The British Association for Counselling and Psychotherapy (BACP) welcomes the opportunity to contribute to this call for evidence to support the Committee’s inquiry into the first 1,000 Days of a child's life. We are the leading professional body for counselling and psychotherapy in the UK, with over 44,000 members, including over 1,800 members in Wales. Our practitioner-members are based in a range of settings, including the NHS and third sector, providing therapy to clients with a wide range of presenting issues. BACP recognises the critical role that counselling and psychotherapy can play in helping to manage the adverse effects of maternal mental illness - our evidence therefore focuses primarily on the role and impact of talking therapies.
BACP are proud supporters of the 1001 Critical Days campaign which aims to ensure that every baby should receive sensitive, appropriate and responsive care from their main caregivers in the first years of life. BACP is also pleased to be a member of the Maternal Mental Health Alliance(MMHA), a coalition of over 60 national professional and patient organisations committed to improving the mental health and wellbeing of women and their children in pregnancy and the first postnatal year. Analysis by MMHA and the London School of Economics, set out in detail below, demonstrates that the cost to the public sector of perinatal mental health problems is five times greater than the cost of providing the services that are needed to address them.
2) The Case for Government Intervention
Whilst traditionally much focus has been placed on Postnatal Depression, recent advances in neuroscience[1] have demonstrated that mental health problems occur during the antenatal period and that problems go beyond depression, to include anxiety, psychosis, post-traumatic stress disorder and other conditions.
The mental health of mothers has a significant impact on the emotional wellbeing and development of their child(ren) within the critical 1000 days period. Some 28 per cent of mothers with mental health problems admit to having trouble bonding with their child[2]. The report, Postnatal Depression and Emotion: The misfortune of mother-infant interactions, notes that ‘mothers suffering from depression find it difficult to respond to their babies’ needs and to communicate with them’[3]. Research suggests that this initial dysfunctioning of mother-baby relationships affects children’s development by impairing babies’ psychomotor and socio-emotional development[4].
As well as the direct impact on the child, it can have longer term adverse effects on the parents and wider family. The onset of a maternal mental health condition can precipitate relapse or recurrence of previous mental illness, has the potential to herald the onset of long-term mental health problems, and is associated with an increased risk of maternal suicide[5]. Postnatal depression has also been linked with depression in fathers and with high rates of family breakdown[6]. In addition, depression in mothers appears to increase the risk of poor birth and child outcomes. These include higher rates of spontaneous abortion, low birth weight babies, developmental delay, retarded physical growth, and physical illnesses such as chronic diarrhoeal illness. There is also evidence that children born to depressed mothers do less well educationally, experience higher levels of behavioural problems[7] and are more likely to develop psychological problems in later life[8].
It is estimated that mental health problems affect more than 1 in 10 women during pregnancy and the first year after childbirth, and can have a devastating impact on new mothers and their families[9]. The Welsh Government has estimated between one in 10 and one in 15 mothers experience postnatal depression and around one in 500 mothers can experience severe but treatable mental illness[10]. However, research by Mind Cymru has estimated that as many as one in three parents suffer from anxiety or depression in the first year of having a baby in Wales.
As well as the impact on the individual child, families and society, analysis by Centre for Mental Health and London School of Economics recently highlighted the real cost in budgetary terms of managing maternal mental health and its wider impact. Their analysis found that perinatal depression, anxiety and psychosis together carry a total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK. This is equivalent to a cost of just under £10,000 for every single birth in the country[11]. Their report concluded that whilst perinatal mental illnesses cost the NHS around £1.2 billion for each annual cohort of births, it would cost only an extra £280 million a year to bring the whole pathway of perinatal mental health care up to the level and standards recommended in national guidance and alleviate many of the challenges.
Evidence demonstrates that psychological therapies are an important intervention in helping to reduce the adverse effects of maternal mental health conditions and in reducing depressive symptoms in mothers[12]. Nice guidelines state that self-help strategies (guided self-help, computerised cognitive behavioural therapy or exercise), non-directive counselling delivered at home (listening visits) or brief cognitive behavioural therapy and interpersonal psychotherapy can be effective psychological interventions for postnatal depression[13]. We believe the evidence for publicly funded intervention of this nature is very strong.
