Perinatal Mental Illness

Debate between Lyn Brown and Paul Williams

Thursday 19th July 2018 Westminster Hall

[Dr Paul Williams (Stockton South) (Lab)]

I beg to move,

That this House has considered perinatal mental illness.

It is a pleasure to serve under your chairmanship, Mr Davies. I and my colleague on the Select Committee on Health and Social Care, the hon. Member for South West Bedfordshire (Andrew Selous), are delighted to have secured this important debate, and I thank the Backbench Business Committee for granting it.

Nothing can prepare someone for the challenge of becoming a new parent—the sleepless nights, the new responsibility and the feeling that they suddenly have to put their old life on hold. As I have found since becoming a parent, a few months before my 40th birthday, raising a newborn child can be hugely rewarding. There is little that compares with the joy of seeing a child grow and develop. For most of us, it is a deeply fulfilling experience. Still, becoming a parent can have a dramatic impact on many people, in terms of both the stresses they experience and the impact it has on their relationships and their emotional wellbeing.

I will talk about how the Government can act to improve the lives of thousands of mothers in England who do not receive adequate support for perinatal mental health problems. The perinatal period is the time during pregnancy and the run-up to a birth, and the time immediately following the birth of a new baby. As a general practitioner as well as a parent, I have worked to provide mothers and newborn babies with the support and care they need in the perinatal period. It is a crucial time not only for the mother, but for the development of her child. It is also a time when great pressure is placed on mothers to care for their baby and simultaneously to be happy, excited and on top of life.

According to the mental health charity Mind, about one in five women experience mental health problems during pregnancy or in the year after they have given birth. Those mental health problems can come in many different forms—from eating disorders, to post-traumatic stress disorder, to anxiety and depression. If left untreated, the mental illnesses that these women experience can affect their whole lives, their ability to cope with being a parent and their relationships within and outside their families. The illnesses can affect attachment and bonding with the baby. At their extreme, perinatal mental health problems can lead to suicide and to long-term health problems for a child.

[Lyn Brown (West Ham) (Lab)]

I understand that one fifth of parents stated that they were not asked about their mental or physical health during the six-week post-natal check-up. Does my hon. Friend think that might be because GPs are massively overburdened and simply do not have the time to deal with this essential issue?

[Dr Williams]

I thank my hon. Friend for raising that point. I will refer to it later in my speech. I think the pressure on GP services that she has identified is one reason, but there are some other reasons to do with training and perhaps resources.

--- Later in debate ---

[Dr Williams]

I thank my hon. Friend for making several points, including that a child whose mum experiences mental health problems is more likely to develop mental health problems themselves. Despite significant Government investment in specialist perinatal mental health services, significant inequalities remain throughout the country and there are still areas where, as he said, one quarter of women with significant mental health problems are not able to access specialist facilities. I hope we will get the chance to talk more later about access to specialist services.

Other adverse childhood experiences include domestic violence; parental separation or divorce; being a victim of physical, sexual or emotional abuse; physical or emotional neglect; or growing up in a household where there are adults experiencing alcohol and drug problems. Mental health problems in a mother can have as significant an impact on a child as some of those other problems. The term ACEs was originally developed in the US, but other studies have reported similar findings in England and Wales. Those ACEs have, as my hon. Friend has said, been found to have lifelong impacts on health and behaviour. They are relevant to all sectors and involve all of society.

An ACE survey of adults in Wales found that, compared with people who had experienced no ACEs, those with four or more were more likely to have been in prison; develop heart disease; frequently visit their GP; develop type 2 diabetes; have committed violence in the last 12 months; and have health-harming behaviours, such as high-risk drinking, smoking or drug use

Children’s exposure to adverse and stressful experiences can have a long-lasting impact on their ability to think and to interact with others, and on their learning. Health and societal inequalities that develop during early years stick with children for life. That is why I chair the APPG for the prevention of adverse childhood experiences. It is also why the identification and treatment of maternal mental health problems is not only important for the individual mother but crucial for all of us in society.

National Childbirth Trust research shows that as many as half of new mothers’ mental health problems are not picked up by a health professional. That is not to say that health professionals are not asking—they often are. There are many fantastic nurses, GPs, midwives, health visitors and others who provide care during pregnancy and during the post-natal period. However, those services, as my hon. Friend the Member for West Ham (Lyn Brown) has said, are overstretched. We all know how hard-pressed GP services are. The Government have acknowledged the problem and have promised to recruit an extra 5,000 GPs by 2020. However, they are failing miserably and are struggling to even maintain GP numbers. NHS Digital reports a decrease in full-time equivalent GPs from March 2017 to March 2018.

