Review of Maternity Services in the UK- Interview with Debra Bick

For the second article in APP’s review of maternity services in the UK, Clare Dolman speaks to Debra Bick, Professor of Evidence Based Midwifery Practice at the Florence Nightingale School of Nursing and Midwifery, King’s College London, about how the services are working – or not working – for women with mental health problems.

Prof. Bick has long been interested in the particular needs of women with mental health problems during the perinatal period, and is outspoken about her concern that their needs are not sufficiently prioritized. When we meet at her London office, she cites the ‘Campaign for Normal Birth’ currently run by the Royal College of Midwives which is focusing on the promotion of normal births as an example of how postnatal  needs are sometimes overlooked.

‘In that campaign, the focus is labour and birth and nothing really before and certainly nothing beyond’, she says. It is preparation and provision for the longer-term picture which is of especial importance for women who suffer psychiatric illness.  Maternity services should promote a continuum of effective care through a woman’s pregnancy, birth and beyond. ‘We have these drivers in our delivery suites to make sure that 75% of women get one to one care in labour from a midwife, a target which means that managers will take midwives off the postnatal ward or from the community to achieve that, and so women don’t get the care when they’re going home and it’s quite dire actually’, she says.

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Response to Sunday Times article published 13/01/13

As Trustees of Action on Postpartum Psychosis (APP), the national charity for severe postnatal mental illness in the UK, we would like to applaud the Sunday Times for publishing an article raising awareness of this little-known condition. We commend the bravery of each family who took part, and thank the Sunday Times for telling their stories in a compassionate and informative way.

The objective of APP is to ensure that high-quality information about Postpartum Psychosis is available to both professionals and members of the public. We feel it is important to make clear that infanticide is an extremely rare and tragic outcome of Postpartum Psychosis. Not all women with this diagnosis will experience thoughts or impulses of harming their baby. While understanding the need to emphasize the seriousness of this condition, we feel that the phrase "can turn mothers into murderers" is both misleading and stigmatizing.

Early warning signs of Postpartum Psychosis are often an inability to sleep, euphoria or high mood, or mixed episodes of both high and low (depressed) mood. It is incorrect to say that in most women the symptoms "pass within days or weeks". The condition often escalates rapidly, and as such must be taken seriously and treated as a psychiatric emergency.

The good news, as Jo Lyall's story illustrates, is that the majority of women who receive the right treatment do very well in their recovery and go on to bond with their babies and enjoy motherhood. The standard of treatment we believe should be available to all women is admission to a Mother & Baby Unit, and medication as well as psychological support.


Naomi Gilbert, Sarah Dearden, Clare Dolman, Andrea Lambert and Nicola Muckelroy - Trustees of APP with personal experience of Postpartum Psychosis

Sunday Times article (subscription needed)

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Life-saving mental health services may be cut as national charity faces funding crisis

The national charity dedicated to supporting individuals and families affected by bipolar faces the threat of closing life-saving services as its income suffers in the economic downturn.

Although a small national charity, Bipolar UK’s reach and impact are vital – it supports more than 65,000 individuals every year.  The charity provides crucial services including information and advice, self help groups, a mentoring service, a youth service and a web-based discussion forum for those affected by this devastating and widely-misunderstood illness.  Bipolar causes severe mood swings from manic highs often involving hospitalisation and sectioning to suicidal lows.  The illness increases the risk of suicide by up to 20 times.

Suzanne Hudson, Bipolar UK’s Chief Executive, says “We desperately need to raise funds to enable us to meet the substantial increase in demand we are witnessing.”

With high profile names like Stephen Fry, Sinead O’Connor and Bipolar UK’s patrons Bill Oddie and Paul Abbott, openly talking about their own experiences, many people now have the confidence to seek support from Bipolar UK to change, and indeed save, lives.

Young mum of three Zoe, has successfully been helped by Bipolar UK, “The Link Mentoring service absolutely changed my life – I now have a life and I like who I am.  I’m not so afraid anymore.  I owe my new life to Bipolar UK.  They gave me and they gave my children a mummy.”  The continued support from Bipolar UK for Zoe not only turned her life around but also her family.

Suzanne Hudson continues  “The sad irony is that this funding crisis comes at a time when bipolar is beginning to be understood.  As a result more individuals and families are finding the courage to seek our support.  2012 was unprec

Bipolar UK Patron, Bill Oddie  “The public could be forgiven for thinking that bipolar only affects celebrities!  The truth is that this severe illness can and does affect anyone and everyone, but only the famous faces get the publicity.  If the services of Bipolar UK are diluted or lost, the consequences will literally be tragic."
edented in terms of the number of individuals contacting us for help and accessing our services.  It is increasingly the case that individuals’ first contact with us is at a time of crisis involving intervention with emergency services.”

