Mental health conditions continue to account for a significant portion of maternal deaths in the UK; in the most recent MBRRACE-UK report, mental health conditions accounted for 10% of maternal deaths (Knight et al, 2023). This report emphasised that pregnant, recently pregnant and breastfeeding women must be treated in the same way as a non-pregnant person, unless there is a very clear reason not to. This reduces the risk of missed diagnosis or treatment where symptoms may be attributed to a benign perinatal cause. This situation was highlighted recently in relation to breast cancer occurring during pregnancy (Bakhuis et al, 2023), and is further emphasised by the National Institute for Health and Care Excellence (2023) conditionally recommending eight digitally enabled therapies to treat depression and anxiety in adults. However, this does not make specific mention of their use in the perinatal period. This article continues the discourse of a previously published article (Gournay et al, 2023), which explored digital mental health platforms.
Within the perinatal period, healthcare professionals can play a significant role in promoting the importance of mental health, the prevention of mental health problems and the care, treatment and interventions for women and their families whose lives may be impacted. Between 10% and 20% of women in the UK experience a mental health problem during their pregnancy, including over 11 000 women per year in Scotland alone (Sambrook Smith et al, 2019). Women with lived experience of trauma, in particular child abuse, have described the ways in which pregnancy or childbirth experiences and provision of services can exacerbate trauma or result in re-traumatisation (Delap, 2021). In addition, with or without pre-existing trauma, many women have reported trauma related to pregnancy and childbirth (Watson et al, 2021). It is therefore essential to embed a trauma-informed approach in maternity services that responds to the woman and her family's needs and mitigates the potential adverse impact of trauma on pregnancy, birth and the transition into parenthood (Kranenburg et al, 2023).
Partners may also be impacted at this time, with additional evidence that untreated maternal mental illness may adversely affect the mother–infant relationship and infant development (Johansson et al, 2020). There is an increasing understanding of the vulnerability of partners, with 5–10% of fathers who develop mental health problems in the perinatal period requiring support (Cameron et al, 2016; Darwin et al, 2021). Maternal perinatal mental health is also closely connected to that of infant mental health, and on the relationship between mother and baby. Working with mothers and infants to improve their interaction and attachment is primary prevention for the development of mental health problems in children (Hoffman et al, 2017; Izett et al, 2021).
A recent systematic review and meta-analysis by Clinkscales et al (2023) looked at the evidence base for the effectiveness of perinatal psychological interventions. They concluded that psychological interventions (cognitive behavioural therapy and mindfulness-based interventions) were effective in reducing symptoms of anxiety and depression in the perinatal period. They also suggested that interventions can be tailored to meet individual and perinatal specific needs of the women across various modes and methods of delivery, such as face to face, online, group or self-guided resources.
Barriers to seeking perinatal infant mental health support
Families need prompt access to evidence-based treatment to improve outcomes. Adversity faced by infants who have a mentally unwell parent, although not universal, can create lifelong challenges, but early intervention can mitigate risk (Bhutta et al, 2023). Psychological interventions are known to be an effective first-line treatment for many perinatal mental health conditions (Cuijpers et al, 2023). Webb et al (2023) identified a multi-level model of barriers and enablers to accessing care in the perinatal period in their meta-review. This included:
- Individual factors, such as beliefs or stigma
- Factors related to the healthcare professional, such as dismissive or normalising behaviour
- Interpersonal factors, such as a person's relationships or communication
- Organisational factors, such as resource inadequacies
- Political factors, such as economic or immigration status
- Societal factors, such as culture or societal norms.
It has been estimated that in the UK, 60% of women have no access to perinatal mental health services and 38% of women wait over a month to be referred (Sambrook Smith et al, 2019).
Despite effective psychological treatments being available, not all women seek help as a result of a range of barriers, including perceived stigma and logistical issues in attending appointments, which limit their engagement with existing treatment services (Woolhouse et al, 2009; Ford et al, 2019). Iturralde et al (2021) identified similar barriers for women from marginalised racial or ethnic groups, with women in socioeconomically deprived circumstances identified to be at a higher risk of perinatal mental health problems (Huschke et al, 2020). Similarly, the prevalence of infant mental health problems is increased in these circumstances (De Natale et al, 2023). Furthermore, families with complex social factors are recognised to be less likely to maintain engagement with antenatal services (Hunter et al, 2019). Stigma and judgement have been quoted as a major factors in poor engagement with antenatal services, alongside the fear of a child being removed (Heys et al, 2021). Further recognition is needed of the higher prevalence of co-morbidity with additional social factors, such as poverty, substance use, domestic violence, links to the justice system and accommodation issues known to impact mental health.
