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Antenatal and postnatal mental health

About

What is covered

In pregnancy and the postnatal period, many mental health problems have a similar nature, course and potential for relapse as at other times. However, there can be differences; for example, bipolar disorder shows an increased rate of relapse and first presentation in the postnatal period. Some changes in mental health state and functioning (such as appetite) may represent normal pregnancy changes, but they may be a symptom of a mental health problem.
The management of mental health problems during pregnancy and the postnatal period differs from at other times because of the nature of this life stage and the potential impact of any difficulties and treatments on the woman and the baby. There are risks associated with taking psychotropic medication in pregnancy and during breastfeeding and risks of stopping medication taken for an existing mental health problem. There is also an increased risk of postpartum psychosis.
Depression and anxiety are the most common mental health problems during pregnancy, with around 12% of women experiencing depression and 13% experiencing anxiety at some point; many women will experience both. Depression and anxiety also affect 15–20% of women in the first year after childbirth. During pregnancy and the postnatal period, anxiety disorders, including panic disorder, generalised anxiety disorder, obsessive–compulsive disorder, post-traumatic stress disorder and tokophobia (an extreme fear of childbirth), can occur on their own or can coexist with depression. Psychosis can re-emerge or be exacerbated during pregnancy and the postnatal period. Postpartum psychosis affects between 1 and 2 in 1000 women who have given birth. Women with bipolar I disorder are at particular risk, but postpartum psychosis can occur in women with no previous psychiatric history.
Changes to body shape, including weight gain, in pregnancy and after childbirth may be a concern for women with an eating disorder. Although the prevalence of anorexia nervosa and bulimia nervosa is lower in pregnant women, the prevalence of binge eating disorder is higher. Smoking and the use of illicit drugs and alcohol in pregnancy are common, and prematurity, intrauterine growth restriction and fetal compromise are more common in women who use these substances, particularly women who smoke.
This pathway makes recommendations for the recognition, assessment, care and treatment of mental health problems in women during pregnancy and the postnatal period (up to 1 year after childbirth) and in women who are planning a pregnancy. The pathway covers depression, anxiety disorders, eating disorders, drug and alcohol-use disorders and severe mental illness (such as psychosis, bipolar disorder, schizophrenia and severe depression). It covers subthreshold symptoms as well as mild, moderate and severe mental health problems. However, the pathway focuses on aspects of expression, risks and management that are of special relevance in pregnancy and the postnatal period.
In this pathway, 'baby' refers to an infant aged between 0 and 12 months, and 'woman' to a female of childbearing potential, including girls and young women under 18 years.

Updates

Updates to this pathway

17 February 2016 Antenatal and postnatal mental health (NICE quality standard 115) added to this pathway.
4 June 2015 Postnatal care quality standard updated.
29 May 2015 Minor maintenance updates.
18 May 2015 Minor maintenance updates.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
26 February 2015 Link to NICE pathway on safe midwifery staffing for maternity settings added.
16 December 2014 Major update on publication of antenatal and postnatal mental health (NICE guideline CG192).

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Antenatal and postnatal mental health

What is covered

In pregnancy and the postnatal period, many mental health problems have a similar nature, course and potential for relapse as at other times. However, there can be differences; for example, bipolar disorder shows an increased rate of relapse and first presentation in the postnatal period. Some changes in mental health state and functioning (such as appetite) may represent normal pregnancy changes, but they may be a symptom of a mental health problem.
The management of mental health problems during pregnancy and the postnatal period differs from at other times because of the nature of this life stage and the potential impact of any difficulties and treatments on the woman and the baby. There are risks associated with taking psychotropic medication in pregnancy and during breastfeeding and risks of stopping medication taken for an existing mental health problem. There is also an increased risk of postpartum psychosis.
Depression and anxiety are the most common mental health problems during pregnancy, with around 12% of women experiencing depression and 13% experiencing anxiety at some point; many women will experience both. Depression and anxiety also affect 15–20% of women in the first year after childbirth. During pregnancy and the postnatal period, anxiety disorders, including panic disorder, generalised anxiety disorder, obsessive–compulsive disorder, post-traumatic stress disorder and tokophobia (an extreme fear of childbirth), can occur on their own or can coexist with depression. Psychosis can re-emerge or be exacerbated during pregnancy and the postnatal period. Postpartum psychosis affects between 1 and 2 in 1000 women who have given birth. Women with bipolar I disorder are at particular risk, but postpartum psychosis can occur in women with no previous psychiatric history.
Changes to body shape, including weight gain, in pregnancy and after childbirth may be a concern for women with an eating disorder. Although the prevalence of anorexia nervosa and bulimia nervosa is lower in pregnant women, the prevalence of binge eating disorder is higher. Smoking and the use of illicit drugs and alcohol in pregnancy are common, and prematurity, intrauterine growth restriction and fetal compromise are more common in women who use these substances, particularly women who smoke.
This pathway makes recommendations for the recognition, assessment, care and treatment of mental health problems in women during pregnancy and the postnatal period (up to 1 year after childbirth) and in women who are planning a pregnancy. The pathway covers depression, anxiety disorders, eating disorders, drug and alcohol-use disorders and severe mental illness (such as psychosis, bipolar disorder, schizophrenia and severe depression). It covers subthreshold symptoms as well as mild, moderate and severe mental health problems. However, the pathway focuses on aspects of expression, risks and management that are of special relevance in pregnancy and the postnatal period.
In this pathway, 'baby' refers to an infant aged between 0 and 12 months, and 'woman' to a female of childbearing potential, including girls and young women under 18 years.

Updates

Updates to this pathway

17 February 2016 Antenatal and postnatal mental health (NICE quality standard 115) added to this pathway.
4 June 2015 Postnatal care quality standard updated.
29 May 2015 Minor maintenance updates.
18 May 2015 Minor maintenance updates.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
26 February 2015 Link to NICE pathway on safe midwifery staffing for maternity settings added.
16 December 2014 Major update on publication of antenatal and postnatal mental health (NICE guideline CG192).

Sources

NICE guidance and other sources used to create this pathway.
Antenatal and postnatal mental health (2014) NICE guideline CG192
Guidance on the use of electroconvulsive therapy (2003) NICE technology appraisal guidance 59
Antenatal and postnatal mental health (2016) NICE quality standard 115
Postnatal care (2013) NICE quality standard 37

Quality standards

Antenatal and postnatal mental health

These quality statements are taken from the antenatal and postnatal mental health quality standard. The quality standard defines clinical best practice for antenatal and postnatal mental health and should be read in full.

Quality statements

Continuity of care

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

The woman and baby's individualised postnatal care plan is reviewed and documented at each postnatal contact.

Rationale

Postnatal care should be a continuation of the care the woman received during her pregnancy, labour and birth. Planning and regularly reviewing the content and timing of care, for individual women and their babies, and communicating this (to the woman, her family and other relevant postnatal care team members) through a documented care plan can improve continuity of care.

Quality measures

Structure
Evidence of local arrangements to ensure that the woman and her baby's individualised postnatal care plan is reviewed and documented at each postnatal contact.
Data source: Local data collection.
Process
The proportion of women and their babies who have an individualised and documented postnatal care plan, which is reviewed at each postnatal contact.
Numerator – the number of contacts in which the woman and baby's individualised postnatal care plan is reviewed and documented.
Denominator – the number of postnatal contacts.
Data source: The Maternity Services Secondary Uses Data Set, once implemented, will collect data on the date on which the care plan was created or changed. This covers antenatal, birth and postnatal care plans (global numbers 17201890 and 17201900).
Outcome
Women's satisfaction with the continuity and content of their postnatal care.
Data source: Local data collection. The Care Quality Commission Maternity Services Survey 2010 collected information about women's experiences of maternity care.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place to provide women and their babies with an individualised postnatal care plan, which is reviewed and documented at each postnatal contact.
Healthcare practitioners provide women and their babies with an individualised postnatal care plan, which is reviewed and documented at each postnatal contact.
Commissioners ensure that they commission services in which women are provided with an individualised postnatal care plan, which is reviewed and documented at each postnatal contact.

What the quality statement means for patients, service users and carers

Women and their babies have an individualised postnatal care plan, which is reviewed and documented at each postnatal contact.

Source guidance

  • Postnatal care (2014) NICE guideline CG37, recommendation 1.1.3 (key priority for implementation)

Definitions of terms used in this quality statement

Postnatal care plan
The individualised postnatal care plan should be documented and developed with the woman, ideally in the antenatal period or as soon as possible after birth. The plan should be comprehensive and include as a minimum:
  • relevant factors from the antenatal, intrapartum and immediate postnatal period
  • details of a named midwife or health visitor, including a 24 hour telephone number to enable the woman to contact her named healthcare practitioner or an alternative practitioner should he or she not be available
  • details of the healthcare practitioners involved in her care and that of her baby, including roles and contact details
  • plans for the postnatal period including:
    • specific plans for managing pregnancy-related conditions when they occur, such as gestational hypertension, pre-eclampsia, thromboembolism, gestational diabetes, postnatal wound care and mental health conditions
    • details about adjustment to motherhood, emotional wellbeing and family support structures
    • plans for feeding, including specific advice about either breastfeeding support or formula feeding
    • plans for contraceptive care.
(Definition adapted with expert group consensus from NICE guideline CG37, recommendation 1.1.3.)
Postnatal contact
Women and their babies should receive the number of postnatal contacts appropriate to their care needs. A postnatal contact is a scheduled postnatal appointment which may occur in the woman or baby's home or another setting such as a GP practice or children's centre. Where a woman remains in hospital following delivery, her postnatal care plan should be reviewed on a daily basis until her transfer home and then reviewed at each subsequent contact.

