(Originally written as an assignment for Masters in Public Health/Global Women’s Public Health)

Nature of Problem:

The perinatal[i] mental health (PMH) of women[ii] in the UK is an area of significant concern, needing investment and prioritisation to protect both women and their families’ lives. Poor mental health affects not just mothers: it can affect the child’s physical and emotional health[1], as well as other members of the familial unit[2]. Poor PMH can impact a foetuses’ heart rate[3], cause pre-term birth[4], and cause epigenetic DNA changes[5]. Prevention, detection, and treatment therefore are all crucial to support wider health.

PMH problems[iii] (PMHP) affect up to 20% of perinatal women[6]. This large sample, mixed-method study of perinatal women had responses from women already likely to be thinking about perinatal mental health, however the NHS[7] [8] support these statistics, making over-representation an unlikely influencer. Suicide is the biggest cause of maternal death in the first year post-birth and the second biggest in the first forty-two days post-birth[9]. These statistics have been collated by MBRRACE-UK from NHS reporting, cross-referenced with government resources, and analysed by multiple Expert Reviewers; the methodological rigour underpins the robustness of findings. PMHP cost the UK £8.1 billion per year[10]; economic modelling which includes a robust systematic review and meta-analysis following NICE standards, increasing internal and external validity. Three-quarters of this cost is associated with childhood morbidity[11].

There are regional variances in PMH in the UK. The North East has a referral rate to support services of 35% compared to the East’s 15%[12]: there is a similar regional response rate of respondents comfortable talking about their mental health with a healthcare professional and the report concludes the difference is likely due to (lack of) care received rather than need. The UK is not alone in its concerns over PMH. High Income Countries have a prevalence of PMHP in 7-15%[13] of perinatal women, Low-Middle Income Countries have a higher frequency of 16-25%[14]. These figures are not as recent as the standalone UK percentage so although the UK seems to have a higher rate it is possible that all countries have crept up over recent years. It is also possible that countries without the infrastructure to support large data collection under-report their prevalence.

Impact of Risk Factors:

Gender is a key determinant of good mental health: in England one in five women and one in eight men suffer a mental health disorder, with this number increasing in women over recent years but remaining stable in men[15]. PMH is clearly a factor in this gender disparity; it is possible that if a gender burden were removed in all other aspects of mental health determinants a disparity in prevalence between genders would still exist due to the perinatal period.

Birth trauma is a key trigger of PMHP, affecting around 30%[16] of women who have given birth. Factors influencing development of PMHP following birth trauma include those who have experienced any type of previous life trauma, an intervention-heavy birth, perceived poor care from their healthcare team, and those whose babies are born prematurely or are admitted to neonatal units[17]. Race, ethnicity, age, low socio-economic standing, and lack of empowerment in the birth-room are themselves a risk factor of developing these outcomes[18] [19] [20].  There is a paucity in research regarding prevention of birth trauma – reducing the root cause of an outcome rather than attempting to change the outcome itself may be the necessary action needed. There is also a disparity between both the topics that have been researched and the findings of the research carried out, and the experiences that women and midwives relay. To understand why such a disparity exists, and why preventing birth trauma has not been studied in any great detail needs the context of the UK’s maternity services. Obstetricians are, by their very specialty, more likely to only experience complicated births and have therefore normalised medical births in a way many midwives have not. Obstetricians are also more likely to conduct research, and their medical, male-orientated research is more likely to be funded than research into promoting the physiological norm due to the patriarchal nature of healthcare[21]. The biases of the researcher, therefore, result in research that misses some fundamental areas of lived experience. This is a situation that is changing, however it has become quite a deep-seated divide and the recent media coverage[22] of the newly released Ockenden Report[23] using the phrase “cult of natural birth” shows just how prevalent and entrenched medicalised birth has become. It is also possible that birth trauma figures are even higher as individuals may not count ‘feeling traumatised’ as a specific mental health problem if a diagnosis of PTSD has not been made, and a diagnosis might not be sought when the narrative around birth expects it to be a traumatic event[24].

