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PERINATAL MENTAL HEALTH IN AOTEAROA
16 | AOTEAROA NEW ZEALAND MIDWIFE
part 1: overview
This article is the first in a series on perinatal mental health and aims to provide an overview of the current landscape in Aotearoa as well as discussing the midwife’s role and screening. Future articles will explore the implications of anti-depressant and anxiolytic medications for wāhine hapū and pēpi, and wider issues around maternal mental health.
The implications of increased maternal mental health needs for both mother and baby are well known, and vary according to the severity of the mental health condition. The distinction, therefore, between mild to moderate mental health issues and severe disorders, is essential in identifying those at immediate risk, so that appropriate, timely referrals can be made and input from specialist services implemented as early as possible. Mild to moderate mental health conditions include depression and anxiety, and are usually managed at primary care level. Severe mental health conditions include severe depression, bipolar disorder, schizophrenia and psychosis.
Severe mental health disorders affect very few New Zealand women giving birth. These women need early referral to specialist services and there are usually clear pathways to multidisciplinary care in these cases. It is far more common for women to experience mild to moderate perinatal mental health concerns, yet they remain the most challenging for midwives to address, given these conditions do not meet referral criteria for specialist services, and fall into what has been coined the ‘missing middle’ of publicly funded mental health services. The main focus of this article is therefore on mild to moderate mental health conditions, with some brief information in Box 1 about recognition and referral for women with severe mental health conditions.
HOW PREVALENT ARE MENTAL HEALTH CONCERNS AMONGST PREGNANT WOMEN IN AOTEAROA?
A 2017 analysis of data collected through the longitudinal Growing Up in New Zealand study, by Underwood et al., revealed that over the perinatal period 16.5% of the
5301 women interviewed had experienced significant levels of either antenatal or postnatal depression symptoms. The participants were interviewed during their third trimester of pregnancy and again at nine months post-partum, and depression symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS), with depression being defined as a score of >12.
Of this cohort, 11.5% of women reported antenatal depression symptoms (ADS) and 8% reported postnatal depression symptoms (PDS). This is consistent with previous international studies which have identified that it is more common for women to experience only ADS than only PDS. Around a quarter of women in the Growing Up in New Zealand study who experienced ADS, went on to have PDS.
An analysis found that PDS was most commonly associated with pre-pregnancy depression but not necessarily antenatal depression. For those women who experienced ADS only, the most significant precursor appeared to be anxiety - experienced either before or during pregnancy.
The analysis also revealed women who experienced both ADS and PDS were more likely to have had higher Edinburgh scores at the antenatal interview. It appears that the more severe the ADS, the more likely it was that PDS would follow.
Other pre-pregnancy or antenatal risk factors for this group included higher perceived stress, difficult family or relationship environment during the third trimester of pregnancy, and lack of exercise pre-pregnancy. Clearly, whilst there is some overlap between ADS and PDS, they are two distinct groups, with differing risk factors, and should be treated as such.
Whilst Pasifika or Asian women made up 26% of the study sample, the same group accounted for 37.7% of women who experienced either ADS or PDS and nearly half (46.5%) of the women who reported significant depression at both the antenatal and postpartum time points. The authors acknowledged the need for more
Severe mental health disorders
BOX 1
Women with a previous history of severe mental health disorders have a high chance of relapse during the perinatal period and therefore require prompt referral to specialist services. To aid in identifying women with this level of care requirement early, the following questions, recommended by the Perinatal and Maternal Mortality Review Committee (PMMRC) in its 2009 report, may be useful for midwives in practice.
At first contact with services, women should be asked:
• Are you currently receiving, or have you ever received treatment for a serious mental illness such as severe depression, bipolar disorder, schizophrenia or psychosis?
• Have you ever had treatment from a psychiatrist or specialist mental health team in the past?
• Do you have a family history of mental illness including perinatal mental illness?
The Referral Guidelines indicate that women who are “stable and/or on medication e.g. bipolar disorder” warrant a referral for specialist consultation, while those who have acute unstable psychosis are recommended to have their care transferred to specialist services.
The PMMRC states: “Women with a previous history of serious affective disorder or other psychoses should be referred in pregnancy for psychiatric assessment and management, even if they are well. Regular monitoring and support is recommended for at least three months following delivery.”
Other women requiring an urgent referral to secondary specialist maternal mental health services include anyone displaying thoughts of harm to either self or baby, suicidal ideation, or recent significant deterioration in mental state (BPACNZ, n.d.). research in this area, to explore specific risk factors for these groups.
Interestingly, despite the Growing Up in New Zealand cohort being an ethnically and socio-economically diverse group reflective of Aotearoa’s population - with 12.7% identifying as Māori - the results did not align with a 2017 study by Signal et al., which found that depression and anxiety symptoms, significant life stress, and a period of poor mood during the current pregnancy were all more prevalent for Māori than non-Māori women.
MIDWIFE’S ROLE The pivotal role midwives play in primary maternity care means the profession is well placed to identify when women are living with mental health issues and facilitate early access to primary medical care, community services or specialist services as indicated. Midwives are encouraged to familiarise themselves with their regional mental health referral pathway/s. As noted in Box 1, the PMMRC recommends mental health screening questions to identify women who are at risk of severe mental illness. It is also recommended that midwives consider general screening questions for all pregnant women to identify mild to moderate depression.
Identification of Common Mental Disorders and Management of Depression in Primary Care, a guideline published by the Ministry in 2008, included a College representative in its working group. It contains a section dedicated to mental disorders in the perinatal period, with recommendations for screening and management, which are still relevant today and midwives may find useful.