Perhaps a little less well known is the dramatic fall in the number of health visitors. Since 2015, there has been a loss of more than 2,000—almost a 20% drop—so each health visitor has to work harder. I commend health visitors for the work they do but, overall, women are experiencing a drop in services.

Staff numbers are part of the problem, but there are many other reasons why the problems of almost half of women with perinatal mental health problems are not identified. Stigma, and the societal pressure to be seen to be coping, makes it hard for some women to disclose that they have a mental health problem. Also, as the hon. Member for Thirsk and Malton (Kevin Hollinrake) has said, health services do not always ask women about their mental health in the most sensitive way. That is sometimes because they are pushed for time and sometimes because they have not been trained to sensitively and gently probe behind the “I’m okay” response that people are primed to give.

As a result, the hidden half of new mums with mental health problems struggle on alone, often afraid to reach out for help. The overwhelming majority of women who experienced a mental health problem said that it had an impact on their ability to cope or look after their children, and also on their family relationships. The mother of a woman suffering from post-natal depression told me:

“As a parent, watching a child go through that and feeling unable to make it better is a horrible experience. Health professionals need to make sure that husbands, partners and the family know about the likelihood of such depression…and know where to get support and help.”

Perinatal mental illness has an immediate effect not only on mothers; it can have lasting consequences for relationships in the wider family. With the added pressure to be a perfect mother, and the expectations from many that come along with that, it is no wonder that so many women feel unable to cope. One constituent described this to me:

“I remember comparing myself to the younger mums who would turn up to the mother and baby groups looking fresh and without a care in the world, making motherhood look like a walk in the park. Although my son was thriving, I felt like I was failing, because I wasn’t like the young mums or the ones in those perfect baby ads. I didn’t want to share my feelings because I felt I’d been a failure in comparison to them. I believe the pressures of our professions and the guilt of parenthood traps us into a dark place.”

It is often the most vulnerable who receive the least support, with evidence suggesting that those in areas of higher deprivation are less likely to be asked about their mental health. In dealing with this issue, the Minister has the chance to fulfil two parts of her ministerial brief, because investing in perinatal mental health will help to improve mental health and reduce health inequalities.

I have described the problem, but what are the solutions? Identification is key. Regardless of what services may or may not be out there—from specialist mother and baby units, to secondary care perinatal mental health teams, to cognitive behavioural therapy and the prescription of medication—half of women with the problem are not even identified. That is where I believe we need to start.

The disinvestment in health visiting is significant; there can be no solution to the problem while health visiting is not properly resourced. Will the Minister say what she intends to do within her Department to ensure that local authorities are adequately funded and supported so that there is investment in crucial services for children aged 0 to 19, rather than the cuts that we have seen in the past three years?

However, there is another, relatively low-cost opportunity to identify the hidden half. About six weeks after giving birth, new mothers see their GP for a six-week baby check, with many practices also offering a maternal health check. Official National Institute for Health and Care Excellence guidance encourages doctors to do that and inquire about a mother’s emotional wellbeing, providing an opportunity for them to spot the development of any mental health problems. That check could be the last time a mother sees a health professional for a routine appointment in which there is the opportunity to focus on the mother, rather than her baby.

While some women get an excellent six-week check, showing its potential, other women miss out. A fifth of women questioned in a recent NCT survey said that they were not asked about their emotional or mental wellbeing at that appointment. Some women’s checks are all about their baby. Why do all women not get the check that they need? Despite the six-week baby check being part of the GP contract, for which they receive funding, doctors do not receive any funding for the check on the mum. It is a credit to many practices that they offer the checks without funding, but making the time for a full appointment can be challenging, meaning that there is little opportunity to encourage a mother to talk about how she feels, which takes time. A rushed appointment can make many, like the constituent of the hon. Member for Thirsk and Malton, feeling dismissed, or like it was a tick-box exercise.

One woman I heard from recently said her appointment made her

“feel like she was a burden”.

Another of my constituents spoke movingly of her experience:

“I knew there was something very wrong almost as soon as my son was born. Nothing I was ‘supposed’ to be feeling was happening. All I wanted to do was cry. I was feeding him and taking good care of him, but I felt empty inside, and so sad. I can’t remember anyone asking me how I was. I only saw my health visitor once, and that wasn’t in private so there was no opportunity to confide in her.

