Submission to the Saskatchewan Mental Health Commission from the MotherFirst: Maternal Mental Health Committee
November, 2013
Maternal Mental Health Committee: Submission to the Saskatchewan Mental Health Commission
Thank you for inviting MotherFirst, the Maternal Mental Health Strategy to submit to the Saskatchewan Mental Health Commission. We are pleased to see this attention to mental health in the province. We are hopeful the findings will include efforts to increase attention to maternal mental health through implementation of the MotherFirst: Maternal Mental Health Strategy. Maternal Mental Health
The World Health Organization states “There is no health without mental health” (p. 4).1 They have decreed that measures to prevent and improve maternal mental health problems are essential to achieve their Millennium Development Goal 5, Improve Maternal Health.2 Maternal mental health is the number one cause of morbidity and mortality in childbearing women;3 however, it remains one of the least investigated and treated medical problems in pregnancy and postpartum. Infanticide and suicide tragedies continue to make headlines worldwide. At the same time, the ongoing burden of maternal mental illness on the health of women and their families is increasing. As a result, there is increasing international attention to prevention, identification, treatment, and policy to address this important public and population health issue. Untreated, maternal mental health problems also pose serious emotional, physical, and economic consequences for the entire family.4, 5
MotherFirst: Maternal Mental Health Strategy for Saskatchewan
A group of concerned women and careproviders came together at a conference focused on Maternal Depression in Regina in the fall of 2009. Subsequently, a working group was formed with representation invited from the health regions, professions, Aboriginal health organizations, government, and other stakeholders, including women who had experienced maternal mental health problems. Dr. Angela Bowen facilitated coordination of this working group. It was initially supported through grants from the Canadian Institutes for Health Research and the Royal Bank of Canada Fund, at the College of Nursing, University of Saskatchewan.
The working group developed a set of policy recommendations, which were presented in a report, MotherFirst: Maternal Mental Health Strategy. These four recommendations included: 1) Increased awareness-education; 2) increased identification-universal screening; 3) increased access to treatment-prioritization of pregnant and postpartum women within mental health services; and 4) accountability for implementation of the recommendations through regional maternal mental health advisory groups and a provincial working group. These recommendations were presented to the Government of Saskatchewan and endorsed by the Ministry of Health in September 2010.
Subsequent meetings with the Minster of Health directed the working group to become an implementation committee, tasked with implementing the recommendations. Progress
Successes throughout the Province include: • •
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The development of the MotherFirst: Maternal Mental Health Strategy and document.6 Increased Awareness − Development and distribution of awareness and screening materials available through the Saskatchewan Prevention Institute. − Numerous public, professional, and various media presentations throughout the Province. A two-year Maternal Mental Health Therapist position within the Battlefords KidsFirst Program. Provision of short-term counselling through HealthLine. Distribution of HealthLine fridge magnets to new mothers throughout the province, using our maternal mental health logo. A pilot project between HealthLine and public health nurses, where HealthLine calls back women who are referred by their nurse and provides short-term therapy for them.
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Maternal Mental Health Committee: Submission to the Saskatchewan Mental Health Commission
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Active interdisciplinary, multi-sector Maternal Mental Health advisory groups in some regions (e.g., Prairie North Health Region). Implementation of the screening guidelines by Public Health Nurses at 2-3 weeks postpartum and 2- and 6month Child Health Clinic visits in at least three health regions (e.g., Kelsey Trail, Prairie North, and Prince Albert). Many other regions have increased attention to maternal mental health and a positive indication of a problem leading to screening using the EDPS tool. Some physician, nurse practitioner, and midwife practices have incorporated the EPDS into their 6-week postpartum check. A Care Guide for professional careproviders that includes suggestions for care and action with different anxiety and depression scores. This also includes an indication for screening the fathers. − Other groups across Canada have adapted this. A Maternal Mental Health Community Care Tool Kit by the Battlefords Maternal Mental Health Advisory Committee. − Adaptation of the Care Guide for use by community, front line workers. − Includes a series of handouts for women and their families (e.g., rest and sleep, exercise, family and friends). KidsFirst, Sunrise Health Region, developed a booklet that promote maternal mental health and attachment. − This has been highlighted at conferences across Canada Universal screening using the MotherFirst guidelines in many Public Health Nursing prenatal, postpartum and Child health Clinic services and programs throughout province. Public Health Agency of Canada funding to the Saskatchewan Prevention Institute, for reprinting and dissemination of awareness, screening, and care materials. Following the Saskatchewan Ministry of Health Strategy for Better Care, Sun Country Health Region developed a Regional strategy, which focused on Maternal Mental Health and Better Care for their clients and families. Facilitator for PPD Support group in Five Hills Health Region (temporarily funded through Community Initiatives Fund).
