Evidence
Alert

Mental health care during pregnancy and afterwards: women from some ethnic minority backgrounds face barriers to access

Women who have mental health problems during pregnancy or in the first year after giving birth (the perinatal period) can face challenges in seeking professional help. New research found the problem is more pronounced for women from Black African, Asian and White Other backgrounds. They had poorer access to services in the community than White British women. They were also more likely to be detained in hospital (involuntary admission) for severe problems requiring urgent treatment.

There is currently a lack of reliable large-scale data about the use of perinatal mental health services by women in different ethnic groups. This population study recorded ethnicity in 16 categories that were each compared with White British women.

The research provides evidence that women from Black African, Asian and White Other backgrounds struggle to access services. Once they have accessed the system, they make good use of services.

The researchers say that hospitals need good interpreters, appropriate information for all groups, and flexible, culturally relevant services. Improved and earlier access to community mental health services may help reduce involuntary hospital admissions during the perinatal period.

These findings will inform the development of new policies, which should see an unprecedented expansion of specialist perinatal mental health services as part of the Five Year Forward View for Mental Health in England and the NHS Long Term Plan.

What’s the issue?

Perinatal mental illness affects up to one in five of new and expectant mothers.  If left untreated, it can have long-lasting negative effects on the woman, her children, wider family and society.

Specialist mental health services can provide care and treatment for women during the perinatal period – and help support the developing relationship between mother and child. But not all women who need this support manage to access it.

All women can face difficulties in accessing help. Some fear that there is a stigma around mental illness in the perinatal period or are unaware of the services available.

Women from some ethnic minority backgrounds are known to encounter additional barriers. These may include:

  • language problems
  • a cultural explanation of mental illness that does not encourage women to seek help
  • a lack of understanding of the services available
  • professionals who are less likely to ask groups other than White British women about their mental health in the postnatal period, and to offer treatment and support.

Improving perinatal mental health services for women from ethnic minority backgrounds first requires a better understanding of how they currently access these services.

What’s new?

This study is the first step of a larger project to understand how women from ethnic minority backgrounds get in touch with  services and how acceptable they found them. The researchers examined two large national databases to assess the extent that women from different ethnic minority backgrounds use mental health services during the perinatal period.

Of 615,092 women who gave birth in England in 2017, 22,073 (3.5%) had their first ever contact with mental health services during the perinatal period. Of these women, 713 (3.2%) were admitted into hospital for treatment, 282 (39.5%) of them involuntarily.

The findings were adjusted to take age and deprivation into account. Ethnicity data were available for 98% of the womenand was recorded in 16 categories.

The researchers found that, in the perinatal period, compared with White British women:

  • women from White Other, Asian, Mixed White/Asian, Black African, Chinese and Other backgrounds had lower access to community mental health services
  • women from Mixed White/Black Caribbean backgrounds had higher access to community mental health services
  • women from White Other, Asian, Black African and Other backgrounds were more likely to have an involuntary hospital admission
  • Black African, Asian and White Other women attended more mental health appointments overall.

Why is this important?

Community mental health teams include a range of professionals including psychiatrists, psychiatric nurses, social workers, occupational therapists and clinical psychologists. They work with people living in the community. This work suggests that women in some ethnic groups have reduced access to community mental health services during the perinatal period.

The results suggest that initial access to services is the key issue. Once women had accessed services, they made good use of them. The researchers say that the lower rate of access – coupled with higher rates of involuntary admissions – suggests many women are not receiving the mental healthcare they need in a timely way. Targeted interventions to improve access to community mental health services might lead to reduced rates of involuntary hospital admissions.

The researchers stress that different groups have different needs and should be considered separately in changes to policy and practice. The results highlight different patterns of access within broad groups, for example between women in the White British and the White Other group or between the Black African and the Black Caribbean group. Interventions need to be targeted at specific groups of women.

The White Other group is the largest ethnic minority group in the data set and includes one in ten (10.4%) births in England. Further study is needed to better understand this group.

What’s next?

Further work is now needed to identify the precise reasons for the lower access to community mental health services of women in these groups.

The researchers are currently conducting interviews with women, their partners and family members, as well as with health professionals. They want to better understand the factors associated with problematic access to services. They will use these data to identify barriers specific to each ethnic minority group.

In the meantime, they suggest that increased awareness of perinatal mental illness among the general population would be helpful. Professionals could benefit from more training to increase expertise in diagnosis and treatment.

Hospitals need good interpreters, appropriate information for all groups, and flexible, culturally relevant services. The researchers say that staff need to work closely with families, social services and community organisations.

You may be interested to read

The full paper: Jankovic J, and others. Differences in access and utilisation of mental health services in the perinatal period for women from ethnic minorities – a population-based study. BMC Medicine. 2020; 18:245.

Information about perinatal health from NHS England

Implementing the Five Year Forward View for Mental Health, which describes how the NHS will improve mental health care

NHS Mental Health Implementation Plan 2019/20 – 2023/24, which provides details on the new framework to help improve mental health care

 

Funding: This study is funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research Programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

Before doing this research,  we thought that both access and utilisation of mental health services would be problematic for ethnic minority women during the perinatal period. However, it surprised us that once these women access mental health services, they tend to attend appointments and engage well. This suggests that the underlying issue is around access.

Women who really need help may not be accessing services or their access is delayed. Because the perinatal period is very short, the mother’s mental health can deteriorate quickly and not accessing treatment promptly could have a detrimental effect on the mother-baby relationship and the baby’s development.

The next step in our research is to understand the barriers and facilitators for accessing these services. Finding ways to improve access for women in specific ethnic minority groups should help to improve outcomes and reduce the impact of these mental health inequalities in the future.

Nikolina Jovanovic, Consultant Perinatal Psychiatrist, Senior Lecturer, Queen Mary University of London and East London NHS Foundation Trust

Member of the public

It’s important to collate figures to ensure that future policies, research and interventions are developed to enable access to perinatal mental health services for all. The barriers faced by ethnic minority groups need to be eradicated.

The research could increase levels of questioning, signposting and support for women by health and social care professionals, and mother and baby group leaders. It would be good to know whether earlier, effective interventions could reduce admissions, both voluntary and involuntary.

Understanding what stops women from ethnic minorities from accessing help will lead to improvements in the future. However, as this is likely to generate increased demand for perinatal mental health issues, it will be vital to ensure there is enough capacity to provide the right treatment and support for all women who need it.

Victoria Bartle, Public Contributor, Newcastle upon Tyne

Mental health midwife

This research can help with the ongoing development of maternity outreach clinics, as part of the NHS Long Term Plan. It can help with the education of healthcare professionals and the local community.

What we need now are voices to tell us what to do. This work is quantitative and gives us the numbers. We now need to know which services work, which don’t. If we get this right for people from ethnic minority backgrounds, we get it right for all.

Laura Bridle, Perinatal mental health midwife, Guy’s and St Thomas’ NHS Foundation Trust