mental disorders in the antenatal and postnatal periods. This will ensure that women requiring psychological treatment are seen within 1 month of initial assessment, and no longer than 3 months afterwards. PCTs and PbCs may wish to refer to the Improving access to psychological therapies implementation plan: national guidelines for regional delivery for more information. In addition, the antenatal and postnatal mental health services commissioning and benchmarking tool can be used to determine the level of service that might be needed locally and to calculate the cost of commissioning the service.
All commissioners should also consider the needs of other special groups such as adolescents, women with learning disabilities and women who misuse substances, and liaise with the appropriate agency to ensure a joint approach to service provision.
Developing a high-quality service
To ensure the effective provision of a high-quality clinical service, PCTs and strategic health authorities need to establish joint working to commission services that meet local needs, based on demographic, epidemiological and geographical information. NICE clinical guideline CG45 on antenatal and postnatal mental health recommends that perinatal mental health networks should be established for perinatal mental health services, managed by a coordinating board of healthcare professionals, commissioners, managers, and service users and carers.
These networks should provide:
- a specialist multidisciplinary perinatal mental health service in each locality, which provides direct services, consultation and advice to maternity services, other mental health services and community services; in areas of high morbidity these services may be provided by separate specialist perinatal mental health teams
- access to specialist expert advice on the risks and benefits of psychotropic medication during pregnancy and breastfeeding
- clear referral and management protocols for services across all levels of the existing stepped-care frameworks for mental disorders, to ensure effective transfer of information and continuity of care
- pathways of care for service users, with defined roles and competencies for all professional groups involved.
NICE clinical guideline CG45 on antenatal and postnatal mental health recommends that each managed perinatal network should have designated specialist inpatient services and cover a population in which there are between 25,000 and 50,000 live births a year, depending on the local psychiatric morbidity rates.
The NICE clinical guideline CG45 implementation advice offers suggested actions for commissioners on how to establish a managed clinical network. The structures within the networks may differ locally; however, a core team is required to coordinate and manage the network. The NICE costing template for CG45 on antenatal and postnatal mental health provides cost data for establishing a core team that consists of a clinical lead, a manager and a coordinator.
Specialist perinatal inpatient mental health services should provide facilities designed specifically for mothers with serious and/or complex mental illness and their babies (typically with 6-12 beds), offer inpatient assessment and treatment and be staffed by specialist perinatal mental health staff and staff who can care for infants. (A separate area on an acute or other psychiatric ward is not regarded as a specialist unit.) They should provide effective liaison with general medical, maternity, and mental health services, have a full range of therapeutic services and be able to offer opportunities for patients at high risk of postnatal mental illness to be admitted prophylactically. Standards for mother and baby inpatient units are available from the Royal College of Psychiatrists Quality Network for Perinatal Mental Health Services. This national network engages with frontline staff and applies a clinical audit method within a peer-support network.
The Department of Health Specialised services national definitions set definition no. 22 includes definitions for specialist perinatal mental health services that include mother and baby units and perinatal mental health community outreach teams. Perinatal community outreach teams are multidisciplinary consultant- and nurse-led teams that work in conjunction with inpatient units and provide alternatives to admission, follow-up support for discharged women and consultation and liaison with generic services. These services are currently subject to specialised commissioning arrangements that take into account the needs of a planning population larger than that of a single PCT.
Commissioners may wish to consider commissioning antenatal and postnatal mental health services in several different ways, and mixed models of provision may be appropriate across a local health economy. The following example of a service model can be found on the NICE shared learning database. This example is offered to share practice and NICE makes no judgement on the compliance of this service with its guidance.
The Northumberland, Tyne and Wear NHS Trust community mental health team provides a community psychiatric nursing service for women with mental disorders related to pregnancy, childbirth and early motherhood. The community psychiatric nurses have established links with primary care and mental health teams. Women referred to the service are seen at home, in GP practices or in maternity services.
Local stakeholders, including service users, should be involved in determining what is needed from antenatal and postnatal mental health services in order to meet local needs. The services should be patient-centred and integrated across primary care, maternity and mental health services and at all levels of healthcare provision.
The service specification needs to consider:
- The required skills, knowledge, competencies and training for all staff including non-specialist health professionals.
- The expected number of patients (this should take into account how quickly any changes in service provision are likely to take place).
- Ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally.
- Care and referral pathways.
- Information and audit requirements, including IT support and infrastructure.
- Planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks. NICE clinical guideline CG45 on antenatal and postnatal mental health recommends access to assessment and psychological intervention within 1 month.
- service monitoring criteria.
Useful sources of information may include:
- Department of Health Specialised services national definitions set definition no. 22 commissioning for perinatal psychiatric services.
- Improving Access to Psychological Therapies commissioning toolkit.
- The Map of medicine provides an information resource that visually organises the care pathway.
This page was last updated: 02 March 2012
- Commissioning antenatal and postnatal mental health services
- Specifying antenatal and postnatal mental health services
- Determining local service levels for antenatal and postnatal mental health services
- Assumptions used in estimating a population benchmark
- The commissioning and benchmarking tool
- Ensuring corporate and quality assurance