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. The individualised postnatal care plan and the information within it should be accessible to women, including women who do not speak or read English and those with additional needs such as physical, sensory or learning disabilities.

Maternal health – life-threatening conditions

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women are advised, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten their lives and require them to access emergency treatment.

Rationale

Women are at increased risk of experiencing serious health events in the immediate hours, days and weeks following the birth, some of which could lead to maternal death or severe morbidity. Providing women with information about the symptoms and signs that may indicate a serious physical illness or mental health condition may prompt them to access immediate emergency treatment if needed. Emergency treatment could potentially avoid unnecessary deaths and severe morbidity.

Quality measures

Structure
Evidence of local arrangements to ensure that women are advised, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten her life and require her to access emergency treatment.
Data source: Local data collection.
Process
The proportion of women who are advised, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten her life and require her to access emergency treatment.
Numerator – the number of women in the denominator who are advised, within the first 24 hours, after birth of the symptoms and signs of conditions that may threaten her life and require her to access emergency treatment.
Denominator – the number of women who have given birth.
Data source: Local data collection.
Outcome
a) Incidence of potentially avoidable maternal morbidity and mortality.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on maternal deaths (global number 17207470). The Confidential Enquiries into Maternal Deaths (now undertaken by MBRRACE-UK) reports on rates of maternal death. MBRRACE are expanding their work programme to include severe maternal morbidity.
b) Women feel informed about symptoms and signs of postnatal life-threatening conditions.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for women to be advised, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten their lives and require them to access emergency treatment.
Healthcare practitioners advise women, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten their lives and require them to access emergency treatment.
Commissioners ensure that they commission services that advise women, within 24 hours of the birth, of conditions that may threaten their lives and require them to access emergency treatment.

What the quality statement means for patients, service users and carers

Women are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions that should prompt her to call for emergency treatment.

Source guidance

Definitions of terms used in this quality statement

Expert group opinion is that the first postnatal contact should occur within 24 hours after the birth.
Information provision
The woman should receive accurate, evidence-based verbal and written information. If the woman is too unwell to receive this information within the first 24 hours after the birth, the information should be discussed once the woman has made a recovery and is able to identify symptoms and signs of life-threatening conditions in herself. All women should also be provided with a contact number that can be used at any time of the day or night to seek urgent maternity advice (for example, the labour ward triage number).
Symptoms and signs of life-threatening physical conditions
The following symptoms and signs are suggestive of potentially life-threatening physical conditions in the woman:
  • sudden and profuse blood loss or persistent, increased blood loss
  • faintness, dizziness or palpitations or tachycardia
  • fever, shivering, abdominal pain, especially if combined with offensive vaginal loss or a slow-healing perineal wound
  • headaches accompanied by visual disturbances or nausea or vomiting within 72 hours of birth
  • leg pain, associated with redness or swelling
  • shortness of breath or chest pain
  • widespread rash.
(Definition adapted with expert group consensus from NICE guideline CG37, recommendation 1.2.1, table 2.)
Symptoms and signs of life-threatening mental health conditions
The following symptoms and signs are suggestive of potentially life-threatening mental health conditions in the woman:
  • severe depression, such as feeling extreme unnecessary worry, being unable to concentrate due to distraction from depressive feelings
  • severe anxiety, such as uncontrollable feeling of panic, being unable to cope or becoming obsessive
  • the desire to hurt others or yourself, including thoughts about taking your own life
  • confused and disturbed thoughts, which could include other people telling you that you are imagining things (hallucinations and delusions).
(Definition adapted with expert group consensus from RCOG's Good practice point 14, section 5.)

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English. Written and verbal information should be appropriate for the woman's level of literacy, culture and language.

Infant health – life-threatening conditions

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women or main carers of babies are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.

Rationale

Babies may experience serious health conditions in the immediate hours, days and weeks following the birth, which can lead to severe illness or in rare cases, death. Providing the mother or main carer with verbal and written information about the symptoms and signs that might indicate their baby has a serious health problem may result in emergency treatment being sought more promptly. This information should be provided within 24 hours of the birth.

Quality measures

Structure
Evidence of local arrangements to ensure that the women or main carers of babies are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.
Data source: Local data collection.
Process
The proportion of women or main carers of the baby who are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.
Numerator – the number of women or main carers of babies who are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.
Denominator – the number of mothers or main carers of babies.
Data source: Local data collection.
Outcome
a) Incidence of potentially avoidable infant morbidity and mortality.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on neonatal deaths (global number 17209680). The Confidential Enquiries into Perinatal Deaths (now undertaken by MBRRACE-UK) reports on rates of perinatal death. MBRRACE are expanding their work programme to include severe infant morbidity.
b) Women and main carers feel informed about symptoms and signs of potentially life-threatening conditions in the baby.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for women or main carers of babies to be advised, within 24 hours of the birth, of the symptoms and signs of potentially life threatening conditions in the baby that require emergency treatment.
Healthcare practitioners advise women or main carers of babies, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.
Commissioners ensure that they commission services that advise women or main carers of babies, within 24 hours of the birth, of the symptoms and signs of potentially life threatening conditions in the baby that require emergency treatment.

What the quality statement means for patients, service users and carers

Women or the main carer of the baby are advised, within 24 hours of the birth, of the symptoms and signs of potentially life threatening conditions in the baby that require emergency treatment.

Source guidance

  • Postnatal care (2014) NICE guideline CG37, recommendations 1.4.2 (key priority for implementation), 1.4.17 and 1.4.31 and expert group consensus

Definitions of terms used in this quality statement

Expert group opinion is that the first postnatal contact should occur within 24 hours after the birth.
Information provision
The woman or main carer of the baby should receive accurate, evidence-based verbal and written information. If the baby is unwell and in hospital, the information should be provided to the mother or main carer prior to the baby's discharge.
The woman or main carer of the baby should also be provided with a contact number that can be used at any time of the day or night to seek urgent advice (for example, the labour ward triage number). The woman or main carer of the baby should be advised to contact the emergency services if they are very concerned about their baby's health.
Symptoms and signs of life-threatening conditions in the baby (0–3 months)
The following symptoms and signs are suggestive of potentially life-threatening physical conditions in the baby (0–3 months):
A major change in the baby's behaviour, for example:
  • less active than usual
  • less responsive than usual
  • more irritable than usual
  • breathing faster than usual or grunting when breathing
  • feeding less than usual
  • nappies much less wet than usual
  • has blue lips
  • is floppy
  • has a fit
  • has a rash that does not fade when pressed with a glass
  • vomits green fluid
  • has blood in their stools
  • has a bulging or very depressed fontanelle
  • has a temperature higher than 38°C
  • with the exception of hands and feet, feels cold when dressed appropriately for the environment temperature
  • within the first 24 hours after the birth:
    • has not passed urine
    • has not passed faeces (meconium)
    • develops a yellow skin colour (jaundice).
(Adapted with expert group consensus from information provided in the Department of Health's Birth to Five book [no longer in print but available for download], NICE guideline CG149 and NICE guideline CG160.)
Main carer
For the majority of babies the main carer will be the mother. For some babies the main carer could be a close relative, for example the baby's father or grandparent, or for looked-after babies this could be a foster parent.

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English.

Infant health – safer infant sleeping

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women, their partner or the main carer are given information on the association between co-sleeping and sudden infant death syndrome (SIDS) at each postnatal contact.

Rationale

Although the cause of SIDS is unknown, there are specific behaviours that may make SIDS more likely. There is some evidence that where co-sleeping occurs there may be an increase in the number of cases of SIDS. Giving information to women, their partner or the main carer about this association will support them to establish safer infant sleeping habits, and may reduce the likelihood of SIDS.