I told my GP I had postnatal depression and that I needed some help. He told me ‘you have a good family, you should be grateful—you need to pull yourself together.’ I don’t think I have the words to explain how damaging that was. I felt too ashamed to see him again so I changed to another medical centre. My first appointment was with a GP who listened to me. I found the courage to confide in her and she offered me support straight away. I remember very little of my child’s first year of life and I’m sure that is because of the trauma and deep depression I experienced.”

That could have been prevented if my constituent had been seen early on in the post-natal period, and if that first GP had delivered open, supportive questioning that reassured her, rather than made her feel ashamed.

Another constituent told me:

“I sat down with my GP, who had a check-list printed out and placed on his desk. He ran through the questions at a rapid rate, didn’t listen to my answers at all and placed ticks in the boxes after he asked the questions—not based on my reply. Hopefully a separate check for mothers can be achieved, as mothers just want someone to talk to who will not judge them for their feelings.”

About 30% of women diagnosed with post-natal depression still have depression beyond the first year of childbirth. If problems are not identified and treated early, they can worsen and develop into a much more severe mental illness. That underlines the need for an early check. If depression was recognised and treated appropriately within the perinatal period, it could prevent some effects that are much harder to treat in the long run.

[Lyn Brown]

I am sorry to intervene again. I intended to make a speech, but I am needed elsewhere, so I will ask a question. I have a lot of time for the Minister and I am wondering how we can help her to make the necessary case to the Treasury. Is it not true that if we look after the parent and the child as early and as well as possible, that will save massive amounts of money in the long term? This is an invest-to-save opportunity, and it would be welcome if the Government took it.

[Dr Williams]

I thank my hon. Friend for her intervention. I have avoided, as much as I can, talking about money in the debate—not all of this is about money, but there are many opportunities to make a massive difference. If we can draw a direct link between a mum’s experiencing mental health problems and the damage that that may do to her child—it increases the child’s chance of developing health problems and even of being involved in crime later in life—there are certainly opportunities to invest to save.

We must not forget, either, that perinatal mental illness has serious consequences for the mother. Suicide is the leading cause of direct maternal deaths occurring within a year after the end of pregnancy in the UK. It is at least possible that if an effective six-week check were in place, some of those deaths would be prevented. Of course, this is, as many hon. Members have said, a complex issue. Diagnosis and treatment are complex, but in addition some health services undoubtedly do not give women the care that they need. Women feel that they are still being dismissed, stigmatised and ignored. However, we should not blame the individual GPs and health professionals who carry out the checks; we should look to change the guidance, the system and the structure in place.

From its research, the NCT has made three recommendations. The first is to fund the six-week maternal post-natal check so that GP surgeries have the time and resources to give every new mother a full appointment for the maternal check. At the moment, although the check focusing on the baby is contracted for and there is funding available for it, there is no requirement for a six-week check on mothers. Checks on mothers, if they are done, are often compressed into the baby’s check, so conversations about mental health may be rushed or sidelined completely.

A constituent got in touch after I said that I was going to speak in this debate. Her response was surprising. She said:

“After the birth of my first child, I suffered terribly with post-natal anxiety—something I didn’t even know was a thing. I don’t remember anyone ever picking up on how I was feeling and no one ever really asked.

Then after the birth of my second child I believe I was depressed. When he was born I didn’t feel anything which then made me feel guilty”—

a common theme—

“and I struggled to bond with him over the first year.”

She then said:

“I believe I met you”—

meaning me, because I was working as a GP in the constituency at the time—

“at my six-week check with him and I remember you asking how I was feeling. After telling you I think I may have needed to”

get some extra help

“for more therapy, you agreed it was a good idea and told me to come back”

for follow-up. She continued:

“I think women need to know where they can go for help and what signs to look out for. I was too scared to tell anyone that I didn’t feel any bond with my son because I think there’s still such a stigma around mental ill health.

I do think the idea of a separate appointment for the mother would be a good idea and more signposting to support groups, how to self-refer, confidential information and advice.”

That experience with my patient, who is now my constituent, demonstrates the value of making time to identify and explore perinatal mental health issues. It might be argued that GPs should be doing that anyway, even if it is not contracted for. I would respond by saying that some are and some are not. GPs do many things that are not in their contract. But the only way of getting true national coverage and the time needed to do a proper job is to resource it.