The effectiveness and implementation of maternal mental health services

There is now a national commitment to implementing Maternal Mental Health Services (MMHS), formally referred to as ‘Maternity Outreach Clinics’ in the NHS long-term plan, and £22.6 million transformation funding for service delivery in 2020-22. NHS England (NHSE) investment in these services in the first phase (2020-22) will be provided to women in approximately 30 sites in all areas of England – ‘Early Implementer’ and ‘Fast Follower’ sites, before commissioning and funding of MMHS goes to Clinical Commissioning Groups (CCG) in the national scale up and sustainability phase (2022-24).

Project aim

The overarching aim of the project is to explore 'which MMHS model works, for whom, in what circumstances, how and why (i.e. what are the underlying mechanisms)?

About the MMHS

MMHS will provide multidisciplinary integrated care and support to women experiencing moderate to complex mental health difficulties arising from trauma or loss related to childbirth (e.g. post-traumatic stress following childbirth, tokophobia, miscarriage, stillbirth, neonatal death, pregnancy termination and loss of custody), whose needs are not currently met in other services. The services will provide trauma focused and psychological based interventions that have a strong clinical and cost-effectiveness evidence-base, however service delivery models will vary in different areas. Therefore, evaluation of the service configuration, delivery, and implementation of MMHS in Early Implementer and Fast Follower Sites is crucial to determine the most optimal and effective delivery models before funding goes to CCGs.

How the project will be carried out

The research team will take a realist evaluation approach which means asking what works, for which people, in what circumstances and why. They will use the following questions:

1. What is the variation in MMHS service delivery models in Early Implementer and Fast Follower sites across England?
2. What are the contexts, mechanisms, and outcome configurations of MMHS in Early Implementer and Fast Follower sites?
3. Are MMHS effective in improving mental health for women who have experienced trauma or loss related to childbirth?
4. Are the MMHS effective in improving psychological, knowledge, skills, and confidence in maternity staff?
5. How successful was the implementation of MMHS in Early Implementers and Fast Follower sites?
6. What factors (challenges and solutions) affected the implementation in Early Implementers and Fast Follower sites?
7. Do MMHS provide equitable access to care and provide opportunities for addressing health inequalities?

How patients and service users are involved in the research

The research team will work with the maternity and perinatal mental health ARC South London PPIE network and the section of women’s mental health Parent Advisory Group (PAG).The ARC South London PPIE group is a well-established diverse group of women, and representatives from service user led organisation with experience of maternity care and/or perinatal mental health difficulties.

The Women’s Mental Health PAG, is a group of women and partners with experience of mental health difficulties related to the perinatal period. These groups meet regularly on a quarterly basis to provide advice and guidance on all aspects of the research process, including research design, use of language, data collection and dissemination. They informed the need to establish a dedicated project PPIE and advisory group for for women who have experienced trauma or loss related to childbirth.

In addition, they will establish an advisory group with representatives from relevant voluntary organisations e.g Birth Trauma Association, Miscarriage Association, SANDs, the International Stillbirth Alliance, Tommy’s Baby Charity and Birth Companions. The advisory group will meet on six occasions throughout project to inform the development and delivery.

Our collaborators

• Professor Pauline Slade and Professor Helen Sharp, Department of Primary Care and Mental Health, Institute of Health and Life Sciences, University of Liverpool
• Professor Heather O'Mahen, Department of Psychology, Mood Disorders Centre, College of Life and Environmental Sciences, University of Exeter
• Laura Bridle, specialist perinatal mental health midwife, Guy’s and St Thomas’ NHS Foundation Trust
• Dr Sarah Brand, University of Exeter Medical School, St Luke’s Campus, Exeter
• Zoe Mulliez, senior programme manager, NHS England and NHS Improvement  

Potential benefits of the project

Findings from this evaluation will help identify the most optimal model to deliver the service and what contexts are barriers to implementation, to inform the national roll-out of this service.  Learning will help improve the effectiveness of the MMHS in identifying women with mental health difficulties associated with loss and trauma related to childbirth and accessing evidence-based treatment. In the longer term, it will help improve psychological outcomes for women and families and therefore has potential long-term benefits for maternal and child health and wellbeing. Inequalities begin before birth and interventions which can facilitate maternal mental health and family relationships provide lifelong scope for reducing health inequity.

This project (ESMI-III) was adopted by ARC South London Executive in January 2022. It is funded by NIHR under the NIHR National Priorities Programme Children’s health and maternity. It will be completed by September 2023.

Read more

Read the first report - ESMI-III: The Effectiveness and Implementation of Maternal Mental Health Services September 2022 Interim Report: Phase 1