Quality measures

Structure
Evidence of local arrangements to ensure that women, their partner or the main carer are given information on the association between co-sleeping and SIDS at each postnatal contact.
Data source: Local data collection.
Process
a) Proportion of women, their partners or main carers of newborn babies who are given information on the association between co-sleeping and SIDS within 24 hours of the birth.
Numerator – the number of women, their partners or main carers of newborn babies who are given information on the association between co-sleeping and SIDS within 24 hours of the birth.
Denominator – the number of newborn babies.
Data source: Local data collection.
b) Proportion of women, their partners or main carers of newborn babies who are given information on the association between co-sleeping and SIDS at every postnatal contact.
Numerator – the number of postnatal contacts in which women, their partners or main carers of newborn babies are given information on the association between co-sleeping and SIDS.
Denominator – the number of postnatal contacts.
Data source: Local data collection.
c) Proportion of women, their partners or main carers of newborn babies who are given information on the association between co-sleeping and SIDS at a postnatal contact 10–14 days after the birth (at the midwifery and health visitor handover when the woman and baby are discharged from the care of the community midwifery team to the care of the health visitor).
Numerator – the number of women, their partners or main carers of newborn babies who are given information on the association between co-sleeping and SIDS at a postnatal contact 10–14 days after the birth.
Denominator – the number of newborn babies.
Data source: Local data collection.
d) Proportion of women, their partners or main carers of newborn babies who are given information on the association between co-sleeping and SIDS at the 6–8 week postnatal check.
Numerator – the number of women, their partners or main carers of newborn babies who are given information on the association between co-sleeping and SIDS at the 6–8 week postnatal check.
Denominator – the number of newborn babies.
Data source: Local data collection.
Outcome
a) Incidence of SIDS.
Data source: Office for National Statistics report Unexplained deaths in infancy – England and Wales, 2010.
b) Women, their partners and the main carers of babies know about the association between co-sleeping and SIDS.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that information about the association between co-sleeping and SIDS is available, and that healthcare professionals are trained to understand and explain the information and to give it to women, their partners or the main carers of babies at every postnatal contact.
Healthcare practitioners ensure that they understand and can explain information about the association between co-sleeping and SIDS, and that they give this information to women, their partners or the main carers of babies at every postnatal contact.
Commissioners ensure that they commission services that provide information about the association between co-sleeping and SIDS, and that train healthcare professionals to understand and explain this information and give it to women, their partners or the main carers of babies at every postnatal contact.

What the quality statement means for patients, service users and carers

Women, their partner or the main carer of babies are given information at every postnatal contact about the link between sleeping with their baby (this is called co-sleeping and includes sleeping with them on a sofa or chair as well as in bed) and sudden infant death syndrome. Sudden infant death syndrome is the sudden, unexpected and unexplained death of a seemingly well baby. It is rare and no one knows what causes it. Some things, such as co-sleeping, may make sudden infant death syndrome more likely.

Source guidance

  • Postnatal care (2014) NICE guideline CG37, recommendations 1.4.45 and 1.4.47

Definitions of terms used in this quality statement

Co-sleeping
Parents or carers sleeping on a bed or sofa or chair with an infant. [NICE guideline CG37 recommendation 1.4.47]
Main carer
For the majority of babies the main carer will be the mother. For some babies the main carer could be a close relative, for example the baby’s father or grandparent, or for looked-after babies this could be a foster parent.
Postnatal contact
Women and their babies should receive the number of postnatal contacts appropriate to their care needs. A postnatal contact is a scheduled postnatal appointment that may occur in the woman or baby’s home, a GP practice or children’s centre, or a hospital setting if the woman or baby needs extended inpatient care. For the majority of women, babies and families the postnatal period ends 6–8 weeks after the birth.

Equality and diversity considerations

Communication and information-giving between women (and their families or the main carer) and members of the maternity team are key aspects of this statement. Relevant adjustments should be in place for people with communication difficulties, and those who do not speak or read English. Verbal and written information should be appropriate for the person’s level of literacy, culture, language and family circumstances. Co-sleeping can be intentional or a necessity, but all women, their partners or main carers of babies should be given information in a format they can understand, irrespective of their culture.

Breastfeeding

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women receive breastfeeding support from a service that uses an evaluated, structured programme.

Rationale

Breastfeeding contributes to the health of both the mother and child in the short and longer term. Women should be made aware of these benefits and those who choose to breastfeed should be supported by a service that is evidence-based and delivers an externally audited, structured programme. Delivery of breastfeeding support should be coordinated across the different sectors.

Quality measures

Structure
Evidence of local arrangements for breastfeeding support to be provided through a service that uses an evaluated, structured programme.
Data source: Local data collection.
Process
a) Proportion of women who receive breastfeeding support through a service that uses an evaluated, structured programme.
Numerator – the number of women in the denominator who receive breastfeeding support through a service that uses an evaluated, structured programme.
Denominator – the number of women who breastfeed (exclusively or partially).
Data source: Local data collection.
b) Proportion of women who wanted to continue breastfeeding but stopped before they had planned to.
Numerator – the number of women who wanted to continue breastfeeding but stopped before they had planned to.
Denominator – the number of women who breastfed (exclusively or partially).
Data source: Local data collection.
Outcome
a) Rates of breastfeeding initiation.
Data source: The Maternity Services Secondary Uses Data Set, once implemented, will collect data on 'baby first feed breast milk status' (global number 17205882), 'baby breast milk status (at discharge from hospital)' including exclusive and partial breast milk feeding (global number 17207550). The Infant Feeding Survey 2010 collected self-report data on the prevalence and duration of breastfeeding in the first 8–10 months after the baby was born.
b) Rates of exclusive or partial breastfeeding on discharge from hospital and at 5–7 days, 10–15 days, 6–8 weeks and 16 weeks after the birth.
Data source: The Maternity Services Secondary Uses Data Set, once implemented, will collect data on 'baby first feed breast milk status' (global number 17205882), 'baby breast milk status (at discharge from hospital)', including exclusive and partial breast milk feeding (global number 17207550). The Children and Young People's Health Services Secondary Uses Data Set, once implemented, will collect data on 'breastfeeding status' (global number 17101340), including 'Exclusively Breast Milk Feeding', 'Partially Breast Milk Feeding' and 'No Breast Milk Feeding at all', and also data on observation date (breastfeeding status) (global number 17104440). The Infant Feeding Survey 2010 collected self-report data on the prevalence and duration of breastfeeding in the first 8–10 months after the baby was born.
c) Women's satisfaction with breastfeeding support.
Data source: The Care Quality Commission Maternity Services Survey 2010 collected information about women's experiences of maternity care and this included a section on 'Feeding your baby'.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that women receive breastfeeding support through a service that uses an evaluated, structured programme.
Healthcare practitioners ensure that women receive breastfeeding support through an integrated service that uses an evaluated, structured programme.
Commissioners ensure that they commission a service that delivers breastfeeding support through an evaluated, structured programme.

What the quality statement means for patients, service users and carers

Women receive breastfeeding support through a service that uses an evaluated, structured programme.

Source guidance

  • Postnatal care (2014) NICE guideline CG37, recommendation 1.3.3 (key priority for implementation)
  • Maternal and child nutrition (2014) NICE guidline PH11, recommendations 1 (key priority for implementation) and 7 (key priority for implementation)

Definitions of terms used in this quality statement

Structured programme
NICE guideline CG37 recommends that all maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated, structured programme that encourages breastfeeding, using the Baby Friendly Initiative as a minimum standard. If providers implement a locally developed programme, this should be evidence-based, structured, and undergo external evaluation. The structured programme should be delivered and coordinated across all providers, including hospital, primary, community and children's centre settings. Breastfeeding outcomes should be monitored across all services.
Breastfeeding support
All people involved in delivering breastfeeding support should receive the appropriate training and undergo assessment of competencies for their role. This includes employed staff and volunteer workers in all sectors, for example, hospitals, community settings, children's centres and peer supporter services.

Equality and diversity considerations

Breastfeeding support should be culturally appropriate and accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English. Women should have access to an interpreter or advocate if needed. Special consideration will be needed if the mother and baby have been separated for any reason, for example if the baby has been admitted to neonatal care or the baby has been taken into care.

Formula feeding

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Information about bottle feeding is discussed with women or main carers of formula-fed babies.

Rationale

Babies who are fully or partially formula fed can develop infections and illnesses if their formula milk is not prepared safely. In a small number of babies these cause serious harm and are life threatening, and require the baby to be admitted to hospital. The mother or main carer of the baby needs consistent, evidence-based advice about how to sterilise feeding equipment and safely prepare formula milk.

Quality measures

Structure
Evidence of local arrangements to ensure that information about bottle feeding is discussed with women or main carers of formula-fed babies.
Data source: Local data collection.
Process
The proportion of women or main carers of formula-fed babies who have information about bottle feeding discussed with them.
Numerator – the number of women or main carers in the denominator who have information about bottle feeding discussed with them.
Denominator – the number of women or main carers of formula-fed babies.
Data source: Local data collection.
Outcome
a) Rates of hospital admissions for formula feeding-related conditions.
Data source: Local data collection.
b) Women's and main carers' knowledge of how to sterilise feeding equipment and safely prepare formula milk.
Data source: The Infant Feeding Survey 2010 collected self-report data on how mothers prepared powdered formula feed in the last 7 days, including whether they had followed all 3 recommendations for making up feeds (only making 1 feed at a time; making feeds within 30 minutes of the water boiling; and adding the water to the bottle before the powder).
c) Women's and main carers' satisfaction with feeding support.
Data source: The Care Quality Commission Maternity Services Survey 2010 collected information about women's experiences of maternity care and this included a section on 'Feeding your baby'.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that information about bottle feeding is discussed with women or main carers of formula-fed babies.
Healthcare practitioners discuss information about bottle feeding with women or main carers of formula-fed babies.
Commissioners ensure that they commission services in which information about bottle feeding is discussed with women or main carers of formula-fed babies.