Bipolar UK desperately needs to raise over £100,000 in the next few weeks to continue providing vital services including Self Help Groups and Information & Advice. To make a donation call Bipolar UK on 020 7931 6480, click below, or text BIPO33 £3 to 70070.  

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Government initiative may highlight regional disparities in care provided to women who suffer a postpartum psychosis

A government initiative to find out new mothers’ views on the quality of the care they have received may highlight the regional disparities in care provided to women who suffer a postpartum psychosis.

Every woman who gives birth is to be asked to rate how the NHS looked after her, as part of a new government drive to improve the quality of maternity care, according to a report by Denis Campbell published in The Observer. [on 29 Dec 2012 – FYI]

All 700,000 women a year who have a child will get the chance to give feedback on how doctors, midwives and nurses cared for them, during one of the most stressful periods of their lives. The ratings will be then published as a way of encouraging hospitals and birth centres to ensure women get high-quality care.

Confirming the plan to the Observer, health minister Dr Daniel Poulter, who still works part-time as an NHS obstetrician at a London hospital, said it was part of the move to introduce a "friends and family test", under which patients will be asked if they would recommend the care they have received to their loved ones. "This will introduce scrutiny and transparency into the quality of maternity care women receive," said Poulter.

"It will bring under the spotlight the satisfaction and quality of care that mothers feel they have received at that particular maternity unit, whether that's an obstetric unit in a hospital or a birthing centre where midwives are in charge. The idea is that hospitals really listen to what women say. If the feedback says that local women wouldn't recommend it as a place to give birth and that there are concerns about that unit, then that's a very strong lever to encourage or force improvements in care," he said.

The "friends and family test" will first be brought in for all patients who arrive in A&E or are admitted as acute cases from April. They will be asked: "How likely is it that you would recommend this service to friends and family?"

Mothers, though, are to be asked more detailed questions, or to rate the care they have received at different stages throughout their pregnancy. The areas will include how they were treated by antenatal staff during their labour and how they were counselled over key tasks in the days after birth, such as learning how to breastfeed and any emotional support they may have received.

The feedback will cover a woman's entire experience of the NHS, from when her 12-week scans confirms the pregnancy to the help she gets if she ends up suffering postnatal depression, and support from community midwives after she returns home.

The Royal College of Midwives, Department of Health and the new NHS Commissioning Board, which will assume responsibility for running the health service from April, are devising exactly what questions should be asked, how and when. The new scheme will be tested in early 2013 in four hospitals, including St Thomas's in central London, which already use questionnaires to collect mothers' opinions. It will then be introduced from October at all 150 hospital trusts which provide maternity care.

Cathy Warwick, chief executive of the RCM, which represents the 30,000 midwives in England, agreed that the move would help women decide where to give birth. "It will lead to women choosing places where they believe they will get high-quality care or go for a home birth or to a midwife-led unit, if these are rated positively by women. Last year's birthplace study showed that women with low-risk pregnancies were more satisfied if they had a home birth or used a midwife-led unit than an obstetric unit", said Warwick.

Sally Russell, a co-founder of the Netmums website, welcomed the move. "What prospective parents want to know is about the experience others have had, not just the facts and figures around quality of care", she said.

Mothers should be asked for feedback when they are being discharged or soon after they get home, as they may feel reluctant to be honest while still being cared for in case that affected their treatment, Russell added.

The feedback will inevitably highlight the ongoing shortage of midwives, which the RCM warns is hindering the efforts by the NHS to properly look after the growing number of women giving birth during a decade-long baby boom, added Russell.

But Poulter said that midwives and other maternity staff should not be anxious. "From working in maternity care myself, I welcome feedback from women and their families. As a doctor or midwife you want to know if you can do better. You need to know that", he said.

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Study suggets the use of anti-depressants during pregnancy is not linked with increased risk of stillbirth or infant death

In a study that included nearly 30,000 women from Nordic countries who had filled a selective serotonin reuptake inhibitor (SSRI) prescription during pregnancy, researchers found no significant association between use of these medications during pregnancy and risk of stillbirth, neonatal death, or postneonatal death, after accounting for factors including maternal psychiatric disease, according to a study in the January 2 issue of JAMA (Journal of the American Medical Association).