Digital mental health provision
Digital mental health provision is not a new concept, with a range of digital mental health interventions having been developed across the world over the last 25 years (Lattie et al, 2022). These have been developed predominantly as an alternative to traditionally delivered care and to address treatment gaps, and accelerated during the COVID-19 pandemic (Zhou et al, 2020). Several studies in both the perinatal and general populations have explored the efficacy of these alternatives to traditional face-to-face cognitive behavioural therapy, indicating comparability with cognitive behavioural therapy delivered by telephone (Mohr et al, 2012; Cuijpers and Karyotaki, 2021) and internet-delivered cognitive behavioural therapy (Olthuis et al, 2016; Carlbring et al, 2018; Loughnan et al, 2019) for depression and anxiety.
SilverCloud® by Amwell® provide additional digital solutions to support mental health and wellbeing for the entire family, including those living with chronic conditions.. For children and young people, the Mental Health Foundation (2020) suggest that one in eight 5–19-year-olds in the UK meet the criteria for intervention every week. A range of SilverCloud® programmes have been designed for their needs, as well as their parents or carers. These programmes range from supporting an anxious child or teenager through to support for low mood and anxiety and provide proven and preventive strategies to manage these symptoms.
The Perinatal Wellbeing Programme
This computerised cognitive behavioural therapy programme was developed by SilverCloud® for the support of those at risk of or experiencing low mood or worry during the perinatal period. It is designed to help individuals learn to better understand their thoughts, feelings and behaviours and positively improve their wellbeing during pregnancy and up until a year after birth. Internationally, it is estimated that one in five women (20%) will experience anxiety and/or depression in the perinatal period (Dennis et al, 2017; Falah-Hassani et al, 2017; Leach et al, 2017; Bryson et al, 2021). Comparatively, one in 10 fathers (10%) will experience similar mental health difficulties (Giallo et al, 2012; Philpott et al, 2019; Chhabra et al, 2020; Leiferman et al, 2021).
The 2023 Perinatal Wellbeing Programme consists of six modules:
- Finding your feet
- Tuning into feelings
- Improving sleep
- Taking action
- Dealing with worry
- Staying well.
These modules are further supported by a range of interactive tools that include support for progressive muscle relaxation, a bedtime routine list and an activity scheduling tool. The programme comprises engaging content, videos, user stories and interactive tools available on demand whenever the user needs to access the system.
One user story features Eva, who experienced mental health problems during her pregnancy in 2020 (SilverCloud, 2024). She found it difficult to explain to her partner how she was feeling, and how the experience of a previous miscarriage was prominent in her mind. Her experiences during the pandemic, where she felt overwhelmed by fear and anxiety, manifested as night terrors in her third trimester. Speaking to her midwife and GP led to a recommendation to use the Perinatal Wellbeing Programme, as there was no access to standard support groups during this time. Eva described how the programme ‘gave her the words’ she needed to explain to her partner how she was feeling and ways of coping. This case also featured in a podcast (CBTALKS, 2022a).
The role of mental health in perinatal care was further explored in a podcast facilitated by Dr Jorge Palacios (CBTALKS, 2022b). This podcast episode outlined the use of computerised cognitive behavioural therapy for practitioners supporting woman and families in the perinatal period, drawing on the experiences of clinicians in an NHS trust in England, and how this method can complement more traditional approaches to mental healthcare and support. The practitioners explored their experiences of using the Perinatal Wellbeing Programme and the benefits they identified with the immediacy of access to support and help where delays to face-to-face clinical support were common.
Conclusions
Digital mental health programmes, such as the Perinatal Wellbeing Programme from SilverCloud®, can positively support those at risk of or experiencing low mood or worry during the perinatal period. An awareness of the availability of these programmes, and routes of access to them, is essential for all midwives and healthcare professionals working within maternity services. Further study of their use and impact is warranted to support the ongoing development of digital therapies.
Key points
- The Perinatal Wellbeing Programme from SilverCloud®provides a comprehensive digital programme to support those experiencing low mood or worry during the perinatal period.
- The experiences of those who have used the programme, and from clinicians supporting its use, suggest it benefits from the immediacy of access to support and complements more traditional approaches.
- However, more study of the use of digital therapies is warranted to understand their impact and to support any ongoing development of this approach.
CPD reflective questions
- What experiences have you had of supporting women, birthing people or their partners with low mood or worry during the perinatal period?
- Having read this article, do you feel more knowledgeable about digital approaches to support mental health and wellbeing and where they could be used in midwifery care?
- Are you aware of what digital and traditional mental health and wellbeing support is available in your local area and how to refer into these services?