Review on perinatal and infant mental health care models and pathways (third-party funded)

Research area: Prevention and screening

Project team: Inanna Reinsperger (first author, AIHTA), Jean Paul (second author, MUI)
Duration: April 2022 – November 2022
Language: English with German summary

This review is part of the project ‘Co-designing perinatal mental health support in
Tyrol’ in which the AIHTA is a partner (host: Medical University Innsbruck)

Publication: HTA Project Report No. 148: https://eprints.aihta.at/1420/

Background: Mental illness is a common and significant complication of pregnancy and the postpartum period: approximately 20% of women and 10% of men are affected from perinatal mental health problems (such as depression, anxiety disorders or postpartum psychosis) during pregnancy and the first year of life of the child [1, 2]. Perinatal mental illness contributes significantly to maternal mortality and adverse neonatal, infant, and child outcomes [3]. Therefore, perinatal mental health has become a focus of interest in recent years [3], and has become even more important with the COVID-19 pandemic and the associated consequences for families [4].

Perinatal mental health services include the prevention, detection and management of perinatal mental health problems, including both new onset problems, recurrences of previous problems, as well as mental health problems already existing before conception [5]. As the promotion of emotional and physical wellbeing and development of the infant is a crucial part of perinatal mental health services, an integrated approach to perinatal and infant mental health (PIMH) services is required, including not only treatment of the parental mental illness, but also addressing, e.g., parent-child relational stress, disrupted parenting behaviours or lack of parenting confidence, as well as viewing the infant as a person with their needs and personality, and working with the parent-child dyad [6]. Other relevant health professionals (e.g. midwives, paediatricians) should also be considered in PIMH care, as they may, for example, be consulted by parents for infant symptoms (e.g. excessive crying, feeding problems) which could be related to the parents' mental health (bidirectional nature of mental health). A range of professionals, organisations, and informal carers may be involved in the delivery of care during the perinatal period. This requires, e.g., coordination, collaboration and integrated care models, clearly defined referral pathways and responsibilities, well trained health-care professionals, and continuity of care [7, 8].

In Tyrol, there are a number of services which provide support for families during the perinatal period (e.g., Frühe Hilfen). Additionally, a nation-wide screening programme exists in Austria (Mutter-Kind-Pass) covering the period of pregnancy until the child’s age of 5 years. Routine universal screening or assessment for perinatal mental health problems is not yet included, although it is recommended by several evidence-based guidelines [9]. Available services are usually uncoordinated and may result in not recognising mental health care needs in affected families or in inappropriate care. Several countries, such as the UK and Australia, have recently been increasing their efforts in perinatal mental health care, e.g., by developing new service delivery models, strengthening care structures or allocating more resources to improve the situation for affected families [3, 10].

Aim of the review: The review aims to give an overview of international care models and pathways for Perinatal and Infant Mental Health (PIMH) from selected countries and to analyse and describe their characteristics as well as requirements for delivery of services.

The review will be conducted as part of the FWF-funded research project “Co-designing perinatal mental health support in Tyrol”, aiming to inform the co-development and implementation of a perinatal mental health intervention in Tyrol.

Research questions: The following research questions (RQ) will be addressed in this review:

• RQ1: Which PIMH care models and pathways have been recommended in selected Western high-income countries? Which recommendations can be identified in evidence-informed guidelines regarding integrated PIMH care?  
• RQ2: What are the characteristics of the identified models and pathways in terms of, e.g., populations addressed, professional groups involved, “components”/different services, coordination of services, health and social care responsibilities, etc.?
• RQ3: Which recommendations for successful service delivery and information on requirements for service delivery can be derived from the identified care models and pathways?

