Perinatal pathways : a mixed methods study of specialist services for women at risk for poor perinatal mental health outcomes

Pregnancy is usually a time of celebration and excitement. It can also be a time of increased emotional and social vulnerability, as women enter a state of personal transition. Women with pre-existing physical or psychosocial needs enter motherhood with additional challenges. Poor perinatal mental health, for example anxiety and depression, stressful life events and poor social health, are associated with adverse outcomes for women, their children and their families. Pregnancy, birth and the postnatal period can therefore be marred by the experience of mental ill-health. Women experiencing complex health and social needs during the perinatal period (conception until 12 months post birth) benefit from early identification, integrated care pathways and comprehensive management plans to improve their emotional wellbeing and prevent mental health problems. Psychosocial assessment and depression screening has been incorporated into policy in New South Wales (NSW), Australia to assist health professionals to identify and refer women at risk of poor perinatal mental health outcomes to specialised or secondary services. Perinatal and infant mental health (PIMH) services are an emerging specialty area in mental health care in Australia. This convergent, embedded, mixed methods study aims to explore and describe two specialist PIMH services in NSW. The research questions in this study address: 1. the characteristics and risk factors of women referred to a specialist PIMH service, 2. the engagement practices of PIMH clinicians, 3. the therapeutic interventions that PIMH clinicians use, 4. collaboration between PIMH clinicians and other service providers, and 5. women's experiences of engaging with a PIMH service. Data were collected by reviewing 244 medical records of women who had been referred to the two PIMH services, transcribing textual illustrations from the medical records, and by interviewing six PIMH clinicians, two PIMH managers, five key stakeholders (four midwives and one social worker) and 11 women service-users. The quantitative data were analysed using SPSS (Statistical Package for the Social Sciences). The qualitative data were analysed in two phases: directed content analysis of all qualitative data and then thematic analyses of the interview data. Integration occurred during the design, data analyses, interpretation and reporting phases of the study. In mixed methods research designs, both the quantitative and qualitative data are synthesised or integrated to report the findings or inferences of a study. The women referred to the PIMH services have multiple and complex needs, indicating that the referral processes and referrals are appropriate. The PIMH clinicians focus on the infant and the mother-infant relationship, and are woman-led to enhance engagement. Clinicians underpin the therapeutic interventions they use with Attachment Theory by modelling a secure-base for women to emulate for their infants. There is a disconnection between the PIMH clinicians' and the key stakeholders' perspectives pertaining to collaboration, PIMH clinicians require support to work in more collaborative ways. Women service-users value their time with the PIMH service, however discharge practices leave some women feeling abandoned. Clinicians enjoy working with women who have been referred to the PIMH service, however they require ongoing support from colleagues and managers to negotiate an emotionally challenging environment and remain effective clinicians. In addition, the review of medical records revealed a lack of documentation about the attachment focus of the PIMH clinicians. Without clear documentation an important component of the clinicians' work remains invisible. The meta-inferences from this study progress from Attachment Theory to a Theory of Attachment Based Exploratory Interest Sharing (TABEIS). In this thesis TABEIS is presented as a model for PIMH clinicians to conceptualise their work with women who have been referred to their service but also as a way of relating to and understanding the actions of their colleagues, engaging with other professionals and working with them in more collaborative ways. The importance of knowledge translation and implications for clinical practice are also discussed. The importance of the perinatal period for the health and wellbeing of future generations has growing international recognition. The inferences and meta-inferences of this study add to the extant literature to promote the further development of policy, education and clinical practice for professionals who work with women and their infants at risk of poor perinatal mental health outcomes