People with mental disorder, especially those in contact with mental health services, are at an increased risk of adverse obstetric and neonatal outcomes, such as low birth weight and prematurity. These adverse outcomes can have lifelong effects on the health of the developing child (Spry et al., 2020, Stein et al., 2014).
Both birthing and non-birthing individuals using mental health services experience some of the worst physical and mental health and are often more likely to be exposed to a range of potentially modifiable risk factors for these adverse outcomes, such as violence and abuse, unplanned pregnancy, substance misuse, poor nutrition, obesity and co-morbid physical ill health (Catalao et al., 2020).
This study aims to investigate how to support individuals of reproductive age in contact with mental health services, to improve planning and preconception physical and mental health.
There is an increasing recognition of the impact that ‘preconception’ (prior to pregnancy) health can have on subsequent parental and child health (Stephenson et al., 2018). In addition, many of the modifiable risk factors for adverse outcomes, such as obesity, may take several months or even years to address, necessitating early intervention to manage risks across the reproductive life course.
Supporting those using mental health services to plan for healthy pregnancy could improve the health of future generations but will also optimise the health and wellbeing of the reproductive age population regardless of their eventual pregnancy intentions.
Since the expansion of community perinatal mental health services in England in response to the NHS England Five Year Forward View and more recently the Long Term Plan, ‘preconception counselling’ is being offered to birthing people with mental disorder actively planning pregnancy, as recommended by the National Institute for Health and Care Excellence (NICE) (NICE, 2020, NICE, 2021).
However, the impact of this expanded service on pregnancy outcomes, specifically what works and for which particular groups, is not yet known. There is evidence that those from minority ethnic groups, who are already at increased risk of mental disorder and adverse obstetric outcomes, may be less likely to use perinatal mental health services (PMHS) (Pilav et al., 2022). Preconception clinics within PMHS usually only serve birthing people actively planning a pregnancy, with a focus on those taking medication.
Mental health services such as community mental health teams are in contact with individuals throughout the reproductive life course, so could provide an opportunity for conversations about optimising health for a planned (or often unplanned) pregnancy and signposting to potential sources of support. My research so far has indicated that people using mental health services want support to plan for pregnancy, through conversations which are sensitive and non-judgemental during periods of stability in their mental health.
Evidence also suggests that mental healthcare professionals would like clear, easily accessible resources on supporting healthy pregnancies and training on how to use them (Dolman et al., 2013, Public Health England, 2021).
Thus, there is an urgent need to understand how all individuals using mental health services, particularly those from under-served groups, can be supported with planning and fitness for pregnancy.
Researchers will use a mixed methods study including focus groups and semi-structured interviews with clinicians and patients across selected mental health services in South London and North East England alongside routinely collected data on service use. They will ask three questions:
Researchers will co-design (with patients and clinicians in South London and the North East) a decision-making tool to support health and wellbeing in the context of planning and fitness for pregnancy. Using qualitative methods, acceptability, appropriateness and feasibility of the tool will be assessed. A cluster randomised feasibility trial will assess feasibility of an effectiveness trial across mental health services in South London and the North East utilising routinely collected data and focus groups with clinicians.
In the short-term, there is transferrable learning to other services supporting those with mental disorder such as, primary care and third sector. The findings from this population could also inform development of preconception interventions in other marginalised groups. In the longer-term, the aim is to further test the tool’s effectiveness and cost effectiveness via a multi-site cluster randomised controlled trial, including its impact on preconception physical and mental health, with potential to also explore birth outcomes of the intervention in the future.
The project lead will work with a range of individuals and organisations with relevant expertise, community connections, social media skills and network building to recruit to a Patient Advisory Group (PAG). The project lead will work with the PAG to draw up a Terms of Reference and discuss the expectations of and motivations for the involvement of each of the individual members of the PAG and work with them to identify their support and training needs.
Members of the PAG will receive peer support from the patient and public involvement coordinator. They will attend regular meetings and will be involved throughout the research process including opportunities to be involved in the manuscript and producing a lay summary of findings, public engagement and dissemination.
This project includes a wide range of collaborators including representatives from: ARC North East and North Cumbria, Northumberland, Tyne and Wear (CNTW) Trust, South London and Maudsley NHS Trust, SHRINE (Sexual and Reproductive Health Rights, Inclusion and Empowerment), UCL and King’s Policy Institute.
The project was adopted by ARC South London Executive in October 2023. It is funded by an NIHR Advanced Fellowship and will be completed by August 2028.
