Understanding perinatal mental healthcare referral decisions among midwives and health visitors

Introduction: Approximately half of women requiring perinatal mental health (PNMH) care do not receive treatment despite having routine contact with midwives (MWs) and health visitors (HVs). Little attention has been paid to MWs’/HVs’ decision-making regarding referring women for secondary PNMH care. In particular, the impact that the level of local specialist PNMH services may have on MWs’/HVs’ referral decisions is unexplored.

Aims: To understand MWs’/HVs’ decision-making in relation to referring women for secondary PNMH care to identify barriers and facilitators to effective and timely referrals including any impact of having local secondary PNMH service provision.

Methods: Participants were recruited from four NHS Trusts in England, located across two geographical areas, that each provided different levels of PNMH services. One area had PNMH services that met NICE guidelines; the other area had no PNMH services. A sequential mixed methods design was employed comprising three phases. Phase 1: Semi-structured interviews with midwifery managers and health visiting clinical leads (n=5, from all four Trusts) to establish PNMH referral pathways and service provision available to the MWs/HVs working in the two geographical areas. Phase 2: In-depth qualitative semi-structured interviews with clinical MWs/HVs (n=24 consisting of: MWs=16, HVs=8; area with PNMH provision=15, area without PNMH provision=9) to explore their approach to PNMH referral decision-making, analysed using thematic analysis. Phase 3: Bespoke questionnaire, based on the findings from Phase 2, administered to 755 MWs and HVs in the two geographical areas, to measure factors that impact on PNMH referral decision-making among MWs/HVs allowing for statistical comparisons to be made between MWs/HVs, and geographical areas.

Findings: Three overarching themes were identified from the qualitative interviews that reflected MWs and HVs perceived barriers and facilitators to PNMH referral decision-making: identifying need; education, skills and training; and referral pathways.

A total of 99 responses were received for the questionnaire (overall response rate: 13.1%. Response rate for: MWs=11%, HVs=18%; area with PNMH provision=8.72%, area without PNMH provision=38%). There were few significant differences between MWs and HVs and between the two geographical areas on the reported barriers and facilitators to referring women for PNMH care. The most commonly overall reported facilitators to referral decision-making among MWs/HVs were a trusted relationship (97%) and routine enquiry of women’s mental health (91%). The most commonly overall reported barriers to referral decision-making were stigma associated with mental ill-health (83%) and the perceived fear by women of losing custody of their child (81%).

Conclusion: Qualitative and quantitative analysis revealed that fundamental to MWs’ and HVs’ decision-making was the relationship between themselves and women. Furthermore, whilst the provision of PNMH services is important for women in ensuring they receive appropriate and timely PNMH care, it appeared less important to MWs’ and HVs’ decision-making than the manner in which maternity and health visiting services were delivered. More important factors to MWs and HVs were whether or not they were able to provide continuity of carer and build trusted relationships with women allowing MWs/HVs to identify those women who would benefit from referral for specialist PNMH care.