Perinatal mental health service specification

1. Introduction and Background

1.1 Purpose

This service specification has been prepared by the Scottish Government to advise clinicians and managers working in NHS inpatient and community perinatal mental health services of the principles of good practice in relation to the delivery of services. It draws on the Women and Families Maternal Mental Health Pledge which was co-created by women with lived and living experience and Perinatal Mental Health Network Scotland (PMHNS) and the Infant Pledge. The NHS Scotland Charter of Patient Rights and Responsibilities summarises patient’s rights to receive services appropriate to their need, be involved in decisions about their care, expect confidentiality and have the right to complain and the complaint dealt with effectively. Both Pledges were created in partnership with women and families and those working to support their voices and inform this service specification.

The specification sits alongside the Core Mental Health Standards and highlights those additional features distinctive to the perinatal context. It is underpinned by (i) the Community Perinatal Mental Health Team (CPMHT) Service Development Guide; (ii) the Scottish Perinatal Mental Health Care Pathways; (iii) the Perinatal Mental Health Specialist Role Definitions; and by (iv) Delivering Effective Services: Needs Assessment and Service Recommendations for Universal and Specialist Perinatal Mental Health Services, produced by PMHNS.

Guidance on the delivery of perinatal mental health services is available elsewhere. Helpful documents include: the Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Standards for Community Perinatal Mental Health Services (2023), the Standards for Perinatal Inpatient Services (2024), the Royal College of Psychiatrists Council Report 232, NICE clinical guideline 192: Antenatal and postnatal mental health: Clinical management and service guidance (update), the MBRRACE reports and SIGN 169 Perinatal Mental Health Conditions. In addition, the Mental Health (Care and Treatment) (Scotland) Act 2003 (amended by the Mental Health (Scotland) Act 2015) places a legal duty on health boards to ensure women and their infants can be admitted jointly to suitable inpatient provision. This Scottish Government service specification will address service delivery in the context of the Delivering Effective Services recommendations and the briefing paper on regional perinatal mental health service provision.

1.2 Context

The Specification should be read alongside relevant legislation (including the Mental Health Act (Mental Health (Care and Treatment) (Scotland) Act 2003, as amended by the Mental Health (Scotland) Act 2015, and the Children and Young People (Scotland) Act 2014), policies, and national health and well-being standards including:

Mental Health and Wellbeing Strategy (Scottish Government & COSLA, 2023)

The Scottish Government and COSLA published their long-term vision and approach to improving the mental health and wellbeing of everyone in Scotland in June 2023. The Strategy is ambitious and describes what the Scottish Government and COSLA think a highly effective and well-functioning mental health system should look like – with the right support available, in the right place, at the right time, whenever anyone asks for help.

Core Mental Health Standards (Scottish Government, 2023b)

These standards have been developed in line with the vision of a Scotland, free from stigma and inequality, where everyone fulfils their right to achieve the best mental health and wellbeing possible.

The diagram below shows the Core Mental Health Standards and their relationship to the Health and Social Care Standards, Mental Health and Wellbeing Strategy and different Specifications including the Perinatal Mental Health Service Specification. They are informed by the principles set out in the Strategy, and clarify what support should look like for people accessing mental health services enabling them to receive the right information, support, care, intervention, or service for their needs and to support their recovery, as quickly as possible, with the fewest steps possible.

The flowchart shows how the:

• Mental Health and Wellbeing Strategy and
• Health and Social Care Standards

Inform the:

• Core Mental Health Standards.  

These underpin the five service specifications which are:

• National Specification for Psychological Therapies and Interventions
• National Specification for Eating Disorder Care and Treatment in Scotland
• CAMHS (Child and Adolescent Mental Health Services) Service Specification
• Children and Young People – National Neurodevelopmental Specification
• Perinatal Mental Health Service Specification

• The Promise (Independent Care Review, 2020)
• Getting It Right For Every Child (GIRFEC)

  Principles and values should underpin all services impacting on children’s welfare. GIRFEC is the Scottish Government’s commitment to children, young people and their families getting the right support at the right time (Scottish Government, 2023c). It provides an evidence-based consistent framework and shared language for promoting, supporting, and safeguarding the wellbeing of all children.

• The United Nations Convention on the Rights of the Child (UNCRC) Has been brought into law in Scotland and provides a foundation which ensures that babies’, children’s and young people’s rights are protected.
• Creating Hope Together - Scotland’s suicide prevention strategy 2022 to 2032 Details the Scottish Government’s strategy and actions to reduce the prevalence of suicide and support those affected by it.

1.3 Principles and Values

The specification is underpinned by principles and values aligned with quality health and social care provision for women, their infants and families in the perinatal period.

1.3.1 Co-production

The active engagement of individuals with lived and living experience in the design and evaluation of services is crucial. This specification has been informed by the Women and Families Maternal Mental Health Pledge which was co-created by women with lived and living experience and the Perinatal Mental Health Network Scotland (PMHNS), and the Infant Pledge which presents the expectations of our youngest citizens.

