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.
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% to 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.
Valproate must not be used in pregnancy. It must not be used in girls and women of childbearing potential (including young girls who are likely to need treatment into their childbearing years) unless other options are unsuitable and a pregnancy prevention programme in place, in line with the MHRA safety advice on valproate. This is because of the risk of malformations and developmental abnormalities in the baby.
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:
service user experience of mental health services
quality of life for women with severe mental illness
neonatal and infant health and wellbeing
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:
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.
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 NICE quality standards.
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.
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.