What the quality statement means for patients, service users and carers

Women or main carers of formula-fed babies have the opportunity to discuss information about bottle feeding.

Source guidance

  • Postnatal care (2014) NICE guideline CG37, recommendations 1.3.42, 1.3.43 and 1.3.45

Definitions of terms used in this quality statement

Formula-fed baby
This statement relates to mothers and main carers who totally or partially formula feed their baby, and breastfeeding mothers who plan to formula feed their baby.
Information provision
The woman or main carer of the baby should receive accurate, evidence-based information that includes written information about formula feeding.
To ensure the mother or main carer has a good understanding of how to prepare formula feeds, it may be appropriate to give a demonstration as well as discussing bottle feeding.
Main carer
For the majority of babies the main carer will be the mother. For some babies the main carer could be a close relative, for example the baby's father or grandparent, or for looked-after babies this could be a foster parent.

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who don't speak or read English. Verbal and written information should be appropriate in terms of women's (and their families) level of literacy, culture, language and family circumstances.

Infant health – physical examination

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Babies have a complete 6–8 week physical examination.

Rationale

The purpose of the examination is to identify babies more likely to have conditions that would benefit from further investigation and management. This includes an overall physical examination as well as screening for eye problems, congenital heart defects, developmental dysplasia of the hip and undescended testicles. Most babies will be healthy, but the small number of babies who do have serious problems will benefit from prompt identification. Early treatment can improve the health of the baby and prevent or reduce disability.

Quality measures

Structure
a) Evidence of local arrangements to ensure that parents or main carers of babies are offered an appointment for the baby to attend for their 6–8 week physical examination before 10 weeks of age.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that a system is in place to monitor the competency of practitioners undertaking the 6–8 week physical examination.
Data source: Local data collection.
Process
Proportion of babies who have undergone a 6–8 week physical examination.
Numerator – the number of babies in the denominator who have undergone a 6–8 week physical examination.
Denominator – the number of babies aged 10 weeks.
Data source: Local data collection.
Outcomes
a) Incidence of physical abnormalities in babies.
Data source: Local data collection.
b) Health outcomes associated with early intervention for babies with physical abnormalities.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that babies are offered a complete 6–8 week physical examination.
Healthcare practitioners ensure that they perform a complete 6–8 week physical examination of babies and that they maintain the necessary competencies for this role.
Commissioners ensure that they commission services that offer a complete 6–8 week physical examination for babies, which is carried out in timely manner and by a competent practitioner.

What the quality statement means for patients, service users and carers

The mother or main carer of the baby is given the opportunity for their baby to have a complete 6–8 week physical examination, which is carried out in timely manner and by a competent practitioner.

Source guidance

  • Postnatal care (2014) NICE guideline CG37, recommendation 1.4.11 and 1.4.13

Definitions of terms used in this quality statement

NICE guideline CG37, recommendations 1.4.11 and 1.4.13, and the Newborn and Infant Physical Examination Standards and Competencies (March 2008) detail the components of the 6–8 week physical examination.
Note on measures
The National Screening Committee recommend that where possible, the baby's 6–8 week physical examination should be combined with the baby's first set of vaccinations to provide a 'one stop service'. However, as the baby's vaccinations should only exceptionally be scheduled before the age of 8 weeks, the 6–8 week examination is usually undertaken when the baby is at least 8 weeks of age. Therefore, for pragmatic reasons the examination should take place before 10 completed weeks of age, that is before 77 days.

Maternal health – weight management

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women with a body mass index (BMI) of 30 kg/m2 or more at the 6–8 week postnatal check are offered a referral for advice on healthy eating and physical activity.

Rationale

The woman's eating habits and physical activity levels could influence the health behaviour of the wider family, including children who are developing habits that may remain with them for life. Supporting the woman in the postnatal period to change her eating habits and physical activity levels may improve her health, her infant's health and the health of the wider family. It may also improve the outcomes of future pregnancies.
Women who are obese during pregnancy face increased risks of complications that include gestational diabetes, miscarriage, pre eclampsia, thromboembolism and maternal death. Risks for the infant include fetal death, stillbirth, shoulder dystocia, and macrosomia. Infants of obese women face health risks in childhood including diabetes and obesity in later life.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women have their BMI assessed and recorded at the 6–8 week postnatal check.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check are offered a referral for advice on healthy eating and physical activity.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that the local workforce has appropriate numbers of staff trained to deliver healthy eating and physical activity services to postnatal women.
Data source: Local data collection.
Process
a) The proportion of women who have their BMI recorded at the 6–8 week postnatal check.
Numerator – the number of women in the denominator who have their BMI recorded.
Denominator – the number of women who attend a 6–8 week postnatal check.
Data source: Local data collection.
b) The proportion of women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check who are offered a referral for advice on healthy eating and physical activity.
Numerator – the number of women in the denominator who are offered a referral for advice on healthy eating and physical activity.
Denominator – the number of women with a BMI of 30 kg/m2 or more who attend a 6–8 week postnatal check.
Data source: Local data collection.
c) The proportion of women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check who accept a referral for advice on healthy eating and physical activity.
Numerator – the number of women in the denominator who accept a referral for advice on healthy eating and physical activity.
Denominator – the number of women with a BMI of 30 kg/m2 or more who attend a 6–8 week postnatal check.
Data source: Local data collection.
Outcome
Women feel able to make informed decisions about healthy eating, physical activity and weight management for themselves and their family.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check to be offered a referral for advice on healthy eating and physical activity.
Healthcare practitioners offer women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check a referral for advice on healthy eating and physical activity.
Commissioners ensure that they commission services that offer women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check a referral for advice on healthy eating and physical activity.

What the quality statement means for patients, service users and carers

Women who have a body mass index of 30 kg/m2 or more at the 6–8 week postnatal check are offered a referral for advice on healthy eating and physical activity.

Source guidance

Definitions of terms used in this quality statement

Structured programme
Women should be offered a referral to an individual or group-based service that uses a structured programme. NICE guideline PH11 recommendation 6 states that services should deliver a structured programme that:
  • addresses the reasons why women may find it difficult to lose weight, particularly after pregnancy
  • is tailored to the needs of an individual or group
  • combines advice on healthy eating and physical exercise (advising them to take a brisk walk or other moderate exercise for at least 30 minutes on at least 5 days of the week)
  • identifies and addresses individual barriers to change
  • provides ongoing support over a sufficient period of time to allow for sustained lifestyle changes.
Services should be delivered by an appropriately trained person. This is someone who can demonstrate expertise and competencies in healthy eating and/or physical activity, including weight management for women in the postnatal period. This may include midwives, health visitors, obstetricians, dietitians, GPs, nurses, midwifery assistants, support workers and those working in weight management programmes (commercial or voluntary).
(Adapted with expert group consensus from NICE guideline PH27, recommendations 3 and 4).
Women who choose not to accept a referral should be given information about where they can get support on healthy eating and physical activity in future.

Equality and diversity considerations

Women should be able to access services that are appropriate to their cultural and religious beliefs, and that make relevant adjustments for anyone who has communication difficulties, and for those who don't speak or read English.

Emotional wellbeing and infant attachment

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women have their emotional wellbeing, including their emotional attachment to their baby, assessed at each postnatal contact.

Rationale

The baby's relationship with the mother (or main carer) has a significant impact on the baby's social and emotional development. In turn, the woman's ability to provide a nurturing relationship is partly dependent on her own emotional wellbeing. Regular assessment of the woman's emotional wellbeing and the impact of this on her attachment to her baby may lead to earlier detection of problems.

Quality measures

Structure
Evidence of local arrangements that women have their emotional wellbeing, including their emotional attachment to their baby, assessed at each postnatal contact.
Data source: Local data collection.
Process
a) Proportion of women whose emotional wellbeing, including emotional attachment to their baby, is assessed at each postnatal contact.
Numerator – the number of postnatal contacts in the denominator in which the mother's emotional wellbeing, including emotional attachment to the baby, is assessed.
Denominator – the number of postnatal care contacts.
Data source: Local data collection.
b) Proportion of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 5–7 days after the birth.
Numerator – the number of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 5–7 days after the birth.
Denominator – the number of women receiving a postnatal contact 5–7 days after the birth.
Data source: Local data collection.
c) Proportion of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 10–14 days after the birth (at the midwifery and health visitor handover when the woman and baby are discharged from the care of the community midwifery team to the care of the health visitor).
Numerator – the number of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 10–14 days after the birth.
Denominator – the number of women receiving a postnatal contact 10–14 days after the birth.
Data source: Local data collection.
d) Proportion of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 6–8 weeks after the birth.
Numerator – the number of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 6–8 weeks after the birth.
Denominator – the number of women receiving a postnatal contact 6–8 weeks after the birth.
Data source: Local data collection.
e) Proportion of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 16 weeks after the birth.
Numerator – the number of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 16 weeks after the birth.
Denominator – the number of women receiving a postnatal contact 16 weeks after the birth.
Data source: Local data collection.
Outcome
a) Incidence of postnatal mental health problems.
Data source: Local data collection.
b) Incidence of mother-to-baby emotional attachment problems.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that women are asked about their emotional wellbeing, including their mother-to-baby emotional attachment, assessed at each postnatal contact.
Healthcare practitioners ensure that women have their emotional wellbeing, including their mother-to-baby emotional attachment, assessed at each postnatal contact.
Commissioners ensure that they commission services that have local agreements to ensure women have their emotional wellbeing, including their mother-to-baby emotional attachment, assessed at each postnatal contact.