1.3.2 Person-centredness

The delivery of care is compassionate and responsive to individual personal preferences, needs, rights and values with patient and family involvement and engagement contributing to clinical decision-making. The delivery of care also reflects a relationship-based approach, in which the importance of attachment and bonding for both infant and mother is paramount. The language used both verbally and in written material should be accessible and reflect this person-centred approach.

1.3.3 Trauma-informed practice Practice should be informed by the Roadmap for Creating Trauma-Informed and Responsive Change - Guidance for Organisations, Systems and Workforces in Scotland (2023), and by Core Mental Health Standards references to trauma-informed care.

1.3.4 Raising awareness and tackling stigma Stigma (negative attitude) and discrimination (negative treatment) continue to exist despite the recognition of perinatal mental health problems and attempts to improve public awareness and understanding. For some groups, the intersectionality of protected characteristics may compound stigma and impact on access to services. Those working in perinatal mental health services should try to address this.

1.3.5 Prevention and Early Intervention

The delivery of specialist perinatal mental health services should include working across all sectors to embed the principles of prevention and early intervention. Universal and third sector support should be available within local communities in accessible, trauma-informed settings.

1.3.6 Safety

Patient safety is fundamental to the delivery of perinatal mental health services. The perinatal period can be a time when symptoms and risk change rapidly. The safety of mother and baby are paramount. Treatment should not contribute to harm.

1.3.7 Equality and equity

There should be a collective approach to understanding and shared responsibility for promoting good mental health and addressing the causes of mental health inequalities, supporting groups who are particularly at risk. This includes marginalised groups who experience discrimination, racism or exclusion (social, political, economic or environmental) solely based on age, race, sex, sexual orientation, disability or other characteristics protected by the Equality Act 2010.

Experiencing minority stress, racism, discrimination and trauma has a significant negative impact on mental health and wellbeing and can disproportionately impact lesbian, gay, bisexual, transgender and intersex (LGBTI) people, minority ethnic groups, and disabled people. LGBTI and minority ethnic people also have reported that staff can lack cultural competency, sensitivity and understanding of their specific needs (Scottish Government & COSLA, 2023).

Services should be provided in a way which ensures that quality does not vary because of personal characteristics such as gender, or because of other protected characteristics, geographic location, or socio-economic status. This specification aims to reduce any unnecessary variability while acknowledging the diverse population needs of Scotland and the need for responsive implementation aligned with local models of delivery and partnership working.

1.3.8 Timeliness

Services should be offered in a timely manner. Rapid changes in mental state are often seen in perinatal mental illness and it is crucial that these are responded to with an appropriate level of urgency. Infant development in this period is also rapid and timescales need to be sensitive to any harm being caused in the context of the mother-infant relationship.

1.3.9 Effectiveness and Evaluability

The guidance within the Specification is underpinned by scientific knowledge and include: the provision of evidence-based interventions (Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Standards for Community Perinatal Mental Health Services (2023) and Standards for Perinatal Inpatient Services (2024), the Royal College of Psychiatrists Council Report 232 and SIGN 169 Perinatal Mental Health Conditions. Services should regularly monitor outcomes, including timeliness, patient satisfaction and the effectiveness of interventions offered.

1.4 Perinatal Mental Health Conditions

1.4.1 Mental distress and illness are common in pregnancy and the first postnatal year, affecting up to one in 5 women, and the period after childbirth is a uniquely vulnerable time for development of severe mental illness for certain groups of women (Langan Martin et al, 2016). In Scotland, it is estimated that:

Around 11,000 women a year would benefit from help such as counselling. Many of these women experience anxiety and low mood but may not appear to reach thresholds for referral to specialist services.

Around 5,500 women may require more specialist help and require rapid access to psychological assessment and treatment within psychological services.

Around 2,250 women will experience severe illness, requiring specialist PMH services, with a small number of them needing inpatient care or the provision of enhanced community care.

1.4.2 The consequences of perinatal mental illness may be severe. Mental health related deaths are now the leading cause of maternal death in the first postnatal year (Cantwell et al, 2018). There is strong evidence that untreated maternal mental illness may adversely affect the mother-infant relationship and infant development (Stein et al, 2014). Fathers, partners and co-parents may also be more vulnerable to illness at this time.

1.4.3 Those working with pregnant and postnatal women in both universal (for example, midwifery and health visiting) and specialist services have a unique opportunity to prevent the development of illness in some women at highest risk and to improve outcomes for children growing up. There is good evidence that early intervention has better, and more cost-effective outcomes than later attempts to address child mental health problems.

1.4.4 In community services, there is a need to respond rapidly to the timescales imposed by pregnancy and critical developmental stages in early infancy.

1.5 Perinatal Mental Health Services

NHS Scotland Perinatal Mental Health Services (PMHS) include both community and inpatient services. Ideally these clinical teams are multidisciplinary and/or multiagency and include nurses, nursery nurses, psychiatrists, psychologists, occupational therapists, parent-infant therapists, peer support workers and social workers. However, in small health boards they may be comprised of only one or two practitioners, who may require input from regional colleagues. Organisationally, these smaller teams often sit within, or are aligned to adult mental health services.