Ethnicity is another key consideration of PMPH. Minority ethnic groups have a higher prevalence of PMHP while simultaneously being less likely to have them detected or treated[25]. Suffering a higher burden of poor mental health already from other determinants such as poverty, inequity in education and healthcare access, English as a second language, and community and cultural environments factor in these figures, however much current research ignores racism – both institutional and direct – in being a trigger for poor PMH. Since the 2018 MBRRACE report [26] a light has been cast on racial inequities in maternal mortality (including mental health) and grass-roots campaigns like FiveXMore[27] are championing change. Challenging deep-seated inequalities is an ongoing and lengthy process; the uncomfortable dissonance felt by maternity service workers has not fully receded to a point where research can be conducted into this with bias eliminated. It is, perhaps, not the ethnicity of a woman that is the determinant of poor mental health per se, but rather the intersection of a lifetime of socioeconomic factors that are underpinned by structural racial discrimination mixed with a healthy dose of individual ethnically-motivated prejudices. Consideration also need to be given to cultural stigma around mental health, which may exacerbate illnesses[28] [29] and ethnicities such as Travellers who commonly underutilise healthcare[30] meaning true data may be under-represented.

Strong links exist between socioeconomic status and mental health illness[31], a link continuing in the perinatal period[32]:  This study by Ban et al shows women in the most deprived quintile are up to 2.63 times more likely to develop PMHP compared to those in the least deprived quintile. It is, perhaps, unsurprising that women who have existing financial pressures would find them exacerbated by having a new addition to the household and that this increased pressure could trigger a PMHP. Linking in not meeting breastfeeding goals (discussed below) adds an additional financial pressure of circa £10 per week for a can of formula powder – doubly critical that when a woman wants or needs to breastfeed she is supported to do so. The large-scale cross-sectional analysis by Ban et al also correlates age and socioeconomic status: the older a woman is and the more deprivation she is in, the higher her chance of developing PMHP. The large sample size of 116,457 increases validity; although it is possible that those younger, those in higher deprivation or those in some minority ethnic groups are under-represented as they may be less likely to seek intervention.

Society has a role in supporting PMH. New mothers face pressure about how they and their baby should be feeling and behaving from multitudes of sources with many losing self-efficacy, triggering episodes of poor mental health due to a lack of empowerment. The decentralisation of extended families can result in a higher reliance on parenting books whose profit-driven priority is to sell a problem to be fixed by their method; reliance and ‘solutions’ that can trigger poor PMH[33].  How a mother feeds her baby is also a risk factor in triggering a PMHP. While breastfeeding is a protective factor against postnatal depression[34], poor mental health can be triggered if a mother does not meet her breastfeeding goals[35] [36].

The current Covid19 pandemic is limiting access to mental health services. A rapid response study has found that depression has increased by 26% and anxiety by 43% in perinatal women during the pandemic compared to perinatal women before the pandemic. Families feel they do not know where to access information and support[37] and service changes have contributed to suicide deaths[38]. With pandemic stressors on top of the ‘normal’ risk factors for poor PMH there is a big risk of a huge mental health crisis, swamping already underfunded and under-resourced services. Where usually women would have face-to-face appointments that would provide the opportunity to detect issues, these are not always happening (occurring virtually, where women have indicated that they are not comfortable talking about mental health issues over the phone[39]) or at all (where the healthcare team have been redeployed). 

Preventative Strategies:

Current detection of PMH relies on three access-points: pro-active requests for support; positively answering a wellbeing request from their healthcare professional; an existing complex mental health need resulting in a referral to a specialist pathway[40], however these are not without their potential pitfalls, the biggest being the woman being capable of vocalising her need – something which may be hard during a PMHP.  The NHS has prioritised mental health in their Five Year Forward View for Mental Health[41], transforming their Perinatal Mental Health Care Pathway[42] guidance, investing to meet greater need, and greater significance on mental health being placed on all contact points of perinatal women, including the newly contracted six-week postnatal maternal check via GP services[iv][43], although as this started at the peak of the pandemic the service has been oft-overlooked[44] this year.

Detection of PMHP could be improved by services strengthening their links; the NHS is not an homogenous entity and siloed working[45] between services creates gaps that women can slip through[46], especially in an under-resourced, over-worked environment where wellbeing checks become tick box exercises through time constraints, relationships between healthcare professional and service user do not have the opportunity to develop, and referred services have lengthy waiting times if a woman does manage to get that far. Healthcare professionals who interact with perinatal women need to have specific PMH training to help identify issues and be able to confidently manage a PMHP caseload in line with evidence-based pathways.