What the quality statement means for patients, service users and carers

Women have their emotional wellbeing, including their relationship with their baby (called 'emotional attachment'), assessed at each postnatal contact.

Source guidance

  • Postnatal care (2014) NICE clinical guideline 37, recommendations 1.2.22 [key priority for implementation] and 1.4.5

Definitions of terms used in this quality statement

Postnatal contacts
Women and their babies should receive the number of postnatal contacts that are appropriate to their care needs. A postnatal contact is a scheduled postnatal appointment that may occur in the woman or baby's home or another setting such as a GP practice, children's centre or this could be a hospital setting where women and/or the baby requires extended inpatient care.
Emotional wellbeing
NICE guideline PH40 defines emotional wellbeing as 'being happy and confident and not anxious or depressed'.
Mother-to-baby emotional attachment
This involves the formation of a secure bond between the mother and the baby, in which the mother responds sensitively and appropriately to the baby's signals, providing an environment in which the baby feels secure.

Equality and diversity considerations

Communication between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who don't speak or read English.

Maternal health – mental wellbeing

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women who have transient psychological symptoms ('baby blues') that have not resolved at 10–14 days after the birth should be assessed for mental health problems.

Rationale

Women experience emotional changes in the immediate postnatal period which usually resolve within 10–14 days after the birth. Women who are still feeling low in mood, anxious, experiencing negative thoughts or lacking interest in their baby at 10–14 days after the birth may be at increased risk of mental health problems. These women should receive an assessment of their mental wellbeing.

Quality measures

Structure
Evidence of local arrangements for women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth to have an assessment for mental health problems.
Data source: Local data collection.
Process
Proportion of women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth who are assessed for mental health problems.
Numerator – the number of women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth who are assessed for mental health problems.
Denominator – the number of women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth.
Data source: Local data collection.
Outcome
Incidence of postnatal mental health problems.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth to have an assessment for mental health problems.
Healthcare practitioners ensure that women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth are assessed for mental health problems.
Commissioners ensure that they commission services with local arrangements for women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth to have an assessment for mental health problems.

What the quality statement means for patients, service users and carers

Women in whom 'baby blues' have not resolved at 10–14 days after the birth are assessed for mental health problems.

Source guidance

  • Postnatal care (2014) NICE guideline CG37, recommendation 1.2.24 and 1.2.25

Definitions of terms used in this quality statement

Transient psychological symptoms (‘baby blues’)
NICE guideline CG37 recommendation 1.2.25 provides ‘tearfulness, feelings of anxiety and low mood’ as examples of the symptoms and signs of unresolved transient psychological symptoms.
Assessment for mental health problems
The NICE guideline on antenatal and postnatal mental health (CG192) provides evidence based advice on the assessment of mental health problems in women during the postnatal period.

Equality and diversity considerations

Communication between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who don’t speak or read English.

Parent–baby attachment

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Parents or main carers who have infant attachment problems receive services designed to improve their relationship with their baby.

Rationale

Problems with parent-to-baby attachment may result in the baby developing emotional, psychological or behavioural issues in childhood. Providing family-based interventions could improve attachment, thereby providing the building blocks for the child to develop healthy behaviours and mental wellbeing.

Quality measures

Structure
Evidence of local arrangements to ensure that parents or main carers with infant attachment problems receive services designed to improve their relationship with their baby.
Data source: Local data collection.
Process
Proportion of parents or main carers with infant attachment problems who receive services designed to improve their relationship with their baby.
Numerator – the number of parents or main carers with infant attachment problems who receive services designed to improve their relationship with their baby.
Denominator – the number of parents or main carers with infant attachment problems.
Data source: Local data collection.
Outcome
a) Emotional, behavioural and social wellbeing of developing babies.
Data source: Local data collection.
b) Parental or main carer satisfaction with services to support parenting skills.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that parents or main carers with infant attachment problems receive services designed to improve their relationship with their baby.
Healthcare practitioners offer parents or main carers with infant attachment problems services designed to improve their relationship with their baby.
Commissioners ensure that they commission services that have systems in place to offer parents or main carers with infant attachment problems services designed to improve their relationship with their baby.

What the quality statement means for patients, service users and carers

Parents or main carers who are having difficulties forming a bond with their child are able to receive services designed to improve their relationship with their baby.

Source guidance

Definitions of terms used in this quality statement

Services to improve parent-baby relationships
Services have the aim of promoting emotional attachment and improving parenting skills. Services should be tailored to the needs of the family and baby and may include the woman, partner and wider family. Services should be sensitive to a wide range of attitudes, expectations and approaches in relation to parenting. NICE guideline PH40 provides guidance about the types of services which may provide additional parenting support, for example a series of intensive home visits delivered by an appropriately trained nurse, baby massage and video interaction.
Main carer
For the majority of babies the main carer will be the mother. For some babies the main carer could be a close relative, for example the baby's father or grandparent, or for looked-after babies this could be a foster parent.

Equality and diversity considerations

In order to promote equality, the parents of babies who are vulnerable to poor parent-baby relationships may require additional intensive support. Services should take into account the parent's first language, and this may influence the interventions to achieve specified goals around the baby's communication, speech and language development.

Valproate

This quality statement is taken from the antenatal and postnatal mental health quality standard. The quality standard defines clinical best practice in antenatal and postnatal mental health and should be read in full.

Quality statement

Women of childbearing potential are not prescribed valproate to treat a mental health problem.

Rationale

Valproate is commonly used to treat epilepsy and some mental health problems. However, it can harm unborn babies when taken during pregnancy. Babies exposed to valproate in the womb are at a high risk of serious developmental disorders (approximately 30–40% of babies) and congenital malformations (approximately 10% of babies). In January 2015, the Medicines and Healthcare products Regulatory Agency issued a Drug safety update on Medicines related to valproate: risk of abnormal pregnancy outcomes. It included a strengthened warning stating that valproate should not be prescribed to female children, female adolescents or women of childbearing potential unless other treatments are ineffective or not tolerated. Valproate should therefore only be prescribed to treat mental health problems in women of childbearing potential in exceptional circumstances. If valproate is prescribed the woman must be informed of and understand the:
  • risks associated with valproate during pregnancy
  • need to use effective contraception
  • need for regular review of treatment
  • need to rapidly consult if she is planning a pregnancy or becomes pregnant.

Quality measures

Structure
Evidence of practice arrangements and written clinical protocols to ensure that women of childbearing potential are not prescribed valproate to treat a mental health problem.
Data source: Local data collection.
Process
Proportion of women of childbearing potential prescribed valproate to treat a mental health problem.
Numerator – the number in the denominator prescribed valproate to treat a mental health problem.
Denominator – the number of women who are of childbearing potential.
Data source: Local data collection.
Outcome
Children with serious developmental disorders or congenital malformations born to mothers who took valproate in pregnancy for treatment of a mental health problem.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care, community health services, general mental health services and specialist secondary care mental health services) have practice arrangements and written clinical protocols in place to ensure that women of childbearing potential are not prescribed valproate to treat a mental health problem.
Healthcare professionals (GPs and mental health professionals) do not prescribe valproate to women of childbearing potential to treat a mental health problem.
Commissioners of primary care and specialist and general mental health services (NHS England regional teams and clinical commissioning groups) specify within contracts that providers should not prescribe valproate to women of childbearing potential to treat a mental health problem.

What the quality statement means for service users and carers

Women who may become pregnant or who are pregnant should not be prescribed a medication called valproate to treat a mental health problem as it can harm unborn babies.

Source guidance

Definitions of terms used in this quality statement

Valproate
At the time of publication 3 formulations of valproate were available in the UK: sodium valproate and valproic acid (licensed for the treatment of epilepsy) and semi-sodium valproate (licensed for the treatment of acute mania and continuation treatment in people whose mania responds to treatment). Both semi-sodium and sodium valproate are metabolised to valproic acid (also known as valproate), which is the pharmacologically active component.
Women of childbearing potential
Childbearing potential should be determined for women on an individual basis. It should not be determined solely by age because childbearing potential can be dependent on factors other than age. It includes girls and young women under 18 and pregnant women.
[Adapted from Antenatal and postnatal mental health (NICE guideline CG192)]

Equality and diversity considerations

When information is provided, there must be equal access to information for all women, including those with additional needs, such as physical or learning disabilities, and those who do not speak or read English. Women receiving information should have access to an interpreter or independent advocate if needed.

