Two sobering facts for you: 1) Suicide is the leading cause of maternal death in the period from six weeks to a year after birth, and 2) There are only 22 mother and baby units in the whole of the UK, with not a single one in Northern Ireland.
Perinatal mental illness – a leading complication of pregnancy – is in the news again. Services are crumbling and overstretched, and a postcode lottery means women are often struggling to access treatment, with devastating consequences. The new Labour MP Laura Kyrke-Smith has been speaking movingly about the death by suicide of her friend Sophie, who ended her life 10 weeks after the birth of her third child. Sophie had been suffering from anxiety, especially around her baby’s feeding, and they had spent a night in A&E, but it is unclear whether signs that she was at risk were picked up by professionals. Her friend has been left wondering if, amid all the worry about the baby, anyone asked her mother if she was OK, and what a difference that might have made not only to Sophie, but to the three young daughters she left behind.
In pregnancy, you are monitored for all sorts of physical complications. In fact, the average woman during pregnancy has 16 contacts with health professionals. They measure you and scan you and take your blood and urine samples and monitor you for pre-eclampsia and gestational diabetes. They should also ask you about your mood, but this doesn’t always happen, or not often enough. After you have your baby, your health visitor and GP should check the baby’s health and ask about the mum’s wellbeing, but it can sometimes feel like a tickbox exercise, and the attention paid to this, and the help available, can vary wildly from place to place.
The Maternal Mental Health Alliance and the Royal College of Midwives say that there are stark variations in the levels of care and the length of time it’s taking to access what could be lifesaving support. They and Kyrke-Smith want to prevent women at risk from slipping through the cracks by making mental health support fully embedded into routine maternity care. There have been great improvements in recent years – including the creation of designated mental health midwife posts – but there is a desperate need for more funding and staff.
I am a mother with some firsthand experience of the perinatal mental health system. I have waddled through the crumbling temporary buildings. I have sat on hold on the phone in tears. And I have felt the shame that sometimes hampers women for asking for help during what everyone tells you should be a wholly joyful period of your life. It took three referrals – two from a hospital consultant, and one from a particularly tenacious health visitor – to get me some specialist help.
There is, understandably, a high threshold for referral (though let’s be honest, it is probably too high). Services are so stretched that it can be difficult to think that you are deserving of care. “There must be so many women worse off than I am,” you think, even if you’re told that you absolutely should be receiving help. At a time of acute need and decades-long issues of underfunding, the notion of preventative maternal mental health care seems like a luxury, even though – as in my case – getting support established in pregnancy can help stop things reaching crisis point once the baby arrives.
I consider myself one of the lucky ones. I received outstanding care, especially from the mental health nurse, who made home visits and was in touch by phone. But sadly, it is help I would not necessarily have got in another borough or region. So many mums that I have met have soldiered on alone, or said, many years after the fact, “I think I had postnatal depression”, or “the thoughts I was having were not normal”. Helping women and their loved ones recognise when they need that extra support – and that they are deserving of it – should be a crucial part of the pregnancy journey. Asking how they are, listening to them, noticing any alarm signals, and signposting to relevant services is now standard in some trusts, but it should be everywhere.
There are places where charities are trying to fill the gaps, but lots of women need a higher level of care than free counselling delivered by volunteers. A friend who moved from London to Somerset is testament to this. She received brilliant care in her first, twin pregnancy, in Islington, but during her second pregnancy she had to opt for expensive private therapy. This was despite writing up a document summarising her history of postnatal depression (PND) and post-traumatic stress disorder (PTSD) and asking health professionals to read it.
What does this tell us? Depressingly, it suggests that even the most vocal self-advocates can struggle to access support, so what hope is there for those who feel they do not deserve it, who are vulnerable, or who haven’t spotted the signs that they need help?
There are many awful details in the story of Sophie’s case, from the messages she sent in those desperate first weeks, to the rich life she left behind. What made my own heart sink was reading about her difficulties with feeding. Kyrke-Smith has said how she doesn’t know “whether the conversations they were having about the baby’s feeding were done in a way that was considerate of the mental health struggles that my friend may have been having”. Since I wrote about my own challenges with breastfeeding, several mental health professionals have told me in private that they believe the way the NHS delivers Unicef’s baby-friendly breastfeeding policy can be incompatible with the safeguarding of women’s mental health. A 2022 study in Nature also raised concerns that exclusive breastfeeding promotion policies may exacerbate adverse maternal mental health outcomes. A truly baby-friendly policy values the sanity of that baby’s mother.
I am so glad that the conversation about maternal mental health is happening, and measures such as the introduction of specialist mental health midwives are a step in the right direction, but more funding, more staff, more education, more monitoring, more data, and more outreach are urgently needed. One in five women suffer from a mental illness in the perinatal period. When will mothers stop being left to cry it out?
Rhiannon Lucy Cosslett is a Guardian columnist and author. She is the author of a novel, The Tyranny of Lost Things, and a memoir, The Year of the Cat
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
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