Introduction

This quality standard covers the recognition, assessment, care and treatment of mental health problems in women during pregnancy and the postnatal period (up to 1 year after childbirth). It also includes providing pre‑conception support and advice for women with an existing mental health problem who might become pregnant, and the organisation of mental health services needed in pregnancy and the postnatal period. For more information see the antenatal and postnatal mental health topic overview.

Why this quality standard is needed

In pregnancy and the postnatal period, women are vulnerable to having or developing the same range of mental health problems as at other times, such as depression, anxiety disorders, eating disorders, drug and alcohol use disorders, post‑traumatic stress disorder and severe mental illness (including psychosis, bipolar disorder, schizophrenia and severe depression). Some changes in mental health state and functioning (such as appetite) may represent normal pregnancy changes, but they may be symptoms of a mental health problem.

Depression and anxiety are the most common mental health problems occurring during pregnancy, with around 12% of women experiencing depression and 13% experiencing anxiety at some point, and many women experiencing both. Depression and anxiety also affect 15–20% of women in the first year after childbirth. Postpartum psychosis affects between 1 and 2 in 1000 women who have given birth. Women with pre‑existing bipolar type 1 disorder are at particular risk, but postpartum psychosis can occur in women with no previous history of mental health problems.

Mental health problems occurring in pregnancy and the postnatal period are often similar to those occurring at other times in their nature, course and potential for relapse, but there can be differences. For example, women have an increased risk of relapse or developing a first episode of bipolar disorder during the early postnatal period than at other times.

The majority of mental health problems during pregnancy and the postnatal period are mild to moderate, and are treated in primary care. Other settings where women with mental health problems during pregnancy and the postnatal period may be treated include obstetric and gynaecological services, health psychology services, general mental health services and specialist secondary care mental health services.

Mental health problems in pregnancy and the postnatal period may often need more urgent intervention than they would at other times because of their potential effect on the baby and on the woman's physical health and care, and her ability to function and care for her family. However, problems frequently go unrecognised and untreated in pregnancy and the postnatal period. Some women do not seek help because of fear of stigma, or fear of intervention by social services. The perinatal period can also present practical barriers to treatment; for example, the demands associated with the care of an infant may interfere with a woman's ability to attend treatment regularly. If mental health problems are left untreated, women can continue to have symptoms detrimental to their wellbeing, sometimes for many years, which can also affect their children and other family members.

There are risks associated with taking psychotropic medication in pregnancy and during breastfeeding, and with stopping medication taken for an existing mental health problem without professional advice, because of the potential to trigger or worsen an episode.

Between 2009 and 2012 there were 0.67 maternal deaths per 100,000 maternal deliveries in the UK that were as a result of psychiatric causes; this is an increase from 0.55 per 100,000 maternal deliveries in the UK between 2009 and 2011 (MBRRACE-UK 2014 Saving Lives, Improving Mothers' Care).

The quality standard is expected to contribute to improvements in the following outcomes:

  • maternal wellbeing

  • service user experience of mental health services

  • quality of life for women with severe mental illness

  • neonatal and infant health and wellbeing

  • suicide rate.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential years of life lost (PYLL) from causes considered amenable to healthcare

i Adults

Improvement areas

Reducing premature mortality in people with mental illness

1.5 Excess under 75 mortality rate in adults with serious mental illness* (PHOF 4.9)

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions** (ASCOF 1A)

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Enhancing quality of life for people with mental illness

2.5 Employment of people with mental illness** (ASCOF 1F and PHOF 1.8)

3 Helping people to recover from episodes of ill health or following injury

Overarching indicators

3b Emergency readmissions within 30 days of discharge from hospital* (PHOF 4.11)

Improvement areas

Improving outcomes from planned treatments

3.1 Total health gain as assessed by patients for elective procedures

ii Psychological therapies

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

4b Patient experience of hospital care

4c Friends and family test

Improvement areas

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to in‑patients' personal needs

Improving women and their families' experience of maternity services

4.5 Women's experiences of maternity services

Improving experience of healthcare for people with a mental illness

4.7 Patient experience of community mental health services

Improving people's experience of integrated care

4.9 People's experience of integrated care** (ASCOF 3E)

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicator

5c Deaths attributable to problems in healthcare

Improvement area

Improving the safety of maternity services

5.5 Admission of full‑term babies to neonatal care

Alignment across the health and social care system

* Indicator is shared

** Indicator is complementary

Table 2 The Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life* (NHSOF2)

Outcome measures

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation

1F Proportion of adults in contact with secondary mental health services in paid employment* (PHOF 1.8 and NHSOF 2.5)

1H Proportion of adults in contact with secondary mental health services living independently, with or without support** (PHOF 1.6)

1I. Proportion of people who use services and their carers, who reported that they had as much social contact as they would like** (PHOF 1.18)

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services

3A Overall satisfaction of people who use services with their care and support

Placeholder 3E The effectiveness of integrated care* (NHSOF 4.9)

4 Safeguarding adults whose circumstances make them vulnerable and protecting from avoidable harm

Overarching measure

4A The proportion of people who use services who feel safe* (PHOF 1.19)

Outcome measures

Everyone enjoys physical safety and feels secure

People are free from physical and emotional abuse, harassment, neglect and self‑harm

People are protected as far as possible from avoidable harm, disease and injuries

People are supported to plan ahead and have the freedom to manage risks the way that they wish

4B The proportion of people who use services who say that those services have made them feel safe and secure

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Table 3 Public health outcomes framework for England, 2013–2016

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

Indicators

1.6 Adults with a learning disability/in contact with secondary mental health services who live in stable and appropriate accommodation* (ASCOF 1G and 1H)

1.8 Employment for those with long‑term health conditions including adults with a learning disability or who are in contact with secondary mental health services* (NHSOF 2.2) ** (ASCOF 1E, NHSOF 2.5 and ASCOF 1F)

1.9 Sickness absence rate

1.18 Social isolation* (ASCOF 1I)

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicators

2.1 Low birth weight of term babies

2.5 Child development at 2–2½ years

2.10 Self‑harm

2.23 Self‑reported well‑being

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.3 Mortality rate from causes considered preventable** (NHSOF 1.1)

4.9 Excess under 75 mortality rate in adults with serious mental illness* (NHSOF 1.5)

4.10 Suicide rate

4.11 Emergency readmissions within 30 days of discharge from hospital* (NHSOF 3b)

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Service user experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to antenatal and postnatal mental health.

NICE has developed guidance and associated quality standards on patient experience in adult NHS services and service user experience in adult mental health services (see the NICE pathways on patient experience in adult NHS services and service user experience in adult mental health services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects people's experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that impact on people's experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for antenatal and postnatal mental health specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole antenatal and postnatal mental health care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to women with a mental health problem in pregnancy and the postnatal period.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing high‑quality services for antenatal and postnatal mental health are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in antenatal and postnatal mental health should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting women with a mental health problem in pregnancy and the postnatal period. If appropriate, healthcare professionals, public health professionals and social care practitioners should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.