3) Existing Government Support
Taking Wales Forward
BACP is supportive of the clear commitment that the Welsh Government has made to secure the mental health and wellbeing of all of its people, as signalled in the Well-being of Future Generations (Wales) Act 2015 and through the publication of Taking Wales Forward[14], which includes seven national wellbeing objectives which will shape Government intervention over the next six years. The first of these is an important commitment to “Create conditions to give every child the best start in life” which clearly commits Government to ensuring that all children reach key developmental milestones to ensure wider adult health and wellbeing.
Whilst we welcome this approach, BACP would like to have seen acknowledgment of the importance of good parental and perinatal mental health in securing this important ambition. As this programme is implemented we would like to see linkages made to appropriate interventions which support good perinatal mental health outcomes, ensuring that there is an integrated approach.
Together for Mental Health
BACP is supportive of The Welsh Government’s flagship Mental Health Action Plan - Together for Mental Health, and its identification of maternal and perinatal mental health as a critical area for Government intervention. Priority 5.1 seeks to provide better outcomes for women, their babies and families with, or at risk of, perinatal mental health problems and 5.2 seeks to ensure that Parents and carers are supported to promote resilience and positive attachment during infancy and early years.
We are supportive of the measures proposed within sections 5.1 to 5.2 of the action plan and the investment set aside by Welsh Government for local Health Boards to deliver the following interventions:
BACP is supportive of these objectives and the ambition to target provision at the most vulnerable to ensure they receive the support they need, to take a more collaborative approach, and to ensure that information is available and assessable. However, whilst we are supportive of the overall approach, the longer term question, which will only be answered by monitoring implementation, is whether these actions are effective and ambitious enough to get to the heart of the challenge.
Alongside the above recommendations, we are also conscious of the importance of continuity of care during this period. Where possible, we would like to see an assurance that pregnant mothers have access to the same health professionals throughout the duration of their pregnancy. When this is not possible, it must be assured that communication sharing is of the highest standard, and that maternity services, health visitors, social care, adult mental health services and Children’s centres should work closely together to share vital data, ensuring those who need additional support receive appropriate, timely and culturally sensitive help.[15]
The Healthy Child Wales Programme
The Healthy Child Wales programme is closely aligned to the Government’s well-being objective – “Create conditions to give every child the best start in life”[16] and aims to ensure that every child up to the age of seven receives consistent and universal health services in Wales. This is a collaborative service-led programme, which will help establish a universal health programme across each of the Health Boards underpinned by a consistent range of evidence-based early intervention measures such as screening and developmental checks. The programme will also provide advice and guidance to support parenting and healthy lifestyle choices. BACP is supportive of this approach and would like to explore whether this programme of advice also provides parents with information on mental health advice and support.
Tackling Adverse Childhood Experiences
There is significant international evidence, including evidence from Public Health Wales (PHW), to demonstrate that children who have experienced stressful and poor quality childhoods are much more likely to experience poor mental health and develop long term health problems as they move into adulthood[17]. This first Welsh Adverse Childhood Experiences (ACE) survey found that substantial proportions of the Welsh population suffered abuse, neglect and other ACEs during their childhood with 47% reporting having experienced at least one ACE and 14% experiencing four or more ACEs[18]. Research has also demonstrated the strong associations between exposure to ACEs and vulnerability to harms including substance use, unintended teenage pregnancy, violence, mental illness and physical health problems, which place the children of those affected by ACEs at increased risk of exposing their own children to these adverse experiences.
BACP supports the Welsh Government’s decision to provide funding of £400,000 in 2017-18 to help Cymru Well Wales establish a specialist hub committed to reducing the impact of Adverse Childhood Experiences. BACP believes that a key focus of the hub should be to ensure that vulnerable teenage mothers are supported to access the support they need throughout their pregnancy, particularly with mental health services, thereby reducing the likelihood of any negative impact on the mother, and hopefully also reducing the likelihood that the child themselves will be exposed to ACEs.