Olof Stephansson, M.D., Ph.D., of the Karolinska Institutet, Stockholm, Sweden and colleagues conducted a study to examine whether SSRI exposure during pregnancy was associated with increased risks of stillbirth, neonatal death, and postneonatal death. The study included women with single births from all Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) at different periods from 1996 through 2007. The researchers obtained information on maternal use of SSRIs from prescription registries; maternal characteristics, pregnancy, and neonatal outcomes were obtained from patient and medical birth registries. The authors estimated relative risks of stillbirth, neonatal death, and postneonatal death associated with SSRI use during pregnancy taking into account maternal characteristics and previous psychiatric hospitalization.

"The present study of more than 1.6 million births suggests that SSRI use during pregnancy was not associated with increased risks of stillbirth, neonatal death, or postneonatal death. The increased rates of stillbirth and postneonatal mortality among infants exposed to an SSRI during pregnancy were explained by the severity of the underlying maternal psychiatric disease and unfavorable distribution of maternal characteristics such as cigarette smoking and advanced maternal age."

"However, decisions regarding use of SSRIs during pregnancy must take into account other perinatal outcomes and the risks associated with maternal mental illness," the researchers conclude.

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Battling for Locally Accessible Perinatal Psychiatric Services

There has been a lot of discussion about the patchiness of perinatal services across the UK: some areas have very good services and excellent Mother and Baby Units while others have little or no service to speak of.

Clare Dolman talks to psychiatrist Dr. Jenny Cooke, who has been trying to improve access to services in her area of East Sussex.

When Dr. Cooke became a higher trainee in psychiatry four years ago, she was surprised at the lack of specialist help for expectant mothers with mental health problems. ‘As a trainee psychiatrist we are allocated time to develop an area of specialist expertise and I was very interested in perinatal psychiatry’, she says.  ‘Fortunately, the local Mental Health Commissioning lead was a GP who shared my interest so we undertook some research to find out what the current clinical pathways were for women with psychiatric needs in the perinatal period.  We talked to all local professionals – psychiatrists, midwives, health visitors and community psychiatric nurses – about where they refer in to services and what the problems were’.

She found many gaps.  ‘Many professionals didn’t know how to refer women on, the system was very unwieldy and complicated, and even if a woman got referred to a psychiatrist, he or she often didn’t have any specialist training in perinatal treatment.  It was really hit and miss’.

‘I discovered that one of the obstetricians who had an interest in mental health had set up her own clinic for midwives to refer into but she was a bit overwhelmed so in my ‘Special Interest’ time, I started helping her.  It was only one morning every fortnight and sometimes we were seeing women with minor anxiety whereas women with bipolar disorder or schizophrenia who had been well for some time and so been discharged from the system but were now pregnant and so at high risk of illness, were being missed’.

Dr. Cooke could also only see women antenatally so it was impossible to have continuity: ‘We had to think about how we could improve the care pathway so we got a steering group together and are working with local mental health and maternity commissioners who see that this is a priority.  We’ve improved the Midwives’ Booking Form, and we’re hoping to provide some mental health training for them so that they can recognize the women who are at greatest risk even if they appear well.  Funding for my time has been doubled to one morning per week for up to a year, which will allow psychiatrists, health visitors and GPs to refer in directly’, she says.

If women do suffer from a severe postpartum illness, there is no NHS-provided Mother and Baby Unit for them to go to: they have to be sent to a private unit in Eastbourne, which is difficult to refer into and so not used as much as it could be.

Dr. Cooke is keen to see the perinatal clinic go on developing: ‘At the moment we can’t of course respond to emergencies and, as demand grows, one morning a week will not be enough to see everyone.  I am hoping we might be able to have a psychiatric nurse linked to the clinic to be a more regular point of contact, and who can visit those women in the community who can’t make it into the clinic for whatever reason’.

She supports APP’s campaign to impress upon funding bodies that good perinatal care should be a priority as it not only helps to keep mothers well and give children the best possible start in life but, if seen in terms of preventing lengthy hospital or MBU admissions, it can also prove cost-effective in the long run. ‘Our local commissioners have been very supportive but, as we all know, funding is very stretched at the moment, and so we have to be hopeful that the importance of this service is recognized’, says Dr. Cooke.

She feels it is important for both clinicians and NHS consumers around the UK to do what they can to bring this to the attention of their local commissioners.  ‘We have had the NICE guidelines since 2007 saying that we should be providing these services but in so many areas of the country they don’t exist, ‘ she says.  Perhaps it will take local campaigning from enthusiastic health professionals like Jennifer Cooke, supported by charities such as APP and the newly-formed Maternal Mental Health Alliance, to get more of them in place.