Areas for improvement for full implementation:
The perceived reasons for lack of uptake of all of the recommendations as endorsed are varied, and include: •
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Lack of an overall strategy for mental health within the province that includes specific policy to address maternal and infant mental health. Autonomy of the health regions. − Lack of power of working/implementation groups, beyond developing and presenting recommendations to decision makers. No expectations by government for the regions to implement the recommendations, which can lead to a lack of accountability by senior leadership to ensure that the needs of women and families at risk or struggling with maternal mental health problems are addressed. − Lack of consistent representation to the working group. If regions or organizations are not required to participate or having a local working group, they can easily pull their staff or not replace those on leave from their position. Lack of a high-profile case, whilst this may seem crude, and perhaps this a result of MotherFirst efforts to date, but unfortunately sometimes change does not occur unless there is external pressure, an index case, to spur implementation of the recommendations. Our goal is to prevent tragedy. − For example, the recent murder –suicide in Winnipeg by a postpartum woman, made national headlines. This could just as easily have been one of our mothers, but it was not, and without pressure, accountability for change can be avoided, and less ominous cases are easily forgotten. Lack of funding for the Maternal Mental Health Strategy: − The strategy started with research funding and with help from a funded graduate student from the Johnson Shoyama School of Public Policy. The Public Health Agency of Canada has provided funding for some reprinting and dissemination, but funding must be ongoing in order to implement and sustain the policy changes recommended in the MotherFirst report. Lack of National policy to address either mental health or maternal mental health.
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Maternal Mental Health Committee: Submission to the Saskatchewan Mental Health Commission
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Ongoing stigma associated with the identification or treatment of mental health problems.
Future Directions
What needs to happen to improve the mental health of our expectant and new mothers and their families? We need the MotherFrist implemented, as it was developed and endorsed, most urgently:
1. Accountability to the Ministry of Health from the regions. • Provide an identifiable maternal mental health service within every region or have a province-wide service available to all women throughout the province with local groups in larger centres. • Having trained staff, a part-time maternal mental health coordinator in each region or in the province as a whole, for women, their families, and care providers to contact with emergent or non-urgent questions about maternal mental health, awareness, and education of professionals. 2. Ensure universal screening is achieved using a validated tool, i.e., the Edinburgh Postnatal Depression Scale, following the guidelines.7 • Require the electronic prenatal record addresses screening before closing the file. • Ensure screening is part of the postpartum public health visit or phone call. • Implement screening at all child health clinics (2- (4) and 6-month immunization visits). 3. Ensure there are treatment services for our mothers and their families. • Provide for different levels of services, using a stepped care6 and shared care approaches for efficient use of tertiary, specialized mental health services.8 • Increase the access to support: − Support groups are effective and efficient ways for mothers to get relief from anxiety and depression symptoms9 and to develop ongoing skills to manage their mood, and increase attachment with their baby, but only three regions have any identifiable postpartum depression support group. − Develop electronic or telephone support services for rural and remote or socially isolated women. • Provide culturally sensitive services to Aboriginal10 (including Elders) and newcomer groups. 4. Provide funding to support the MotherFirst Activities, particularly awareness. • Provincial Working Group-secretarial and electronic meeting support. • Maintain www.skmaternalmentalhealth.ca, with a listing of identifiable maternal mental health services and resources within every region. • Ongoing provision and access to awareness and screening materials for public and professional use. • Provide funding to provide culturally and ethnically sensitive materials. 5. Support research into the factors associated with and particularly treatment of maternal mental health problems in our families. • Fund specific maternal mental health research awards and grants through the Saskatchewan Health Research Foundation. • Funding for regions to develop maternal mental health projects and pilot initiatives to meet the needs of their constituents.
The Maternal Mental Health Working/Implementation Group thanks the Commission for its interest in maternal mental health. We look forward to your final report. We are available to speak to the Commission further or provide clarification at any time. Respectfully submitted.
Attachments: Care Guide; MotherFirst Report.
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Maternal Mental Health Committee: Submission to the Saskatchewan Mental Health Commission
References 1. World Health Organization. Mental health: strengthening our response. Fact sheet N°220: WHO; 2010. 2. World Health Organization. Millennium Guideline 5. Maternal Mental Health. Switzerland: World Health Organization2008. 3. World Health Organization. Gender and Women's Mental Health. Geneva: World Health Organization; 2010; Available from: http://www.who.int/mental_health/prevention/genderwomen/en/. 4. World Health Organization. Women's mental health: A public health concern. 2006; Available from: http://www.searo.who.int/en/Section1243/Section1310/Section1343/Section1344/Section1353_5282.htm. 5. Wisner K, Buist A, Bowen A, Cantrell R, Glangeaud N. International Approaches to Perinatal Mental Health Screening as a Public Health Priority In: Gemmill A, Milgrom J, editors. Identifying Perinatal Depression and Anxiety: Evidence-based Practice in Screening, Psychosocial Assessment and Management. UK: Wiley; 2014. 6. MotherFirst. Maternal Mental Health Strategy: Building Capacity in Saskatchewan2010. 7. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry. 1987 Jun;150:782-6. 8. Bowen A, Baetz M, McKee N, Klebaum N. Optimizing maternal mental health within a primary health care centre: a model program. Canadian Journal of Community Mental Health. 2008;27(2):105-16 9. Dennis CL. Postpartum depression peer support: Maternal perceptions from a radomized controlled trial. International Journal of Nursing Studies. 2010;47:560-8. 10. Bowen A, Duncan V, Peacock S, Bowen R, Campbell D, Gawley L, et al. The state of the literature regarding depression, anxiety, and mood disorders in pregnant and postpartum First Nations, Inuit, and Indigenous women in North America (including Hawaii), Australia, and New Zealand. Transcultural Psychiatry. 2013;in press.
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