16th June 2017
A blog written by Catherine Lowenhoff, one of our Fellows, in support of Infant Mental Health Awareness Week (#IMHAW17), to share her research into perinatal and infant mental health. Catherine is a PhD student at Oxford Brookes University and is funded by a Nigel Groome studentship.
I am now in my third and final year of a full-time PhD. I started off with the intention of exploring the role of health visitors in supporting mothers with mental health problems.
Survey and research
Thanks to the collaboration and support from the iHV and its members, I have been able to collate the views of over 1500 health visitors regarding what they think about current health visiting perinatal mental health practice and their suggestions for the future.
As a result of the analysis of the survey, it became very clear to me that, in order to develop an intervention that is going to work in practice, it is absolutely vital to integrate the views of practising clinicians with the evidence of effectiveness from RCTs (Randomised Controlled Trials) and the views of women regarding what they find acceptable and helpful. The most effective intervention in the world will not work if the clinicians expected to deliver it are unable to do so (for whatever reason) or the people for whom it is intended do not think it is going to work. As well as the survey, I have therefore also completed literature reviews of the views of health professionals involved in delivering perinatal mental health interventions and the views of women about their experiences of care.
Maternal and infant mental health
Of course, it is impossible to think about maternal mental health without thinking about the bidirectional influence between the mother’s mental health, and the health and wellbeing of other members of the family, especially the baby. Maternal and infant mental health are inextricably linked. The way that a mother feels can affect the way that she looks after herself and the way that she interacts with, and cares for, her baby.
Health visitors know this. 95% of health visitors who responded to my survey affirmed that they used techniques to promote positive mother-infant interactions in the work that they do with mothers with mental health problems. I have also looked into the research that details the many ways that maternal mental ill-health can affect the developing child, not just in the present but also in the future. This just affirms for me the importance of doing what we can to prevent maternal mental health problems from occurring in the first place or providing support as early as possible to limit the impact on all members of the family.
In my view, one of the problems with the recommendations in the updated NICE guideline for antenatal mental health is that the recommendation to offer facilitated self-help for mothers with mild to moderate depression does not acknowledge the importance of thinking about the mother, the baby and the relationship between them. It can’t …because it is based on the protocol for self-help included in the NICE guideline for depression in adults.
Actually, the definition of ‘listening visits’ used in the NICE guideline does not explicitly acknowledge the importance of thinking about infant emotional wellbeing either, although the NICE guideline does have a separate recommendation (recommendation 1.9.12, NICE 2014) that requires health professionals to assess the nature of the mother-infant relationship at every postnatal contact. I don’t know who is expected to do this if assessing maternal mental health is no longer considered a priority for health visitors.
Only 27% of heath visitors in my survey felt that commissioners thought that supporting mothers with mental health problems should be a core component of health visiting practice. 30% were confident that health visitors were assessing maternal mental health at 3-4 months. Although 90% of respondents said that they were assessing maternal mental health at 6-8 weeks, this means that 10% were not. In the free text responses some health visitors said that maternal mental health was no longer considered a high impact area where they worked and some of them said that even if they assessed maternal mental health they did not have the capacity to provide support to every mother whom they felt needed it. These variations in practice will inevitably exacerbate rather than ameliorate inequalities in health.
Linking maternal and infant mental health
I believe that it is time to stop trying to divide the mother’s mental health from her physical health; her relationship with her baby and her partner; and the health and wellbeing of her baby. All these aspects of pre and postnatal life are inter-related. Mothers need to be offered choice in terms of what might be helpful but they also need to have access to an expert who understands the inter-related nature of all these things. In my view, that expert is the health visitor.
Effective intervention framework
So, as a result of my findings from the survey, the literature reviews and the existing evidence of effectiveness, I have also worked with the iHV North East network of champions and Fellows to identify the core components and key clinical activities of a feasible, acceptable and effective intervention framework that could be used to guide health visiting perinatal and infant mental health practice in the future.
It has been an exciting and challenging journey and there is still a lot more that needs to be done. I am hopeful that the work that we have done together will lead to a more clearly defined role for health visitors, and better outcomes for mothers, fathers and babies.
PhD student, Oxford Brookes University