Pre-conception information

This quality statement is taken from the antenatal and postnatal mental health quality standard. The quality standard defines clinical best practice in antenatal and postnatal mental health and should be read in full.

Quality statement

Women of childbearing potential with a severe mental health problem are given information at their annual review about how their mental health problem and its treatment might affect them or their baby if they become pregnant.

Rationale

Women with a severe mental health problem can make informed decisions about safe treatments and managing their condition if they understand how their mental health problem, or its treatment, could affect them or their baby if they become pregnant.

Quality measures

Structure
Evidence of local arrangements to ensure that women of childbearing potential with a severe mental health problem are given information at their annual review about how their mental health problem and its treatment might affect them or their baby if they become pregnant.
Data source: Local data collection.
Process
Proportion of women of childbearing potential with a severe mental health problem given information at their annual review about how their mental health problem and its treatment might affect them or their baby if they become pregnant.
Numerator – the number in the denominator who have received information as part of their annual review about how their mental health problem and its treatment might affect them or their baby if they become pregnant.
Denominator – the number of women of childbearing potential with a severe mental health problem having an annual review.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (general mental health services and specialist secondary care mental health services) have systems in place to ensure that the annual review for women of childbearing potential with a severe mental health problem includes information about how their mental health problem and its treatment might affect them or their baby if they become pregnant.
Mental health professionals provide information at the annual review for women of childbearing potential with a severe mental health problem about how their mental health problem and its treatment might affect them or their baby if they become pregnant.
Commissioners (commissioners of general and specialist and mental health services, clinical commissioning groups) specify and check that annual reviews for women of childbearing potential with a severe mental health problem include giving women information about how their mental health problem and its treatment might affect them or their baby if they become pregnant.

What the quality statement means for patients, service users and carers

Women with a severe mental health problem who might become pregnant are given information at their annual review about how their mental health problem might affect them or their baby if they become pregnant. It should include the possible benefits and harms of any treatment they are having for their mental health problem. This will help them to make decisions about pregnancy and treatment for their mental health problem.

Source guidance

Definitions of terms used in this quality statement

Annual review
The Care Programme Approach sets out support that women with a severe mental health problem should receive from secondary mental health services. It includes a formal review at least once a year.
Information
The following information should be discussed with women of childbearing potential who have a mental health problem:
  • the use of contraception and any plans for a pregnancy
  • how pregnancy and childbirth might affect a mental health problem, including the risk of relapse
  • how a mental health problem and its treatment might affect the woman, the fetus and baby
  • how a mental health problem and its treatment might affect parenting.
[Antenatal and postnatal mental health (NICE guideline CG192) recommendation 1.2.1]
Mental health professionals providing detailed advice about the possible risks of mental health problems or the benefits and harms of treatment in pregnancy and the postnatal period should include discussion of the following, depending on individual circumstances:
  • the uncertainty about the benefits, risks and harms of treatments for mental health problems in pregnancy and the postnatal period
  • the likely benefits of each treatment, taking into account the severity of the mental health problem
  • the woman’s response to any previous treatment
  • the background risk of harm to the woman and the fetus or baby associated with the mental health problem and the risk to mental health and parenting associated with no treatment
  • the possibility of the sudden onset of symptoms of mental health problems in pregnancy and the postnatal period, particularly in the first few weeks after childbirth (for example, in bipolar disorder)
  • the risks or harms to the woman and the fetus or baby associated with each treatment option
  • the need for prompt treatment because of the potential effect of an untreated mental health problem on the fetus or baby
  • the risk or harms to the woman and the fetus or baby associated with stopping or changing a treatment.
[Antenatal and postnatal mental health (NICE guideline CG192) recommendation 1.4.6]
Healthcare professionals discuss breastfeeding with all women who may need to take psychotropic medication in pregnancy or in the postnatal period. This should include an explanation of the benefits of breastfeeding, the potential risks associated with taking psychotropic medication when breastfeeding and with stopping some medications in order to breastfeed. Healthcare professionals should discuss treatment options that would enable a woman to breastfeed if she wishes and support women who choose not to breastfeed.
[Antenatal and postnatal mental health (NICE guideline CG192) recommendation 1.4.4]
Postnatal period
Up to 1 year after childbirth.
[Antenatal and postnatal mental health (NICE guideline CG192)]
Severe mental health problem
A severe mental health problem includes severe and incapacitating depression, psychosis, schizophrenia, bipolar disorder, schizoaffective disorder or postpartum psychosis.
[Antenatal and postnatal mental health (NICE guideline CG192)]

Equality and diversity considerations

When information is provided, there must be equal access to information for all women, including those with additional needs, such as physical or learning disabilities, and those who do not speak or read English. Women receiving information should have access to an interpreter or independent advocate if needed.

Information for pregnant women

This quality statement is taken from the antenatal and postnatal mental health quality standard. The quality standard defines clinical best practice in antenatal and postnatal mental health and should be read in full.

Quality statement

Pregnant women with a previous severe mental health problem or any current mental health problem are given information at their booking appointment about how their mental health problem and its treatment might affect them or their baby.

Rationale

It is important that pregnant women with a previous severe mental health problem, or any current mental health problem, understand how their mental health problem might affect them during and after pregnancy, and how pregnancy and childbirth might affect their condition, including the risk of relapse. In particular, it is important that the risks of using some medications to treat mental health problems during pregnancy and while breastfeeding are discussed, and alternatives considered to help women make informed decisions about managing their condition. This discussion might happen earlier for some women if they have a discussion with a specialist before their booking appointment.

Quality measures

Structure
Evidence of local arrangements to ensure that women with a previous severe mental health problem or any current mental health problem are given information at their booking appointment about how their mental health problem and its treatment might affect them or their baby.
Data source: Local data collection.
Process
Proportion of pregnant women with a previous severe mental health problem or any current mental health problem who are given information at their booking appointment about how their mental health problem and its treatment might affect them or their baby.
Numerator – the number in the denominator who have received information about how their mental health problem and its treatment might affect them or their baby.
Denominator – the number of pregnant women with a previous severe mental health problem or any current mental health problem attending their booking appointment.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (antenatal care providers) have systems in place to ensure that women with a previous severe mental health problem or any current mental health problem are given information at the booking appointment about how their mental health problem and its treatment might affect them or their baby.
Healthcare professionals (midwives) provide information at the booking appointment to women with a previous severe mental health problem or any current mental health problem about how their mental health problem and its treatment might affect them or their baby.
Commissioners (clinical commissioning groups) specify and check that booking appointments for women with a previous severe mental health problem or any current mental health problem include midwives giving information to women about how their mental health problem and its treatment might affect them or their baby.

What the quality statement means for patients, service users and carers

Women who are pregnant and who have had a severe mental health problem in the past or have any current mental health problem are given information at their booking appointment about how their mental health problem might affect them or their baby during pregnancy and after their baby is born. They are also given information about the possible benefits and harms of any treatment they might have for their mental health problem during this time and while breastfeeding, if they choose to breastfeed. This will help them to make decisions about pregnancy and their treatment.

Source guidance

Definitions of terms used in this quality statement

Information
Discuss treatment and prevention options and any particular concerns the woman has about the pregnancy or the fetus or baby. Provide information to the woman and, if she agrees, her partner, family or carer, about:
  • the potential benefits of psychological interventions and psychotropic medication
  • the possible consequences of no treatment
  • the possible harms associated with treatment
  • what might happen if treatment is changed or stopped, particularly if psychotropic medication is stopped abruptly.
[Antenatal and postnatal mental health (NICE guideline CG192) recommendation 1.4.3]
Healthcare professionals discuss breastfeeding with all women who may need to take psychotropic medication in pregnancy or in the postnatal period. This should include an explanation of the benefits of breastfeeding, the potential risks associated with taking psychotropic medication when breastfeeding and with stopping some medications in order to breastfeed. Healthcare professionals should discuss treatment options that would enable a woman to breastfeed if she wishes and support women who choose not to breastfeed.
[Antenatal and postnatal mental health (NICE guideline CG192) recommendation 1.4.4]
Postnatal period
Up to 1 year after childbirth.
[Antenatal and postnatal mental health (NICE guideline CG192)]
Severe mental health problem
A severe mental health problem includes severe and incapacitating depression, psychosis, schizophrenia, bipolar disorder, schizoaffective disorder or postpartum psychosis.
[Antenatal and postnatal mental health (NICE guideline CG192)]

Equality and diversity considerations

When information is provided, there must be equal access to information for all women, including those with additional needs, such as physical or learning disabilities, and those who do not speak or read English. Women receiving information should have access to an interpreter or independent advocate if needed.

Asking about mental health and wellbeing

This quality statement is taken from the antenatal and postnatal mental health quality standard. The quality standard defines clinical best practice in antenatal and postnatal mental health and should be read in full.