Prevention is better than cure: optimising preventative strategies is needed to reduce the burden of PMHP. The intersection and correlation of risk factors means that reducing prevalence of PMHP is no small task, starting with reducing long-term health inequalities in at-risk groups: gender, socioeconomic status, race, ethnicity, and LGBT+ status. If a woman is less likely to develop a mental health problem in a wider context it will only help in a perinatal context. However, much is to be done specifically in the perinatal period too. Reducing birth trauma – changing the narrative around how childbirth is ‘horrendous’ so people expect better[47], reducing unnecessary intervention[48], establishing strong relationships through continuity of carer[49], increasing doula use[50], good quality feeding support[51], and supporting new mothers instead of adding pressure to them[52] will all reduce a woman’s chance of developing a PMHP. Indeed, continuity of carer during pregnancy, the intrapartum and postnatal periods is of great benefit not just in preventing birth trauma and detecting mental health problems themselves, but also in detecting other psychosocial factors that can increase a woman’s chance of developing PMHP. Intimate partner violence increasing during pregnancy[53], poor social support, financial pressures and life stresses are all risk factors for developing PMPH[54] [55] and can all be reduced by a woman being cared for by a trusted midwife over the entire period.

The cost of funding sufficient PMH services is £0.28 billion per year compared to an annual cost to the UK of £8.1 billion[56]  – a compelling argument for public health strategic intervention. Key to all prevention strategies is the co-creation of services with experts-through-experience, paying particular attention to the most at-risk cohorts of women giving birth. World-beating PMH services are useless if mothers cannot attend[v]; women’s lived experiences and needs must be listened to. Although the NHS commits to co-production of services in all the guidance documented in this essay, the reality is that services are so fragmented and under resourced that co-production is often lip service at best.

It is inevitable that some PMHP will exist no matter how stringent the prevention and detection measures put in place are. Treatments need to be timely and accessible, and they need to take into consideration the family constraints a new mother has on her, including high-needs inpatient services. If drug treatment is deemed necessary it is important that prescribers consider a woman’s desire to continue breastfeeding and ensure that the prescribed medication is suitable for breastfeeding mothers, otherwise not meeting her breastfeeding goal could trigger poor mental health.

Peer support as well as medical care is a useful intervention in the treatment of PMHP[57]. It can help reduce feelings of isolation, validate feelings, and provide signposting to specialist services. Peer support services tend to be charity or third-sector led, a wary consideration that may lead to reduced public spending on essential services as the gaps are plugged by volunteers. Peer support is also a useful tool in encouraging under-represented groups to seek additional support, helping to validate feelings in demographics where taboos exist about talking about mental health[58].

There is a wealth of data showing facts and figures around PMH: qualitative research is needed – and the importance of findings acknowledged – to prevent and detect PMHP and create services fit for purpose at treating. Only a multi-factorial position that puts women at the heart of the framework will reduce prevalence of PMHP.

Conclusion

PMHP are a changing burden on women in the UK. Women bear the brunt of the burden for obvious gender reasons, and the burden is increasing over time. Birth trauma is increasing, driven by increasing medicalisation of birth, advancing maternal age, and pandemic restrictions[59] [60]. Non-white-British population is increasing[61], and although work is being done to combat health inequities in ethnic minority populations it is yet to be seen whether this will offset an increase in racially motivated prejudice[62]. Women continue to bear the burden of socioeconomic deprivation, a trend not declining[63]. The intersection of all these risk factors seems set to continue to adversely impact the burden of PMH. Existing strategies for prevention need to be strengthened and optimised to reduce prevalence – including society changing to meet its obligation in reducing the burden on women.

REFERENCES

---

[i] Using the widely used definition being from conception to one year post childbirth unless explicitly stated.

[ii] This report recognises that not all people who give birth are women, however for stylistic purposes ‘women’ has been used throughout.

[iii] ‘Problems’ has been used rather than ‘disorders’ as disorders implies a medical diagnosis which may not be true for all women.

[iv] A check that has been done for years but has not been contracted – therefore GP’s paid for and obliged to complete – until April 2020.

[v] A conversation with a new mother in 2019: a need specialist PMH support was detected, a local service available and had capacity – the mother unable to attend as babies not allowed to attend appointments. Her partner worked and could not take time off without financial impact. Financial strain would have added to the poor mental health situation. No family available to assist and baby was exclusively breastfed anyway.

---

[1] Stein A. Pearson R.M. Goodman S.H. Rapa E. Rahman A. McCallum M. Effects of perinatal mental disorders on the fetus and child. The Lancet, 2014.