The below questions are from the updated Maternity Information System (MIS) and Maternity Clinical Information System (MCIS) currently being used by MMPO midwives and a number of DHBs.
At the booking visit and postnatally, possible depression can be identified by asking: • Have you ever experienced any mental health problems?
• Are any of the problems ongoing at the moment?
• During the past month, have you often been bothered by feeling down, depressed or hopeless?
• During the past month, have you often been bothered by having little interest or pleasure in doing things?
• Is this something you feel you need or want help with?
Midwives will also be familiar with the EPDS, which can be used as a further assessment tool, to assist in determining the urgency of issues and/or any follow up actions required.
If the woman identifies that she would like help, midwives need to explore what the woman feels would be helpful and which services are available in the area. The Referral Guidelines indicate that depression and anxiety disorders are primary level referrals. In ideal circumstances, the woman would have a continuity of care relationship with her GP or primary care nurse practitioner (NP), although this may not be the case, and for some women, cost is a significant barrier. In some regions, hauora Māori services or non-governmental organisations may offer mental health support during pregnancy.
SHOULD WE HAVE A NATIONAL APPROACH TO SCREENING FOR MENTAL HEALTH ISSUES IN THE PERINATAL PERIOD? Any national screening programme or tool would need to be considered within the unique context of Aotearoa’s maternity system - an important point raised by Mellor et al. in their 2019 study. The authors outline how the continuity of care model allows LMC community-based midwives to build a relationship with wāhine over time, meaning they are well positioned to detect even minor changes in a woman’s mood or behaviour. It could be argued that community-based midwives are already screening women at every antenatal visit, albeit informally, and Viveiros & Darling (2019) in their review of perceptions of barriers to accessing perinatal mental health care in midwifery caution against the implementation of a formal screening tool as merely a ‘tick box exercise’. In-depth, meaningful conversations between a midwife and wahine may be more likely to elicit honest responses to questions exploring overall wellbeing.
CHALLENGES Given Aotearoa’s most recent data shows New Zealand women are affected by ADS in higher numbers than PDS, and that the severity of ADS is associated with increased risk of developing PDS, midwives have an important role to play in assisting women, to identify any issues and access the care needed. However, the lack of a streamlined national approach poses challenges, as does the question of whether culturally appropriate resources or services - or any help at all, for that matter - will be available to a woman and her whānau once she has disclosed her concerns.
The lack of a nationally co-ordinated policy or screening programme was highlighted by Underwood et al (2017) in their analysis of the Growing Up in New Zealand data, as well as by Mellor, Payne & McAra-Couper in their 2019 qualitative study, which explored midwives’ perspectives of assessment and screening during pregnancy.
Additionally, the question of whether or not to implement a formal national screening programme becomes an ethical one, when the obvious gap in current service provision is taken into account. A theme which emerged from Mellor et al.’s analysis - based on the reports of 27 LMC midwives - found a clear disparity between women’s mental health needs and service provision. Midwives perceived the referral process as unreliable, with the most notable shortfall affecting women with mild to moderate mental health issues, for whom there was a distinct lack of appropriate services.
HOPE ON THE HORIZON
The maternity sector has not sat quietly on this issue, with a number of groups publicly articulating the problem and advocating for improvements in availability and accessibility of care for affected women and their whānau.
In its 14th annual report published this year, the PMMRC issued a wero (challenge) to the sector to urgently take action on its recommendations of the past 13 years, which are yet to be fully implemented. It called on the Ministry to invest in maternal and infant mental health, urgently recommending the development and funding of a Maternal and Infant Mental Health Network and clearly identifying the need for a national, culturally appropriate pathway. Furthermore, the National Maternity Monitoring Group (NMMG) also expressed concern in their 2019 report, reiterating that New Zealand women do not have equitable access to appropriate mental health services throughout the perinatal period.
The College, in collaboration with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), has also been advocating for action, most recently submitting a joint letter to the Minister and Associate Ministers of Health in April 2021. The letter directly challenged the Ministry on its failure to implement the longstanding PMMRC recommendations, further outlining the sector’s concern that maternal mental health needs have not been specifically prioritised, or even addressed, in the roll-out of the additional funding allocated to mental health at the 2019/20 budget announcement.
He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction, published in 2018, acknowledged maternal mental health as a major public health issue. The establishment of the Initial Mental Health and Wellbeing Commission as part of the Government’s response holds promise, as does the most recent announcement by Health Minister Andrew Little, to centralise New Zealand healthcare and establish a Māori Health Authority. The finer details are yet to be revealed, including exactly how additional resources and funding allocated to primary mental health and addictions will funnel specifically into perinatal mental health, and to what degree.
In the meantime, the College acknowledges that midwives are working tirelessly throughout Aotearoa to keep wāhine, pēpi and whānau as safe as possible, and that women trust their midwives with very personal and sometimes painful disclosures about their mental health. Midwives are well placed to work with women in these circumstances, but need an integrated network of responsive services to wrap the necessary support around each person. This requires the health system to recognise the importance of maternal mental health not only for the wahine, but also her pēpi and whole whānau, and to urgently commit sufficient resources to this care provision. The College understands that until this happens, midwives can sometimes feel isolated, and encourages any midwife in this position to discuss their concerns with a colleague, a College advisor, or a DHB midwifery leader. square
Support Services
Perinatal Anxiety & Depression Aotearoa (PADA) - pada.nz
depression.org.nz 0800 111 757 or free text 4202
Anxiety New Zealand - 0800 269 4389
Healthline - 0800 611 116
Suicide Crisis Helpline - 0508 828 865
References available on request.