Quality statement

Women are asked about their emotional wellbeing at each routine antenatal and postnatal contact.

Rationale

Routine antenatal and postnatal appointments are opportunities for health professionals to discuss emotional wellbeing with women and identify potential mental health problems. It also gives women an opportunity to talk about any concerns they might have, such as fears around childbirth, multiple pregnancy, or past experiences, such as loss of a child or traumatic childbirth. This will help health professionals provide appropriate support.

Quality measures

Structure
Evidence of arrangements for healthcare professionals to ask women about their emotional wellbeing at all routine antenatal and postnatal contacts.
Data source: Local data collection.
Process
The proportion of routine antenatal and postnatal contacts at which woman are asked about their emotional wellbeing by a healthcare professional.
Numerator – the number in the denominator at which women were asked about their emotional wellbeing by a healthcare professional.
Denominator – the number of routine antenatal and postnatal contacts.
Data source: Local data collection.
Outcome
a) Women’s satisfaction with being able to discuss any concerns or worries at routine appointments.
Data source: Local data collection. The Care Quality Commission’s Maternity services survey asks women whether a midwife or health visitor had asked how they were feeling emotionally at the postnatal stage.
b) Identification of mental health problems.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (antenatal and postnatal care service providers in community, primary and secondary care) have protocols in place to ensure that healthcare professionals ask women about their emotional wellbeing at each routine antenatal and postnatal contact.
Healthcare professionals (GPs, midwives, health visitors and consultant obstetricians) ask women about their emotional wellbeing at each routine antenatal and postnatal contact to support identification and discussion of mental health problems.
Commissioners (NHS England area teams, clinical commissioning groups and local authorities) specify and check that antenatal and postnatal care providers have protocols in place to ensure that healthcare professionals ask women about their emotional wellbeing at each routine antenatal and postnatal contact.

What the quality statement means for patients, service users and carers

Women who are pregnant or in the first year after giving birth are asked how they are feeling at every routine appointment. This is so that they can talk to their healthcare professional about any concerns they have, and any problems can be identified.

Source guidance

Definitions of terms used in this quality statement

Mental health and wellbeing
Healthcare professionals should consider asking the following questions at a woman’s booking appointment and at regular contacts in pregnancy, as part of a general discussion about her mental health and wellbeing:
  • The depression identification questions:
    • During the past month, have you often been bothered by feeling down, depressed or hopeless?
    • During the past month, have you often been bothered by having little interest or pleasure in doing things?
  • Questions about anxiety using the 2-item Generalized Anxiety Disorder scale (GAD‑2):
    • Over the last 2 weeks, have you been feeling nervous, anxious or on edge?
    • Over the last 2 weeks, have you not been able to stop or control worrying?
[Antenatal and postnatal mental health (NICE guideline CG192) recommendation 1.5.4]
Recommendations 1.5.5–1.5.7 in antenatal and postnatal mental health (NICE guideline CG192) set out additional questions to ask if initial questioning indicates the need for further investigation.
Routine antenatal contacts
Routine antenatal contacts include:
  • a pregnant woman’s first contact with a midwife or doctor to discuss their pregnancy
  • the booking appointment (between 8 and 12 weeks of pregnancy)
  • the dating scan (between 8 and 14 weeks of pregnancy)
  • the 16-week check
  • the anomaly scan (between 18 and 20 weeks of pregnancy)
  • further routine scheduled checks (the frequency of these will vary depending on whether it is the woman’s first pregnancy).
Routine postnatal contacts
Women should receive the number of postnatal contacts that are appropriate to their care needs. A routine postnatal contact is a scheduled postnatal appointment that may occur in the woman or baby’s home or another setting such as a GP practice, children’s centre or a hospital setting if the woman or baby needs extended inpatient care. All women should have a postnatal check about 6 weeks after their baby’s birth to make sure that they feel well and are recovering properly.
[Expert consensus]
Postnatal period
Up to 1 year after childbirth.
[Antenatal and postnatal mental health (NICE guideline CG192)]

Equality and diversity considerations

Women with complex social needs may be less likely to access or maintain contact with antenatal and postnatal services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol and/or drugs)
  • have recently arrived as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that localities give special consideration to these groups of women. NICE’s guideline on pregnancy and complex social factors has recommendations about how to make antenatal care accessible to women with complex social needs and how to encourage ongoing contact.

Comprehensive mental health assessment

This quality statement is taken from the antenatal and postnatal mental health quality standard. The quality standard defines clinical best practice in antenatal and postnatal mental health and should be read in full.

Quality statement

Women with a suspected mental health problem in pregnancy or the postnatal period receive a comprehensive mental health assessment.

Rationale

A comprehensive mental health assessment can support accurate diagnosis of a mental health problem in pregnancy or the postnatal period, and can ensure that women are offered the most appropriate treatment at the earliest opportunity. Factors specific to pregnancy or the postnatal period, such as a previous traumatic birth, loss of a child, and other individual circumstances, can help identify additional support needs.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that women with a suspected mental health problem in pregnancy or the postnatal period receive a comprehensive mental health assessment.
Data source: Local data collection.
Process
Proportion of women with a suspected mental health problem in pregnancy or within 12 months of giving birth who receive a comprehensive mental health assessment.
Numerator – the number in the denominator who receive a comprehensive mental health assessment.
Denominator – the number of women with a suspected mental health problem who are pregnant or have given birth within the past 12 months.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care and general mental health services) provide resources that support professionals to carry out comprehensive mental health assessments for women with a suspected mental health problem in pregnancy or the postnatal period.
Healthcare professionals (GPs and mental health professionals) carry out comprehensive mental health assessments for women with a suspected mental health problem in pregnancy or the postnatal period to aid diagnosis and identify appropriate support.
Commissioners (NHS England area teams and clinical commissioning groups) specify that comprehensive mental health assessments are carried out for women with a suspected mental health problem in pregnancy or the postnatal period.

What the quality statement means for patients, service users and carers

Women who may have a mental health problem in pregnancy or within a year after giving birth have a full assessment to find out if they have a mental health problem and whether they need extra support.

Source guidance

Definitions of terms used in this quality statement

Comprehensive mental health assessment
Assessment and diagnosis of a suspected mental health problem in pregnancy and the postnatal period should include:
  • history of any mental health problem, including in pregnancy or the postnatal period
  • physical wellbeing (including weight, smoking, nutrition and activity level) and history of any physical health problem
  • alcohol and drug misuse
  • the woman’s attitude towards the pregnancy, including denial of pregnancy
  • the woman’s experience of pregnancy and any problems experienced by her, the fetus or the baby
  • the mother–baby relationship
  • any past or present treatment for a mental health problem, and response to any treatment
  • social networks and quality of interpersonal relationships
  • living conditions and social isolation
  • family history (first-degree relative) of mental health problems
  • domestic violence and abuse, sexual abuse, trauma or childhood maltreatment
  • housing, employment, economic and immigration status
  • responsibilities as a carer for other children and young people or other adults.
[Antenatal and postnatal mental health (NICE guideline CG192) recommendation 1.6.1]
Postnatal period
Up to 1 year after childbirth.
[Antenatal and postnatal mental health (NICE guideline CG192)]
Suspected mental health problem
Women might be suspected to have a mental health problem if they have a history of a mental health problem or possible symptoms (such as mood difficulties or detachment from their pregnancy or baby).
[Expert consensus]

Equality and diversity considerations

Healthcare professionals should ensure that, in comprehensive mental health assessments with all women, they understand variations in the presentation of mental health problems, and are sensitive to any potential concerns about disclosing mental health problems. This includes ensuring that they are culturally competent in their discussions with women from black, Asian and minority ethnic groups to support full and meaningful discussion. Women should have access to an interpreter or independent advocate if needed.
When assessing or treating a mental health problem in pregnancy or the postnatal period, healthcare professionals should take account of any learning disabilities or acquired cognitive impairments, and assess the need to consult with a specialist when developing care plans.

Psychological interventions

This quality statement is taken from the antenatal and postnatal mental health quality standard. The quality standard defines clinical best practice in antenatal and postnatal mental health and should be read in full.

Quality statement

Women referred for psychological interventions in pregnancy or the postnatal period start treatment within 6 weeks of referral.

Rationale

It is important that women with a mental health problem in pregnancy or the postnatal period receive prompt treatment to manage their condition and prevent their symptoms worsening. More urgent intervention may be needed at these times (and women with acute mental health problems will need to be seen as quickly as possible) because of the potential effect of the untreated mental health problem on the baby and on the woman’s physical health and care, and her ability to function and care for her family.