[2] Watson H, Harrop D, Walton E, Young A, Soltani H. A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe. 2019. PLoS ONE 14(1): e0210587. doi.org/10.1371/journal.pone.0210587

[3] Kinsella MT, Monk C. Impact of maternal stress, depression and anxiety on fetal neurobehavioral development. Clinical Obstetrics and Gynecology. 2009;52:425–440.

[4] Yonkers K A, Smith MV, Forrary A, Epperson C N, Costello D, Lin H, Belanger K. Pregnant women with posttraumatic stress disorder and risk of preterm birth. JAMA Psychiatry. 2014;71,897-904

[5] Serpeloni F, Radtke K M, Hecker T, Sill J, Vukojevic V, Assis S G. Schauer M, Elbert T, Natt D. Does Prenatal Stress Shape Postnatal Resilience? – An Epigenome-Wide Study on Violence and Mental Health in Humans. Frontiers in Genetics. 2019;10,269. Doi: 10.3389/fgene.2019.00269

[6] Russell K, Ashley A, Chan G, Gibson S, Jones R on behalf of Royal College of Obstetricians and Gynaecologists. Maternal Mental Health – Women’s Voices. 2017. [https://www.rcog.org.uk/globalassets/documents/patients/information/maternalmental-healthwomens-voices.pdf]

[7] NHS. Mental Health Implementation Plan. July 2019. [https://www.longtermplan.nhs.uk/publication/nhs-mental-health-implementation-plan-2019-20-2023-24/]

[8] NHS England, NHS Improvement, National Collaborating Centre for Mental Health. The Perinatal Mental Health Care Pathways. May 2018. [https://www.england.nhs.uk/wp-content/uploads/2018/05/perinatal-mental-health-care-pathway.pdf]

[9] Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. Oxford: National Perinatal Epidemiology Unit, University of Oxford. 2019

[10] London School of Economics and Centre for Mental Health. The costs of perinatal mental health problems. October 2014 [https://www.centreformentalhealth.org.uk/sites/default/files/2018-09/costsofperinatal.pdf]

[11] Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313-327. doi:10.1002/wps.20769

[12] Russell K, Ashley A, Chan G, Gibson S, Jones R on behalf of Royal College of Obstetricians and Gynaecologists. Maternal Mental Health – Women’s Voices. 2017. [https://www.rcog.org.uk/globalassets/documents/patients/information/maternalmental-healthwomens-voices.pdf]

[13]  Maternal Health taskforce. Center of Excellence in Maternal and Child Health. 2018. [https://www.mhtf.org/topics/perinatal-mental-health/]

[14] Maternal Health taskforce. Center of Excellence in Maternal and Child Health. 2018. [https://www.mhtf.org/topics/perinatal-mental-health/]

[15] McManus S, Bebbington P, Jenkins R, Brugha T. Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. [http://content.digital.nhs.uk/catalogue/PUB21748/apms-2014-full-rpt.pdf]

[16] Ayers, S. (2014). Fear of childbirth, postnatal post-traumatic stress disorder and midwifery care. Midwifery 30, 145–148. doi: 10.1016/j.midw.2013.12.001

[17] Soet, J. E., Brack, G. A., and Dilorio, C. Prevalence and predictors of psychological trauma during childbirth. Birth 2003;30, 36–46. doi: 10.1046/j.1523-536X.2003.00215.x

[18] Attanasio LB, Hardeman RR, Kozhimannil KB, Kjerulff KH. Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status. Birth. 2017;44(4):306-314. doi:10.1111/birt.12305

[19]  Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. Oxford: National Perinatal Epidemiology Unit, University of Oxford. 2019

[20] Greenfield M, Jomeen J, Glover L. “It Can’t Be Like Last Time” – Choices Made in Early Pregnancy by Women Who Have Previously Experienced a Traumatic Birth. Frontiers in Psychology. 2019; 10,56.