1.5.1 All mothers, infants and families should receive support and services that are appropriate to their needs, with both community and inpatient assessment and care being available in a timely manner. For most people, that support is most likely to be provided in the community (by Community Perinatal Mental Health Teams - CPMHTs), though a small number of women will require inpatient care (in a Mother and Baby Unit (MBU)).

1.5.2 All perinatal mental health services sit within a pathway of mental health support and care for women, infants and families affected by maternal mental ill health, which should include universal maternity, health visiting, Family Nurse Partnership, primary care services, local authority provision, third sector support and other specialist provision including maternity and neonatal psychological interventions (MNPI) teams, infant mental health teams, adult mental health and Child and Adolescent Mental Health Services (CAMHS). Referrals to PMHS may also come from acute mental health services or crisis support services. There should be close working relationships with these, and with local authority social work and early years services, and third sector social care partners, to ensure that care is seamless and follows the woman’s and infant’s journey from preconception through to postnatal care, with the service most appropriate to their needs providing a timely response.

1.5.3 PMHS will also support professionals in other services through consultation, advice, training and, where appropriate, supervision to ensure women and infants receive informed mental health and relationship care at all points in their journey, with well-managed transitions to and from specialist PMH services.

1.5.4 PMHS will accept referrals from universal health professionals and specialist services professionals involved in preconception, maternity, neonatal and postnatal care of women who meet agreed referral criteria for PMHS. In general, referral criteria reflect those for adult mental health services, but thresholds should be altered to take into account:

i. The modifying effects of pregnancy and infant care on mental illness

ii. The need to address the mother-infant relationship and promote infant development

iii. The need to provide preventative assessment and interventions for currently well women at high risk of postpartum severe mental illness

1.5.5 PMHS should assess and care for women and their infants during pregnancy and to the end of the first postnatal year, where clinically indicated. Decisions on transitions of care back to other services, where required, should be based on clinical need in line with best practice principles. It may be appropriate for patients to be transferred to another service earlier in the postnatal period, or later than one year post-delivery, depending on individual clinical need. The needs of the infant should always be given due priority.

1.5.6 PMHS should work in collaboration with other specialist services, where they exist, for women with distinctive needs such as those who are care-experienced, neurodivergent or learning disabled or who have specific conditions requiring specialist input, such as eating disorders. Those under 18 may require a particular developmental approach which could be enhanced by the involvement of CAMHS clinicians. PMHS would not routinely provide care for women with a primary substance use disorder unless there is significant comorbidity. In response to the Supporting Women, Reducing Harm report (2021), best practice guidelines are being prepared by the Scottish Government.

1.5.7 Community Perinatal Mental Health Teams (CPMHTs) are multidisciplinary teams which provide:

i. Prevention, detection, care and treatment of new or pre-existing moderate to severe mental illness occurring in women during pregnancy or the first postnatal year

ii. Preconception advice for women at high risk of severe postpartum mental illness

iii. Assessment and facilitation of the mother-infant relationship and promotion of infant development in the context of maternal mental illness

iv. Mental health liaison to maternity services in relation to the acute presentation of mental illness, or where there is an identified care plan /risk. This is distinct from the psychological assessment and interventions provided by maternity and neonatal psychological interventions (MNPI) teams to mothers and fathers in the perinatal period.

1.5.8 CPMHTs have a responsibility to work collaboratively to ensure that all women and infants who require it have access to specialist advice and care. This may be achieved through regional working. This also applies to pathways to inpatient care.

1.5.9 MBUs are staffed by multidisciplinary teams which provide:

i. Assessment, care and treatment of severe mental illness occurring in women during pregnancy or the first postnatal year

ii. Assessment and facilitation of the mother-infant relationship and promotion of infant development in the context of maternal mental illness

1.5.10 Where women require inpatient care, they should be admitted with their infants, only if satisfied that doing so would be beneficial to the wellbeing of the child, to facilities that can ensure the baby is safely cared for, avoiding disruption to the developing mother-infant relationship. This is a legal requirement in Scotland (Mental Health (Scotland) Act, 2015). Clear protocols should be in place, in collaboration with social work, detailing issues around parental responsibility and duty of care by staff to the infant.

1.5.11 MBUs can admit women with moderate to severe mental illness from 32 weeks of pregnancy, or earlier in pregnancy if clinically indicated. They also admit women at risk of recurrence of serious mental illness in the early days after delivery.

1.5.12 MBU patients receive a comprehensive mental health assessment. This includes consideration of the patient’s mental health and medication, and their psychosocial and psychological needs including an activity of daily living assessment as soon as is practically possible. Patients should also have a comprehensive physical health review.

1.5.13 The health of the infant and the quality of care given by the mother should be assessed promptly. The assessment of the mother-infant relationship will take place over a longer period. The environment should conform to UNICEF Baby-Friendly recommendations (United Nations Children’s Fund UK, 2017).