Quality measures

Structure
Evidence of local arrangements to ensure psychological interventions can be started within 6 weeks of referral for women with a mental health problem in pregnancy or who have a mental health problem in the postnatal period.
Data source: Local data collection.
ProcessProcess measures have been included to reflect that the 6 weeks to treatment set out in the quality statement comprises 2 weeks to assessment and 4 weeks to treatment, as recommended in NICE’s guideline on antenatal and postnatal mental health, recommendation 1.7.3.
a) Proportion of women referred for psychological interventions in pregnancy or within 12 months of giving birth who are assessed for treatment within 2 weeks of referral.
Numerator – number of women in the denominator who are assessed for treatment within 2 weeks of referral.
Denominator – the number of women referred for psychological interventions in pregnancy or within 12 months of giving birth.
Data source: Local data collection.
b) Proportion of women assessed as appropriate for psychological interventions in pregnancy or within 12 months of giving birth who start psychological interventions within 4 weeks of assessment.
Numerator – number of women in the denominator who start psychological interventions within 4 weeks of assessment.
Denominator – number of women assessed as appropriate for psychological interventions in pregnancy or within 12 months of giving birth.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (general mental health services, primary care psychological therapy services and specialist secondary care mental health services) have service capacity to ensure that women who are referred for psychological interventions in pregnancy or the postnatal period are assessed within 2 weeks of referral and treatment is started within 6 weeks of referral.
Healthcare professionals (mental health professionals) assess women who are referred for psychological interventions in pregnancy or the postnatal period within 2 weeks of referral and start treatment within 6 weeks of referral.
Commissioners (clinical commissioning groups) commission psychological interventions and specify that assessment of women referred for psychological interventions in pregnancy or the postnatal period should take place within 2 weeks of referral and treatment should start within 6 weeks of referral.

What the quality statement means for patients, service users and carers

Women with a mental health problem who are pregnant or have had a baby in the past year and who have been referred by their healthcare professional for psychological therapy start their therapy within 6 weeks of being referred, so they can receive the treatment they need as soon as possible.

Source guidance

Definitions of terms used in this quality statement

Psychological interventions
Psychological interventions should be tailored to the (sometimes highly specialist) needs of women in pregnancy and the postnatal period, and to support the baby’s development, attachment and mental health. All healthcare professionals providing assessment and interventions for mental health problems in pregnancy and the postnatal period should understand the variations in their presentation and course at these times, how these variations affect treatment, and the context in which they are assessed and treated (for example, maternity services, health visiting and mental health services).
[Antenatal and postnatal mental health (NICE guideline CG192)]

Equality and diversity considerations

When tailoring psychological interventions to women’s individual needs, health professionals need to ensure that assessments and interventions are culturally competent and that women are able to understand and communicate effectively. An independent interpreter should be provided if needed.

Specialist multidisciplinary perinatal mental health services (developmental)

This quality statement is taken from the antenatal and postnatal mental health quality standard. The quality standard defines clinical best practice in antenatal and postnatal mental health and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Developmental quality statement

Specialist multidisciplinary perinatal community services and inpatient psychiatric mother and baby units are available to support women with a mental health problem in pregnancy or the postnatal period.

Rationale

Access to specialist multidisciplinary perinatal community services and inpatient psychiatric mother and baby units can help to ensure that the most appropriate assessment, monitoring and treatment is provided. Access currently varies considerably, because services are not available in all localities.
In particular, women with severe mental health problems need specialist perinatal support to ensure that their condition is monitored appropriately, and that they can access the most suitable treatment. This is because severe mental health problems can be associated with significant impairment in social and personal functioning, which might affect the woman’s ability to care for herself and her child. Psychiatric causes of maternal death, particularly suicide, continue to be a significant cause of maternal mortality in the UK.

Quality measures

Structure
a) Evidence of local arrangements to provide specialist multidisciplinary perinatal community services.
b) Evidence of local arrangements to ensure that women needing inpatient care for a mental health problem within 12 months of childbirth can be admitted to an inpatient psychiatric mother and baby unit.
c) Evidence of referral arrangements for women with a severe mental health problem to be referred to specialist multidisciplinary perinatal community services and inpatient psychiatric mother and baby units.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (mental health trusts and specialist tertiary services) provide specialist multidisciplinary perinatal community services and inpatient psychiatric mother and baby units for women with a mental health problem in pregnancy or the postnatal period.
Healthcare professionals (GPs, midwives, health visitors and mental health professionals) support women with a mental health problem in pregnancy or the postnatal period through specialist multidisciplinary perinatal community services and inpatient psychiatric mother and baby units. They are aware of local referral pathways and use them to refer women with a mental health problem in pregnancy or the postnatal period.
Commissioners (NHS England specialised commissioning teams) commission specialist multidisciplinary perinatal community mental health services and inpatient psychiatric mother and baby units for women with a mental health problem in pregnancy or the postnatal period. NICE has produced a costing report that can support commissioners to consider the cost impact of commissioning specialist perinatal mental health services.
Commissioners of primary and secondary care services (NHS England and clinical commissioning groups) should check that providers refer women with a mental health problem in pregnancy or the postnatal period to specialist multidisciplinary perinatal community mental health services and inpatient psychiatric mother and baby units when appropriate.

What the quality statement means for patients, service users and carers

Women who have a mental health problem during pregnancy or in the year after having a baby receive support from services that are specially designed for women with a mental health problem during these times. These services can give them the care and support they need.

Source guidance

Definitions of terms used in this quality statement

Specialist multidisciplinary perinatal mental health service
A specialist multidisciplinary perinatal mental health service that provides direct services, consultation and advice to maternity services, other mental health services and community services, and is available in all localities.
[Antenatal and postnatal mental health (2014) NICE guideline CG192, recommendation 1.10.3]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

When prescribing psychotropic medication for women of childbearing potential, take account of the latest data on the risks to the fetus and baby.
Consider gradually stopping benzodiazepines in women who are planning a pregnancy, pregnant or considering breastfeeding.
When choosing an antipsychotic, take into account that there are limited data on the safety of these drugs in pregnancy and the postnatal period.
Do not offer depot antipsychotics to a woman who is planning a pregnancy, pregnant or considering breastfeeding, unless she is responding well to a depot and has a previous history of non-adherence with oral medication.
Do not offer valproate for acute or long-term treatment of a mental health problem in women who are planning a pregnancy, pregnant or considering breastfeeding.
If a woman is already taking valproate and is planning a pregnancy, advise her to gradually stop the drug because of the risk of fetal malformations and adverse neurodevelopment outcomes after any exposure in pregnancy.
Do not offer carbamazepine to treat a mental health problem in women who are planning a pregnancy, pregnant or considering breastfeeding.
If a woman is already taking carbamazepine and is planning a pregnancy or becomes pregnant, discuss with the woman the possibility of stopping the drug (because of the risk of adverse drug interactions and fetal malformations).
Do not offer lithiumAlthough this use is common in UK clinical practice, at the time of publication (December 2014), lithium did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective.
If antipsychotic medication has not been effective and lithium is offered to a woman who is planning a pregnancy or pregnant, ensure:
  • the woman knows that there is a risk of fetal heart malformations when lithium is taken in the first trimester, but the size of the risk is uncertain
  • the woman knows that lithium levels may be high in breast milk with a risk of toxicity for the baby
  • lithium levels are monitored more frequently throughout pregnancy and the postnatal period.
Recognise that women who have a mental health problem (or are worried that they might have) may be:
  • unwilling to disclose or discuss their problem because of fear of stigma, negative perceptions of them as a mother or fear that their baby might be taken into care
  • reluctant to engage, or have difficulty in engaging, in treatment because of avoidance associated with their mental health problem or dependence on alcohol or drugs.
All healthcare professionals providing assessment and interventions for mental health problems in pregnancy and the postnatal period should understand the variations in their presentation and course at these times, how these variations affect treatment, and the context in which they are assessed and treated (for example, maternity services, health visiting and mental health services).
  • she should not be secluded after rapid tranquillisation
  • restraint procedures should be adapted to avoid possible harm to the fetus
  • when choosing an agent for rapid tranquillisation in a pregnant woman, an antipsychotic or a benzodiazepine with a short half-life should be considered; if an antipsychotic is used, it should be at the minimum effective dose because of neonatal extrapyramidal symptoms; if a benzodiazepine is used, the risks of floppy baby syndrome should be taken into account
  • during the perinatal period, the woman's care should be managed in close collaboration with a paediatrician and an anaesthetist.
If a pregnant woman has taken psychotropic medication with known teratogenic risk at any time in the first trimester:
  • confirm the pregnancy as soon as possible
  • explain that stopping or switching the medication after pregnancy is confirmed may not remove the risk of fetal malformations
  • offer screening for fetal abnormalities and counselling about continuing the pregnancy
  • explain the need for additional monitoring and the risks to the fetus if she continues to take the medication.
Seek advice from a specialist if there is uncertainty about the risks associated with specific drugs.

Glossary

Cognitive behavioural therapy
Severe and incapacitating depression, psychosis, schizophrenia, bipolar disorder, schizoaffective disorder and postpartum psychosis.
A formal psychological intervention usually delivered face to face (either in a group or individually) by a qualified therapist who has specific training in the delivery of the intervention.
(Serotonin-) noradrenaline reuptake inhibitor
Selective serotonin reuptake inhibitor
Tricyclic antidepressant

Paths in this pathway

Pathway created: November 2011 Last updated: February 2016

© NICE 2016

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