[https://www.frontiersin.org/article/10.3389/fpsyg.2019.00056]

Doi:10.3389/fpsyg.2019.00056

[21] https://www.theguardian.com/education/2018/aug/10/female-scientists-urge-research-grants-reform-tackle-gender-bias

[22] https://www.independent.co.uk/news/health/shrewsbury-maternity-scandal/shrewsbury-maternity-normal-birth-baby-deaths-b1769399.html

[23] Ockenden D on behalf of Independent Maternity Review. Emerging Findings and Recommendations from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust. 2020. [https://www.donnaockenden.com/downloads/news/2020/12/ockenden-report.pdf]

[24] Ashworth S. It’s time to raise your standards and stop expecting birth to be hell. Huffington Post. 2015. [https://www.huffingtonpost.co.uk/suzy-ashworth/stop-expecting-birth-hell_b_6461242.html?guccounter=1]

[25] Watson H, Harrop D, Walton E, Young A, Soltani H. A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe. 2019. PLoS ONE 14(1): e0210587. doi.org/10.1371/journal.pone.0210587

[26] Knight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2018

[27] FiveXMore. [https://www.fivexmore.com/]

[28] Time To Change. Family Matters: A report into attitudes towards mental health problems in the South Asian community in Harrow, North West London. 2010. [https://www.time-to-change.org.uk/sites/default/files/imce_uploads/Family%20Matters.pdf]

[29] Rethink Mental Illness. Black, Asian and Minority Ethnic Mental Health Factsheet. 2020. [https://www.rethink.org/advice-and-information/living-with-mental-illness/wellbeing-physical-health/black-asian-and-minority-ethnic-mental-health/]

[30] Smith, D. Ruston, A. ‘If you feel that nobody wants you you’ll withdraw into your own’: Gypsies/Travellers, networks and healthcare utilisation. Sociol Health Illn. 2013;35:1196-1210. doi.org/10.1111/1467-9566.12029

[31] Lorant V, Deliège D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic Inequalities in Depression: A Meta-Analysis. American Journal of Epidemiology. 2003;157(2):98–112, doi-org.manchester.idm.oclc.org/10.1093/aje/kwf182

[32] Ban L, Gibson J E, West J,  Fiaschi L, Oates M R, ata L J. British Journal of General Practice. 2012;62(603):e671-e678. doi.org/10.3399/bjgp12X656801

[33] Harries V, Brown A. The association between use of infant parenting books that promote strict routines, and maternal depression, self-efficacy, and parenting confidence, Early Child Development and Care. 2019;189:8, 1339-1350. 10.1080/03004430.2017.1378650

[34] Butler M S, Young S L, Tuthill E L. Perinatal depressive symptoms and breastfeeding behaviors: A systematic literature review and biosocial research agenda. Journal of Affective Disorders. 2020. doi.org/10.1016/j.jad.2020.11.080

[35] Dennis C. L., McQueen, K. The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics. 2009;123(4), e736-e751.

[36] Brown A, Rance J, Bennett P. Journal of advanced nursing. 2016;1;72(2):273-82.

[37] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. 2020. [https://babiesinlockdown.info]

[38] Knight M, Bunch K, Cairns A, Cantwell R, Cox P, Kenyon S, Kotnis R, Lucas N, Lucas S, Marshall L, Nelson-Piercy C, Page L, Rodger A, Shakespeare J, Tuffnell D, Kurinczuk, J. Saving Lives, Improving Mothers’ Care Rapid report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK Maternal, Newborn and Infant Clinical Outcome Review Programme. 2020. [www.hqip.org.uk/national-programmes]

[39] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. 2020. [https://babiesinlockdown.info]

[40] NHS England, NHS Improvement, National Collaborating Centre for Mental Health. The Perinatal Mental Health Care Pathways. May 2018. [https://www.england.nhs.uk/wp-content/uploads/2018/05/perinatal-mental-health-care-pathway.pdf]

[41] Mental Health Taskforce on behalf of NHS England. 2016. [https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf]

[42] NHS England, NHS Improvement, National Collaborating Centre for Mental Health. The Perinatal Mental Health Care Pathways. May 2018. [https://www.england.nhs.uk/wp-content/uploads/2018/05/perinatal-mental-health-care-pathway.pdf]

[43] NHS England. Investment and Evolution: Update to the GP contract agreement 2020/21 – 2023/24. 2020. [https://www.england.nhs.uk/wp-content/uploads/2020/03/update-to-the-gp-contract-agreement-v2-updated.pdf]

[44] Multiple authors. 2020. Personal Conversations from [redacted]; Birth Rights; Pregnant Then Screwed.

