Perinatal mental health and the COVID-19 pandemic.

Abstract

Howard and Khalifeh1 provide us with an excellent account of the epidemiology of perinatal mental health; the importance of social determinants of mental ill health, such as poverty, racism, and gen-der-based violence; and the state of current evidence to inform intervention and service delivery models. Their timely and comprehensive review of the current state of evidence identifies critical gaps in knowledge that will be important to address as the COVID-19 pandemic unfolds, particularly with regard to the intersection of individual level and community level interventions. Once the worst impacts of the COVID-19 pandemic are past, the questions that should concern us are: a) how well prepared were we for an event on this scale; b) what service delivery models and intervention strategies are the most effective in supporting parent mental health when families and communities are faced with such large-scale upheaval; and c) what can be done to guard against events such as COVID-19 further entrenching mental -hea-lth inequalities, both within high income countries, and between low, middle and high income countries. With governments enforcing restrictions on travel, closing schools and workplaces, encouraging people to stay at home and limiting social gatherings, families with young children face a series of multi-faceted and unanticipated challenges. First-time parents are finding themselves caring for a newborn at home with limited or no access to support from extended family and restricted access to primary health care and mental health services. Parents of older children are faced with keeping them occupied at home for an extended (and unknown) period of time, coupled with responsibility for supervision of home schooling. Millions of people previously employed have lost their jobs, with little chance of finding alternative employment at least in the short term. Those fortunate enough to have ongoing employment are having to navigate ways of maintaining paid work schedules and simultaneously manage the care of children at home. Not surprisingly, by early April 2020, the Australian national helpline for parents experiencing perinatal depression or anxiety (PANDA) had already recorded a 30% increase in calls to its telephone counselling service. Globally, family violence services are also gearing up for an escalation of domes-tic violence in coming months. Governments everywhere are struggling to manage both the economic and social fallout of containment measures, and what this means for citizens. In the past few months, the Aus-tralian government has announced an ad-ditional $150m for domestic violence services and free child care for working parents with children under five years of age. These measures are welcome and, in the case of free child care, represent a huge turnaround in Australian government policy. However, other public health measures that normally provide support to families have been drastically curtailed. For example, publicly funded maternal and child health services can no longer provide new mothers groups or home visiting services. Programs specifically designed to provide culturally appropriate care and support to socially disadvantaged populations, such as group pregnancy care for families of refugee background, have also been wound back2. In low and middle income countries, evidence suggests there will be even more stark consequences of containment measures for children and families who are already vulnerable3. It has long been recognized that perinatal mental ill health has a complex etiology with both biological and social determinants4. The contribution of social and environmental factors such as gender-based violence, racism and forced migration is reflected in the higher prevalence of perinatal mental health disorders among women experiencing intimate partner violence and other adverse life circumstances5, 6. In a longitudinal study of over 1,500 first-time mothers conducted by our group, one in three women experienced depressive symptoms during the first 12 months postpartum, and of these, two fifths (40%) had experienced emotional and/or physical violence by a current or former intimate partner in the first year after childbirth6. Gender-based violence, racism and other forms of human rights abuse have their roots in institutions and systems that fail to give all citizens equitable access to social and economic resources. Consideration of these contextual factors in framing service delivery responses is a critical element of high-quality mental health care, clearly articulated in the United Nations Sustainable Development Goals. As Howard and Khalifeh argue, public health interventions are also needed to tackle social determinants of risk for poor perinatal mental health at a systems and community level. The COVID-19 pandemic necessitates worldwide action to strengthen both public health interventions promoting perinatal mental health and the capacity of mental health care services to support and enable the resilience of families dealing with cumulative social and economic stresses at times of crisis7. Howard and Khalifeh identify significant evidence gaps related to treatment efficacy, especially for women facing difficulties related to poverty, racism, stigma and interpersonal violence. They also draw attention to the paucity of evidence regarding large scale community-level interventions tackling system change with local contextual solutions. Strategies that work for particular communities and contexts may not work in others. In the Australian setting, this is most evident in relation to First Nations people, who experience markedly worse perinatal mental health outcomes than non-Indigenous Australians8. Mental health clinicians, health services and communities all have important roles to play in the development of rapid responses to limit the escalation and persistence of perinatal and other mental health disorders as a result of the COVID-19 pandemic. It is critical that the opportunity is not lost to ensure that these responses include the development and testing of co-designed strategies that build community-level resilience, foster strengths-based, trauma informed approaches, and tackle the sources of mental health inequalities globally. Better tailoring of individual level responses, taking account of social, economic and cultural contexts and engaging consumers and communities in the co-design of local primary health care and mental health services, is also needed to avoid further entrenchment of health inequalities9.