Provision for neonatal support and specialist care
Premature and sick babies are currently cared for in 11 neonatal units across Wales. These are co-ordinated by the Wales Neonatal Network, which advises Health Boards and works with units and neonatal transport services to ensure that babies receive the care they need, as close to home as possible. Research from Bliss shows that only five out of 11 neonatal units in Wales are able to offer parents access to psychological support, and none of the three neonatal intensive care units had dedicated trained mental health support available to parents without delay.[19] BACP would like the committee to explore whether this shortfall in provision is addressed by community perinatal services.
Evidence demonstrates that women with serious perinatal mental health problems have better outcomes and better relationships with their babies if they are cared for in Mother and Baby Units[20]. However, members will be aware of the adverse national publicity surrounding the closure, in November 2013, of the Wales’s only dedicated Mother and Baby Unit, at the Cardiff University Hospital. Parents now face traveling to either Bristol or Birmingham to secure this support and are then not guaranteed to be seen. BACP would welcome the committee exploring the impact of the closure further with Welsh Government.
4) Proposed Areas of Further Examination
As many of the interventions to improve perinatal mental health are either newly established, or yet to fully bed in, it is difficult to fairly and accurately assess how effective they have been in addressing the significant challenge. We would therefore welcome the Committee consider the following areas of further questioning as part of their inquiry:
[1] BPS Journal Vol 28, What has neuroscience ever done for us?, Roiser, J, April 2015
[2] Boots Family Trust (2013) Perinatal Mental Health: Experiences of Women & Health Professionals
[3] Gil, S. Drot-Volet, Lavel, V. and Teissedre, F. (2012) Depression and Emotion: The Misfortune of Mother-Infant Interactions. Taken from Glavin, K (2012) Perinatal Depression. Croatia: InTech
[4] Glavin, K. Smith, L. Sorum, R. and Ellefsen, B. (2010) Redesigned Community Postpartum Care to Prevent and Treat Postpartum Depression in Women – a one-year follow up study. Journal of Clinical Nursing, Vol 19 (21-22): pp 3051-62
[5] Oates M. Suicide: the leading cause of maternal death. British Journal of Psychiatry 2003; 183: 279-281
[6] Ballard CG, Davis R, Cullen PC, Mohan RN, Dean C. Prevalence of postnatal psychiatric morbidity in mothers and fathers. British Journal of Psychiatry 1994; 164: 782-788
[7] Weissman M, Feder A, Pilowsky D, Olfson M, Fuentes M, Blanco C, Lantigua R, Gameroff M, Shea S. Journal of Affective Disorders 2004; 78: 93-100(8)
[8] Lees M. Gender, ethnicity and vulnerability in young women in local authority care. British Journal of Social Work 2002; 32: 907-922
[9] O’hara, M. W., & Swain, A. M. (1996). Rates and risk of postpartum depression—a meta-analysis.
International review of psychiatry, 8(1), 37-54.
[10] Speech by Health and Social Services Minister Mark Drakeford following announcement of new perinatal mental health services – 16 March 2016
[11] LSE and Centre for Mental Health, 2014, The costs of perinatal mental health problems
[12] Glavin, K. (2012) Screening and Prevention of Postnatal Depression. Perinatal Depression. Croatia: InTech
[13] NICE (2007) Antenatal and Postnatal Mental Health: Clinical management and service guidance.
[14] Welsh Government, Taking Wales Forward, November 2016
[15] The 1001 Critical Days – A cross Party Manifesto (2013)
[16] Welsh Government, Taking Wales Forward 2016-21, November 2016
[17] Welsh Adverse Childhood Experiences (ACE) Study, January 2016
[18] Public Health Wales and Liverpool John Moores University, 2015
[19] Bliss baby report 2016: time for change, Wales, 2016
[20] Hogg, S. (2013). Prevention in mind All Babies Count: Spotlight on Perinatal Mental Health.
Retrieved from https://www.nspcc.org.uk/globalassets/documents/research-reports/allbabies-
count-spotlight-perinatal-mental-health.