24th January 2025

Great things come in all sizes: Small-scale project makes big impact in improving evidence-based perinatal mental health provision in a health visiting service in Wales

We are delighted to publish our latest Voices Blog by Amanda Holland, Professional, Education, Learning and Development Lead at the iHV. Amanda shares the importance of small-scale quality improvement projects and benefits of publishing the results in an academic journal – to preserve knowledge and contribute to the knowledge base in health visiting to improve practice and advance the profession.

Local quality improvement initiatives, no matter the size, are important to understand current health visiting practice, recognise strengths, and to identify where continual improvements can be made. Small-scale projects are often just the first step in a process that can lead to significant improvements in care provision, with benefits to patients, staff and the NHS.

Before I joined the iHV in April 2023, I was working as a senior lecturer at Cardiff University. In 2021, I was selected and funded by the university for a place on the Joanna Briggs Institute (JBI) Clinical Fellow Programme. This enabled an amazing opportunity to learn and apply an evidence-based quality improvement model and lead a small-scale project in collaboration and partnership with a local health board. The project resulted in some significant implications and ongoing developments. As part of the JBI programme, I was supported and funded to author and publish an open access paper in the JBI Evidence Implementation Journal¹ – Assessing the risk of postnatal depression in mothers receiving the health visiting service. Writing up project results and publishing is important to preserve knowledge and provide evidence to improve practice and advance the health visiting profession.

The project took place during the COVID-19 pandemic. The report, Babies in Lockdown: listening to parents to build back better², involving over 5000 respondents, indicated that during the most restrictive period of the COVID lockdown (23 March 2020 and 4 July 2020), only 1 in 10 parents of babies under two-years of age saw their health visitor face-to-face. This was at a time when there were high levels of concern about parental mental health, low confidence and challenges in accessing mental health support services – factors known to make parenting more difficult and result in negative outcomes.

Around 1 in 4 women and 1 in 10 men experience perinatal mental health problems^3,4,5. It is the most common serious health problem that a woman can experience in the perinatal period⁶_.  The latest  report of the Confidential Enquiry into Maternal Deaths and Morbidity⁷ between 2020 and 2022 indicated that deaths from mental health related causes accounted for a large proportion (34%) of deaths occurring between 6 weeks and in the first year after giving birth. Suicide continues to be the leading cause of direct deaths. Disparities in the identification, diagnosis and treatment of maternal mental health conditions were reflected in maternal mortality rates, with Black women at higher risk followed by Asian women and women living in the most deprived areas⁷_. The total long-term cost of perinatal mental illness to society is estimated at £8.1 billion for each annual group of births in the UK – 72% of this cost relates to the adverse impacts on the child⁸. Prioritising prevention and early intervention is important to reducing health inequalities and improving outcomes. Assessment, recognition and support of perinatal mental health is a core component of national child health programmes, and a crucial aspect of health visiting – evidence-based practice is key to positive outcomes.

Due to the impact of the COVID pandemic and the evidence which indicated gaps in mothers’ perinatal health care, the project team’s aim was to assess health visitors’ concordance with evidence-based guidance for identifying and supporting mothers experiencing, or at risk of experiencing, postnatal depression (PND)⁸. Our objectives were to determine current concordance with evidence-based guidelines, identify barriers and facilitators, and implement evidence-based strategies to enhance best practice⁸.

As the project took place during the COVID pandemic and the recovery phase, it faced many challenges. Effective leadership, good project management and communication, collaboration and partnership working enabled the project team to overcome many barriers and successfully complete the project.

Through application of the JBI Evidence Implementation Framework and the JBI Model of Evidence-based Healthcare, we followed a seven-phase implementation framework involving a structured approach grounded in audit and feedback. A baseline audit enabled identification and a good understanding of the gaps in evidence-based practice, and where improvements could be made through evidence-based strategies. The project also reinforced the need for the health board to recruit a specialist heath visitor in perinatal mental health who was subsequently employed as strategic lead to educate and support the workforce. A training programme was put in place which included iHV’s evidence-based Perinatal and Infant Mental Health Awareness training. A follow up audit found improvements in health visitors’ concordance with evidence-based practice.

Overall, the project was successful and resulted in some significant implications and ongoing developments:

• the recruitment of a specialist health visitor in perinatal mental health
• plans for an ongoing education and training programme in perinatal mental health
• plans for continued improvements through the development of health visitor perinatal mental health champion roles.

It was a privilege and pleasure to lead this project and collaborate with colleagues in a local health board. I extend my thanks to all involved, particularly Rachel Raymond, senior nurse, and Kim Jones, specialist health visitor in perinatal mental health. Thanks also to to those who provided support and guidance throughout the JBI Clinical Fellows Programme. I continue to apply and build on the learning I gained from this experience in my current role with iHV as I lead on various workstreams and projects to support continued professional development in health visiting.

“This project was important to a continuous cycle of quality improvement in perinatal mental health provision in the health visiting service. Since the completion of this project, the workforce have all received the iHV Perinatal Mental Health Awareness training, and this has resulted in a more confident workforce when identifying and managing perinatal mental health. We have also identified champions across the service to continue to cascade the training to new starters, preceptors and skill mix within the health visiting service.”
Rachel Raymond, Senior Nurse

“Since starting my role as specialist health visitor for perinatal mental health, I have been encouraged to see the greater understanding around the emotional wellbeing of parents and the importance of the first 1001 days of a baby’s life, becoming more prominent in policies and service direction. By being involved with this project, it has been wonderful to highlight the important and vital role that health visitors play in supporting mothers and fathers with their mental health during the perinatal period – ensuring that all babies have the best start in life.”
Kim Jones, specialist Health Visitor in Perinatal Mental Health

Assessing the risk of postnatal depression in mothers receiving the health visiting service: a best practice implementation project by Holland, Raymond and Jones (20024) can be accessed here.

For more information contact Amanda Holland  – [email protected]

For more information on the full range of iHV’s learning and development programmes, including Perinatal and Infant Mental Health and Leading Excellence in Practice, please contact [email protected] or visit our website www.ihv.org.uk

Amanda Holland, Professional, Education, Learning and Development Lead at the iHV

References

1. Holland A, Raymond R, Jones K. Assessing the risk of postnatal depression in mothers receiving the health visiting service: a best practice implementation project. JBI Evidence Implementation. 2024;11097.
2. Saunders B, Hogg S. Babies in Lockdown. Listening to parents to build back better. 2020. [Accessed 19.01.2025]. Available from: https://parentinfantfoundation.org.uk/our-work/campaigning/babies-in-lockdown/
3. Howard LM, Ryan EG, Trevillion K, Anderson F, Bick D, Bye A et al. Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy. Br J Psychiatry. 2018 Jan; 212(1): 50–56.
4. Paulson JF, Bazemore SD. Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA. 2010; 303:1961–1969.
5. Cameron EE, Sedov ID, Tomfohr-Madsen LM. Prevalence of paternal depression in pregnancy and the postpartum: an updated meta-analysis. J Affect Disord 2016; 206:189–203.
6. Knight M, Bunch K, Kelly T et al, eds. MBRRACE-UK. Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. 2022; Oxford: National Perinatal Epidemiology Unit, University of Oxford.
7. Felker A, Patel R, Kotnis R, Kenyon S, Knight M, eds. MBRRACE-UK. Saving Lives, Improving Mothers’ Care. Lessons learned to inform maternity care for the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2020-22.
8. Bauer A, Parsonage M, Knapp M, Lemmi V, Adelaja B. The costs of perinatal mental health problems. Centre for Mental Health and London School of Economics. 2014.