Methods: The research questions will be answered using the following methods:

RQ1: identification of international PIMH care models and pathways and guideline recommendations

• comprehensive hand search in databases and on websites of relevant institutions (such as ministries of health, public health institutes, perinatal care providers) for relevant reports, policy documents, articles on PIMH care models and pathways
• comprehensive hand search in guideline databases (Guidelines International Network, TRIP database) and on websites from relevant guideline developing institutions for evidence-based guidelines on PIMH care
• additionally, contact of experts to identify relevant documents
• quality assessment of the identified guidelines (using the AGREE II instrument) and of the documents/reports on care models (using pre-defined criteria, e.g., evidence base of the models; transparent description of the development of the models)
• tabular presentation and description of identified PIMH care models and pathways

RQ2: characteristics of the identified PIMH care models

• inductive identification of categories describing the characteristics of identified PIMH care models and pathways, e.g., target populations, health care professionals, “components”/different services, …
• data extraction for each category in a narrative form
• tabular presentation, qualitative content analysis of each category and narrative synthesis

RQ3: requirements for service delivery of the identified PIMH care models

• data extraction of the available information on requirements for service delivery of the identified PIMH care models and pathways
• tabular presentation, qualitative content analysis and narrative synthesis

Inclusion criteria for relevant care models:

Population	Parents with a mental health problem during pregnancy and in the first year after birth and their infants
Intervention	Perinatal and infant mental health care models and care pathways
‘extracted’ categories	Characteristics of care models: e.g., populations addressed professionals involved health and social care responsibilities coordination “components” of the care models  …  Requirements for delivery of PIMH care models: e.g., legal framework conditions, resources facilitators and barriers involvement of stakeholders  …
Study Design	All types of studies: e.g., policy documents, reports, evidence-based guidelines, (systematic) reviews, …
Setting	Countries of the Global North
Languages	English, German
Search period	until May 2022

Timetable:

April – May 2022	scoping, study protocol
May – June 2022	comprehensive hand search for models/pathways hand search for guidelines contact of experts selection of PIMH care models and pathways
July 2022	quality assessment data extraction and synthesis
August - September 2022	drafting the report
October - November 2022	internal and external review finalisation of the report layout and publication of the report

References:

[1]         Darwin Z., Domoney J., Iles J., Bristow F., Siew J. and Sethna V. Assessing the Mental Health of Fathers, Other Co-parents, and Partners in the Perinatal Period: Mixed Methods Evidence Synthesis. Front Psychiatry. 2020;11:585479. Epub 2021/01/30. DOI: 10.3389/fpsyt.2020.585479.

[2]         O'Hara M. W. and Wisner K. L. Perinatal mental illness: definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):3-12. Epub 2013/10/22. DOI: 10.1016/j.bpobgyn.2013.09.002.

[3]         Howard L. M. and Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313-327. Epub 2020/09/16. DOI: 10.1002/wps.20769.

[4]         Papworth R., Harris A., Durcan G., Wilton J. and Sinclair C. Maternal mental health during a pandemic. A rapid evidence review of Covid-19's impact. London, Centre for Maternal Health: 2021 [cited 27/04/2022]. Available from: https://maternalmentalhealthalliance.org/wp-content/uploads/CentreforMH_MaternalMHPandemic_FullReport.pdf.

[5]         Joint Commissioning Panel for Mental Health. Guidance for commissioners of perinatal mental health services. 2012 [cited 25/04/2022]. Available from: https://mentalhealthpartnerships.com/wp-content/uploads/sites/3/jcpmh-perinatal-guide.pdf.

[6]         Lim I., Newman-Morris V., Hill R., Hoehn E., Kowalenko N., Matacz R., et al. You can't have one without the other: The case for integrated perinatal and infant mental health services. Aust N Z J Psychiatry. 2022:48674221083874. Epub 2022/03/09. DOI: 10.1177/00048674221083874.

[7]         Webb R., Uddin N., Ford E., Easter A., Shakespeare J., Roberts N., et al. Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review. Lancet Psychiatry. 2021;8(6):521-534. Epub 2021/04/11. DOI: 10.1016/S2215-0366(20)30467-3.

[8]         Royal College of Psychiatrists. Perinatal mental health services: Recommendations for the provision of services for childbearing women. 2021 [cited 27/04/2022]. Available from: https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/college-reports/2021-college-reports/perinatal-mental-health-services-CR232.

[9]         Reinsperger I. Parent-Child-Pass Update 2020/21 – Screenings for mental health, nutrition and social competence. AIHTA Policy Brief 005. Vienna: 2021. Available from: https://eprints.aihta.at/1303/.

[10]       Royal Australian and New Zealand College of Psychiatrists. Perinatal mental health services. Position statement 57. 2021 [cited 27/04/2022]. Available from: https://www.ranzcp.org/news-policy/policy-and-advocacy/position-statements/perinatal-mental-health-services.