[45] McCartney M. Breaking down the silo walls. BMJ. 2016;354:i5199 [https://www-bmj-com.manchester.idm.oclc.org/content/354/bmj.i5199]

[46] NHS Partners Network. NHS Confederation. A stitch in time – the future is integration. 2012. [https://www.nhsconfed.org/-/media/Confederation/Files/Publications/Documents/A_stitch_in_time_the_future_is_integration.pdf?dl=1]

[47] Duncan L G, Cohn M A, Chao MT et al. Benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with active comparison. BMC Pregnancy Childbirth. 2017;17,140. [https://doi-org.manchester.idm.oclc.org/10.1186/s12884-017-1319-3]

[48] Greenfield M, Jomeen J, Glover L. “It Can’t Be Like Last Time” – Choices Made in Early Pregnancy by Women Who Have Previously Experienced a Traumatic Birth. Frontiers in Psychology. 2019; 10,56. [https://www.frontiersin.org/article/10.3389/fpsyg.2019.00056] Doi:10.3389/fpsyg.2019.00056

[49] Homer C, Leap N, Edwards N, Sandall J. Midwifery continuity of carer in an area of high socio-economic disadvantage in London: A retrospective analysis of Albany Midwifery Practice outcomes using routine data (1997–2009). Midwifery. 2017;48:1-10. [https://doi.org/10.1016/j.midw.2017.02.009]

[50] Gruber KJ, Cupito SH, Dobson CF. Impact of doulas on healthy birth outcomes. J Perinat Educ. 2013;22(1):49-58. doi:10.1891/1058-1243.22.1.49

[51] Brown A, Rance J, Benett P. Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing. 2015;72(2). doi.org/10.1111/jan.12832

[52] Harries V, Brown A. The association between use of infant parenting books that promote strict routines, and maternal depression, self-efficacy, and parenting confidence, Early Child Development and Care. 2019;189:8, 1339-1350. 10.1080/03004430.2017.1378650

[53] Finnbogadóttir H, Dykes A K. Increasing prevalence and incidence of domestic violence during the pregnancy and one and a half year postpartum, as well as risk factors: -a longitudinal cohort study in Southern Sweden. BMC Pregnancy Childbirth. 2016;16,327. doi.org/10.1186/s12884-016-1122-6

[54] O’Hara M W, Wisner K L. Perinatal mental illness: Definition, description and aetiology. Best Practice & Research Clinical Obstetrics & Gynaecology. 2014;28(1);3-12. doi.org/10.1016/j.bpobgyn.2013.09.002

[55] Phillis S. The benefits of Continuity of Carer: a midwife’s personal reflection. Patient Safety Learning Hub. 2020. [https://www.pslhub.org/learn/patient-safety-in-health-and-care/high-risk-areas/maternity/midwifery-continuity-of-carer/the-benefits-of-continuity-of-carer-a-midwife%E2%80%99s-personal-reflection-r3573/?fbclid=IwAR05njsyuvBmwyUvdyDJwSlhsESMN1vhd6NbaRyZJFjdQf5SCB3dtA5328U]

[56] London School of Economics and Centre for Mental Health. The costs of perinatal mental health problems. October 2014 [https://www.centreformentalhealth.org.uk/sites/default/files/2018-09/costsofperinatal.pdf]

[57] Jones C, Jomeen J, Hayter M. The impact of peer support in the context of perinatal mental illness: A meta-ethnography. Midwifery. 2014;30(5):491-498. doi.org/10.1016/j.midw.2013.08.003

[58] Billsborough J et al. Evaluating the side by side peer support programme. McPin Foundation. St George’s University of London. 2017. [https://mcpin.org/wp-content/uploads/side-by-side-final-impact-evaluation-report.pdf]

[59] NHS Digital. NHS Maternity Statistics, England 2019-2020. 2020. [https://digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2019-20/deliveries—time-series]

[60] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. 2020. [https://babiesinlockdown.info]

[61] Office for National Statistics. Population of England and Wales. 2020. [https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/population-of-england-and-wales/latest]

[62] Home Office. Official Statistics; Hate Crime, England and Wales: 2019-2020. 2020. [https://www.gov.uk/government/publications/hate-crime-england-and-wales-2019-to-2020/hate-crime-england-and-wales-2019-to-2020]

[63] Reis S. DWP data reveals: women and children continue to be worst affected by poverty. Women’s Budget Group. 2019. Available at https://wbg.org.uk/blog/dwp-data-reveals-women-continue-to-be-worst-affected-by-poverty/. Accessed 5 January 2020.