International Focus: Perinatal care, Australia

CYP Now has teamed up with the Churchill Fellowship to publish a series of articles summarising key findings from studies undertaken worldwide by Churchill Fellows (see below). This is an abridged version of Learning From Best Practice in Australia: Developing Perinatal Mental Health Services by clinical psychologist Jill Domoney. The report details the findings of Jill’s visit to both research departments and clinical services in New South Wales, Queensland and Victoria in 2016. She interviewed key professionals about their work and the wider context of their organisation, attended meetings and case conferences, and observed clinical practice within services. Here, she highlights findings on agencies’ work on early intervention and prevention.

UK CONTEXT

Perinatal mental health is a major public health problem with around one in five women thought to have a mental health difficulty during the perinatal period from conception to 12 months postnatally. Many of these women are struggling with depression and anxiety, but a significant number also suffer from eating disorders, posttraumatic stress, and psychotic disorders. These difficulties not only affect the wellbeing of the mother but also impact on the wider family and the mental and physical health of the infant. The consequences of untreated mental health difficulties can be far reaching both in terms of the emotional and psychological health of the family, and also the wider costs to society.

In January 2016, the UK government pledged to invest £365m in perinatal mental health to improve provision. This was followed in February by the publication of the Five Year Forward View for Mental Health for the NHS in England, which provided a national strategy for improving mental health outcomes across the health and social care system.

Perinatal mental health is a highly specialist area. Professionals working with these difficulties need knowledge of both adult and infant mental health; an understanding of how physical and mental health interact; the ability to gauge the quality of the relationship between parent and infant; careful assessment of risk; and good knowledge of process and language around pregnancy and birth.

AUSTRALIAN CONTEXT

In 2008, Australia launched the National Perinatal Depression Initiative, a five-year plan developed to translate research on perinatal depression and anxiety into practice on a national level. The initiative set out six objectives: to develop clinical practice guidelines; to increase workforce training and development; to roll out routine and universal screening for depression; to provide follow-up support and care for women at risk; to undertake research and data collection; and to improve community awareness and tackle stigma.

As a result of this work Australia is a world leader in developing practices around identification and treatment of perinatal mental health disorders and also has a significant amount of research and development around whole-family approaches to perinatal mental health intervention and prevention, specifically around engaging fathers and targeting early parenting practices.

PUTTING THE BABY FIRST

Infant mental health can be compromised when parents are suffering from mental health difficulties, but also in situations where the parents struggle to provide adequate care for the baby for other reasons, for example when the infant has physical illness or where parents’ own experiences of being parented were poor. The Fellowship provided an opportunity to visit several services which primarily target the infant with the aim of intervening early to prevent the development of further problems.

INFANT MENTAL HEALTH SERVICES

The infant mental health group at the Royal Children’s Hospital in Melbourne provides outpatient services through links with community CAMHS. In addition, they provide training and supervision for CAMHS clinicians. This has helped to grow capacity for infant mental health within existing CAMHS and ensured that infant work is sustained despite clinical priorities in older age groups.

The group are a multidisciplinary team, led by a consultant infant and child psychiatrist and incorporating social workers, psychologists, speech and language therapists, nurses and psychotherapists.

Main reasons for referral include difficulties in the parent-infant relationship and regulatory problems such as feeding disturbances, and parental mental health is often a key feature of referrals. They provide a range of interventions including infant-parent psychotherapy, family therapy and speech therapy, as well as offering consultation to staff within the hospital.

Associate Professor Frances Thomson Salo is also a member of this group. She is based in the neonatal unit at the Royal Women’s Hospital across the road from the children’s hospital and has spent many years gradually shifting staff attitudes towards infant mental health and supporting both staff and parents in the neonatal unit to think about the mind and needs of the baby.

