The WRISK project regularly asks contributors to share their perspectives on a range of issues related to risk communication in pregnancy to further understanding of the challenges faced by scientists, clinicians, policy makers, and of course women themselves when trying to navigate risk messaging. These represent individual and personal viewpoints, and are aimed at encouraging reflection and discussion, rather than reaching conclusions.
Dr Stephanie de Giorgio is a GP and the Perinatal Mental Health Lead for Kent and Medway. She is also the GP Champion Programme Lead for NHSE. In this blog to mark Maternal Mental Health Awareness Week 2020, she reflects on the enormous efforts taken to raise awareness of perinatal mental illness and get the 6 week maternal postnatal check back into GP contracts- a huge victory for women and those that care for them. Stephanie tweets at @DrSdeG.
About 17 years ago, I stood on the postnatal ward, as an obs and gynae doctor, and had a moment. I looked around at the women who were trying to nap, trying to get to grips with feeding, trying to just pick up their baby or simply get used to having a new human that they were completely responsible for and thought, we simply don’t look after women well enough in the postnatal period and if I can change something in my career, it would be that. I hadn’t had a baby at that point in my life, but I knew it just didn’t seem good enough. Then I had one….and realised that I hadn’t even begun to understand the difficulties some women go through.
Fast forward 14 years and I found myself as part of a group of individuals and organisations who were pushing to get a fully funded maternal postnatal check back into the GP contract due to my role in Perinatal Mental Health Education. Maternity and postnatal care had been removed from the GP contract in 2004, which meant that not all women were now seen routinely by their GP during pregnancy or postnatally. In some areas there were arrangements for this to happen, but it was not countrywide. Postnatal maternal checks were done by some GPs as appointments of their own, some tagged onto the baby check (still funded) and some women had none at all.
In 2016, Perinatal Mental Health had become a priority for NHS England and funding was announced to improve care for women and families during this sometimes very difficult time. The fact that it had become a priority was almost certainly in part due to the amazing campaigning and motivation of many women with lived experience, voluntary organisations, professional groups and charities involved, who had, through social media, main stream media and personal lobbying, begun to significantly raise awareness of Perinatal Mental Illness around the country. The Royal College of General Practitioners had also made Perinatal Mental Health one of their priorities.
This positive perfect storm of circumstances meant that finally, better community provision of specialist teams was being introduced and new mother and baby units could be opened. Women and wider society were also becoming aware that they, their loved ones, friends and work colleagues were quite likely to become affected by perinatal mental health problems, as up to one in four women may be. It was also becoming more widely known that partners can be affected too.
This specialist provision was hugely welcomed, but it was still the case that 90% of women struggling with their mental health postnatally, would need to be seen within Primary Care by their GP or an allied health professional. At a time when Health Visiting numbers were being cut and midwifery care finishes on day 10 postnatally, there remained a huge provision gap to ensure that women with mental and physical health needs postnatally would be picked up. Research commissioned by the Centre for Mental Health and the NCT showed that many women were “falling through the gap” and that half of women who were unwell were not being picked up at all. Women with incontinence and physical health issues postnatally were also being missed and it appeared that one of the most sensible ways to try to pick up these problems postnatally would be to get the postnatal check back into the GP Contract. But this was not without difficulties.
Primary Care is hugely overburdened at the moment, and so simply asking GPs to take on roles without funding was not an option. By attaching funding to the check, as there is for the baby check, it would allow practices the freedom to provide the service in the way that was best for them and their patients. This involved getting agreement from the treasury, dept of health and social care, NHS England and the General Practice Committee of the British Medical Association.
Over 2 years there were many meetings and political events. Those involved included the NCT, NHSE, GPC, RCGP, expert professional and lived experience groups who were convened for political events at Westminster to explain the importance of good postnatal care to those in government. It was a brilliant example of people committed to the same goal, working together to try to achieve the best for women and families. And it worked. From April 2020, every woman in the UK will be getting a dedicated postnatal check for herself.
However, having a check in itself, doesn’t guarantee that we will ensure that women get the care they need. Many women tell us that this is just a tick box exercise when they do have one, and that simply isn’t good enough. To prevent this happening, there will be a suggested template which we have created but is to be approved by another expert panel of which I am part, and education for GPs about what the check should include. The importance of listening, really listening and understanding what the woman is telling us will be emphasised. Asking the difficult questions about incontinence, domestic abuse, intrusive thoughts must all be done, sensitively and compassionately. We must then ensure that women are directed in a timely fashion, to good quality services to help them with any problems.
To ensure perinatal mental health problems are recognised and treated appropriately in primary care, NHSE have been funding for 2 years the GP Spotlight programme. Myself and my colleague Carrie Ladd have trained GP Champions around the country and those GPs then teach their peers. We have so far reached about 7000 GPs and HCPs and we are hoping to roll it out further and continue to educate our colleagues to ensure they ask the right questions and feel confident in treating those who can be looked after in primary care and those who need referral to specialist services.
Some people ask about the evidence for a 6 week check and whether it is really what women need. As part of the research into this, myself, Charles Podchies from NHSE and the National Perinatal Epidemiology Unit worked together to look at provision of care and when women present (data not yet published formally). The health inequality that this research demonstrated was stark, women from socioeconomically deprived areas were less likely to get a check.
What horrified me on searching the literature for postnatal care, is the lack of research that has gone into this topic historically. The 6 week timeline, is genuinely, based on the biblical, yes, I do mean that, notion of 40 day recovery postnatally. This time period is interestingly replicated in many different cultures around the world. Some research from the US suggests that women should ideally be seen at 3 days, 3 weeks and 3 months postnatally to ensure as many problems as possible are picked up. Sadly, this is not practicable in the current financial and workforce constraints of the NHS. It was therefore decided to continue with the accepted 6 week framework, but that we must ensure that women know that they can return if problems show up later, it can be used as the opening of a conversation.
Now that funding has been approved and it is set to be launched from April 2020, the hard work begins. Those of us involved will be doing our best to ensure that women in the UK are given the opportunity to have a high quality, evidence based, compassionate and useful discussion with a health professional in the postnatal period. This includes women whose babies have died as a result of a stillbirth or neonatal death.
Having been part of this process and having the opportunity to do some of what I wanted to achieve standing on the postnatal ward 17 years ago, has been an utter privilege. The dedication, motivation and professionalism of all of those involved has been inspiring and as a mother who had a tough time postnatally, I want to say thank you.