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Bringing postnatal depression out of the shadows

Lancet editorial on the stigma of perinatal mental illness 10/11/12.

Last week, it fell to a judge in a UK court to decide the fate of a woman who had killed both her children, while suffering from postnatal depression. The court heard from three psychiatrists who gave evidence that Felicia Boots, who suffocated her 14-month-old and 10-week-old children, had postnatal depression. She had stopped her prescribed antidepressants because she was convinced that the drugs would harm her baby through her breast milk and feared that her children would be taken away from her. Justice Fulford said: “A prison sentence would be wholly inappropriate in this case…I unreservedly accept that what she did to the two children, that she and her husband loved and nurtured, were the results of physical and biological factors beyond her control.” The verdict was manslaughter due to diminished responsibility (murder charges were dropped), and the outcome is inpatient psychiatric treatment...Read more>>

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Land's End to John O'Groats (LEJOG) Fundraiser

When asked why they climbed Everest, some mountaineers reply, “Because it’s there”. Alex Heron and his jolly bunch of paramotoring mates, John Casson, Henry Glasse and Brian Pushman, couldn’t be accused of a similar approach to LEJOG (Land’s End to John O’ Groats) since they’d already completed the reverse journey (JOGLE) by paramotor in 2009.Though blessed with good weather and favourable winds on that flight, they made the mistake of not using the epic adventure as a fund-raising opportunity. So ...3 years later they embarked on the crazy notion of cycling the route in the opposite direction to raise money for various charities, not “Because it’s there”, but because, “We missed a great opportunity last time and we want to make amends”, and, secretly, “It’ll be a jolly good wheeze for a bunch of old codgers anyway”.

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APP Media Engagement Training

The workshop is run by Action on Postpartum Psychosis, in collaboration with The University of Birmingham and the University of Cardiff, for women who have experienced Postpartum Psychosis.

Engaging with the media can be a good way of raising awareness about Postpartum Psychosis and getting information out to health professionals and the general public. However, deciding to talk openly about PP requires careful consideration. During the workshop, we’ll hear from women who have shared their stories, whether in a magazine, newspaper or on the radio; hear how they felt it went, and discuss the issues to consider when engaging with the media. Producers and journalists will tell us about their motivations, how they approach stories and what makes things work for their outlets. We’ll learn about ways of preparing for interview, the art of ‘story telling’ and building confidence, and we’ll discuss any anxieties people have about dealing with the media. We’ll have an update on the latest facts and research about PP, and start to develop APP’s media strategy for raising awareness of PP.

For those who wish to, there will be a chance to practice being interviewed for broadcast and for print, with individual feedback from professionals. Over the 2 days we will develop audio and video podcasts for the APP website on a range of topics determined by you. Aside from the ‘work’ part of the workshop, it will be a good chance to get to know more about APP and meet other APP members. The workshop will be informal, friendly and low stress – no role playing or audiences to watch you have a go!

When: The course will take place over 2 days on Friday 19th (11am – 5.30pm) and Saturday 20th October (9.30am – 3.30pm).

Where: University of Birmingham, Edgbaston campus, Birmingham.

Who: A group of 8 women who have all experienced PP and expressed an interest in helping to increase media coverage of PP and developing resources to raise awareness of PP. The workshop is being organised by Dr Jessica Heron (Vice Chair - Action on Postpartum Psychosis; Perinatal Research Fellow - University of Birmingham) and Lucy Vernall (Media Coordinator - Action on Postpartum Psychosis; IdeasLab Project Director, University of Birmingham).

Funding: The workshop is funded by the Big Lottery. We are able to cover participant’s travel expenses, accommodation on Friday night, meals, and other costs necessary to attend the course (such as childcare).

Accommodation: Friday night’s accommodation will be in University of Birmingham Conference Facilities

Contact: If you would like further details about taking part in the workshop, please contact Jessica Heron:


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Derby Fundraising & Awareness Event

Derby Cattle Market was the venue for an APP awareness raising & fundraising "Purple Party" in Sept. It was a very successful event... leaflets were distributed and APP magazines were handed out to those who requested information. We were pleased to engage with midwives and with those who had stories to tell of their postnatal mental illnesses. Huge thanks are due to Adrian Blamire and Steph and Geoff Brackpool (who have always been good friends of APP) who helped Sue Blamire and Heather Heron (APP trustees) throughout the day. It is no mean feat getting up at 5.30 in the morning to brave the Derby crowds. Thanks also are due to Mary Heron for her donation and also to all of those who donated items for sale. The total raised was an impressive £440! Excellent work everybody!

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