She has introduced books into the unit so that parents can read to their babies, has started a fathers’ group for dads to talk about their experience, and has helped to create care plans for families in specific circumstances, for example, when parents struggle to come into the unit because of childcare of older children. She described how having an infant mental health clinician embedded into the care of these vulnerable babies has helped to ensure their needs are kept in mind.

The services I visited in Australia also showed the importance of linking with hospital-based services and paediatric teams to strengthen this work and provide support for families of medically unwell infants, as well as ensuring there are strong care pathways between hospital and community services for these very vulnerable infants.

EARLY PARENTING SUPPORT

Residential Early Parenting Services are a completely unique type of service provided in Australia. These are short-term, residential, structured programmes for families who require support with building practical skills and confidence in parenting from 0-3 years, specifically around settling and feeding. One such centre in Queensland, a state funded service called the Ellen Barron Family Centre (EBFC), provides a structured, psycho-educational residential programme for families over five days, or 10 days if there are more complex difficulties.

The EBFC is not classed as a psychiatric facility as it is focused on parenting and therefore parents need to have the cognitive capacity to take on the messages and learning of the centre. However, it is a psychological intervention, assisting in the adjustment to parenthood and providing support that can significantly reduce the risk factors for depression and anxiety in the postnatal period.

The aim is to support the development of the attachment relationship between parents and infants, and it is therefore an early intervention that can help to prevent the development of serious perinatal and infant mental health issues later on.

The residential stay is usually part of a package of care for struggling families. On arrival families are given their own room with a nursery attached and have an allocated nurse to provide individualised guidance for their needs and 24-hour support. The model of care focuses on sleep and settling, breastfeeding and feeding, child behaviour and development, and general parenting skills.

The centre has a multidisciplinary team of nurses, paediatricians, psychologists, and social workers. They provide a range of groups and sessions during the day, including mindfulness, adjusting to parenthood and more general sessions about sleeping, feeding and play. The messages given are careful to provide choices for the parent rather than dictating a particular method. However, they are all geared towards supporting parents to notice and respond to infant cues, building the relationship between infant and parent and providing the building blocks for the development of secure attachment.

Both mothers and fathers can be admitted to the programme and the rooms have double beds to encourage whole family participation. A father-only group is run one evening a week for those fathers who work during the day.

Staff at the centre also provide training and support to child health nurses in the community, helping to ensure consistent messages about best practice following discharge and build confidence in the workforce to support parents.

A stay at EBFC has been transformational for many families, helping them find new patterns and methods for caring for their babies with the support of a caring, friendly and encouraging team.

IMPLICATIONS FOR UK

It may seem like an expensive intervention to provide residential care in this way. However, given the £8.1bn estimated costs of perinatal mental health difficulties in the UK, 70 per cent of which are borne by the impact on the infant, investment at this time is essential.

Since undertaking this Fellowship there has been a huge expansion of perinatal mental health services in England, with women in every area of the country now having access to specialist support. In addition, these services continue to develop and expand their reach, working with families up to 24 months postpartum and beginning to introduce mental health assessment for partners. These are welcome changes which will have a positive impact for many families. Despite this, preventative services such as health visiting and children’s centres continue to face funding cuts, meaning that access to early intervention that could prevent the development of mental health difficulties is reduced.

As always, there is more to do, but the hope is that, as narratives around mental health and parenthood change, and campaigning continues to protect preventative interventions, more families will be able to benefit from early support to give their babies the best start in life.

ABOUT THE CHURCHILL FELLOWSHIP

• The Churchill Fellowship is a national network of 3,800 inspiring individuals whose mission is to find the world’s best solutions for the UK’s current challenges.

• Up to 150 Churchill Fellows are funded each year to visit the world’s leading practitioners and projects on a topic of their choice – from social policy to healthcare to education and more – and bring back new ideas for their communities and sectors across the UK.

• Any UK adult citizen can apply, regardless of qualifications, background or age. Fellows are chosen for their potential as change-makers, not their past track record or status.

• Find out about fellows and their ideas at www.churchillfellowship.org