Clinical practice guidelines are key in evidence-based practice. They are “statements that include recommendations intended to optimise patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” (US Institute of Medicine, 2011).

There is evidence supporting the importance of clinical practice guidelines in the perinatal period. For example, a 2014 NHS England guideline recommended that women with pre-existing (complex and severe) mental health difficulties should be referred to specialist mental health services during pregnancy and the postnatal period for timely assessment and treatment (Howard et al., 2014). Alongside this, NHS England invested £365 million to increase the availability of perinatal mental health services from 2016. Recent research, covered in this blog, assessed the implementation of community perinatal mental health teams and found a lower risk of relapse for women with a history of severe mental illness after giving birth in regions with access to these teams (Gurol-Urganci et al., 2024).

Now that community perinatal mental health teams are up and running, it is important that clinical practice guidelines are used to ensure equity of care amongst services in the NHS. This review helps to summarise current guidelines for psychological and psychosocial assessment and intervention during the perinatal period.

Methods

This review was pre-registered, followed Johnston and colleagues’ (2019) methodological guidelines for systematic reviews of clinical practice guidelines, and used the PRISMA checklist for the preparation of systematic reviews.

A systematic search was conducted on databases of literature and guidelines, and a search was also conducted of relevant healthcare professional bodies. Guidelines that were published between 2012 and 2022 were included. Search terms were adapted for each database and combined terms for the perinatal period with the term ‘mental.’ In the database searches, when available, filters for guidelines were applied.

Guidelines were included that described psychological assessment and/or intervention for perinatal mental health difficulties. The guidelines could be for women, the mother-baby dyad and/or partners.

Two reviewers conducted the title and abstract screens. Data were extracted for each guideline to record whether it covered the target population (e.g., women, mother-infant dyad, partners) and the four stages of assessment and intervention (e.g., antenatal and postnatal assessment and intervention). A narrative synthesis was conducted to describe the recommendations, identify themes and compare the guidelines.

Study quality was assessed by two reviewers using the Appraisal of Guidelines for REsearch & Evaluation (AGREE-II) Instrument, which is an instrument specifically designed for assessing guideline quality. The overall quality score was presented alongside whether the authors recommended the guideline to be used (‘yes’, ‘yes with modifications’ or ‘no’).

Results

The results were presented through 1) a brief summary of each guideline, 2) themes from all the guidelines on recommendations for assessment/intervention and 3) comparisons between the guidelines.

Summary and quality of guidelines

Seven guidelines were included in the review, which are briefly summarised below:

Most guidelines covered all assessed areas of the target populations (i.e., women, mother-infant dyad, partners) and stages of assessment and intervention (i.e., antenatal and postnatal assessment and intervention). However, SIGN did not cover the mother-infant dyad or partners in the antenatal period or partners in the postnatal period, and RNAO did not cover partners in either period.

COPE received the highest quality rating, with a mean of 99% across the AGREE-II domains. This guideline was reviewed as clearly presented, easy to follow, covering a wider range of areas, culturally sensitive and family-centred.

Themes from guidelines

Three themes were identified among the guidelines:

1. Specific therapeutic approaches in perinatal context (e.g. CBT for mothers, video interaction guidance for the mother-infant dyad)
2. Equitable care considerations
3. Individual and systemic considerations (e.g. safety planning, care planning).

Within the equitable care consideration theme, recommendations were grouped into three categories:

1. Therapeutic relationship
2. Cultural and diversity considerations
3. Environmental considerations such as timing.

Comparisons between the guidelines

Although the guidelines varied in their recommendations for psychological and/or psychosocial assessment and intervention in the perinatal period, the key recommendations remained consistent.

SIGN, COPE and RNAO included consensus-based recommendations based on the expertise of the guideline development groups in the absence of quality evidence (e.g., regarding trauma-informed care). Notably, there were more consensus-based than evidence-based recommendations.

Conclusions

The authors note that the content of the key recommendations was generally consistent between the seven included guidelines but that the quality of the guidelines varied. Guidelines were generally broad (i.e., not specific to psychiatric diagnoses). As well as mothers, partners and the mother-baby dyad were considered in most recommendations, however, the authors advocate for more research with these populations.

Strengths and limitations

This review provides a useful summary of clinical practice guidelines on psychosocial and psychological assessment and intervention during the perinatal period. The overview of each guideline will be particularly useful for busy NHS clinicians working in perinatal services. Since the guidelines were generally broad, this can help clinicians meet the contextual needs of people with mental health difficulties in the perinatal period instead of the needs of specific mental health difficulties, which can be found elsewhere.

The authors recognise the need for all guidelines to include recommendations for working with modern family forms in the perinatal period. This review focused on mothers, and it is possible that not using search terms such as ‘birthing people,’ ‘paternal,’ or ‘partner’ meant that relevant guidelines for these populations were not found in the search.

It is a strength of the review that it was pre-registered with PROSPERO and that it followed Johnston and colleagues’ (2019) methodological guidelines for systematic reviews of clinical practice guidelines. Although the review states it used the 2020 PRISMA checklist for manuscript preparation, which is best practice, a copy of the checklist is not provided, which can be useful for other researchers to use when reading a systematic review. Notably, although the process for the title and abstract screens is reported, the process for the full-text screen is not reported. Further, it would have also been useful to have reported the inter-rater reliability of the title and abstract screens.

The authors recognise the limitation of only including guidelines written in English, meaning that it is unsurprising that all the included guidelines were from Australia (n=1), the UK (n=3), and Canada (n=3). Whist it is an understandable constraint of the project, it could mean that the guidelines are not representative of guidelines from other cultures.

The included guidelines had several limitations. First, only SIGN and NICE included service users as guideline developers. Second, several guidelines did not explicitly report on the methods for searching the evidence to develop their guidelines. This means it is hard to assess the methodological rigour of creating the guidelines. Further, the authors note that in some guidelines, there were more consensus-based than evidence-based recommendations, and therefore a need for research to enable evidence-based recommendations.

Implications for practice

Guideline developers should use the AGREE-II Instrument to develop their guidelines. At a minimum, guidelines must outline the methods used to gather the evidence on which the guidelines are based.

The NICE guidance was “recommended for use” through quality assessment, which is positive since it is used in NHS services. Clinicians working in perinatal services should be familiar with this guidance, and services should routinely assess themselves against it.

The review noted that guidelines had made consensus-based rather than evidence-based recommendations for the following in the perinatal period: trauma-informed care, the provision of mother-infant interventions and psychological approaches for borderline personality difficulties. Therefore, this has highlighted a need for research in these areas.

Statement of interests

None.

Links

Primary paper

O’Brien, J., Gregg, L., & Wittkowski, A. (2023). A systematic review of clinical psychological guidance for perinatal mental health. BMC psychiatry, 23(1), 790.

Other references

Gurol-Urganci, I., Langham, J., Tassie, E., Heslin, M., Byford, S., Davey, A., … & O’Mahen, H. A. (2024). Community perinatal mental health teams and associations with perinatal mental health and obstetric and neonatal outcomes in pregnant women with a history of secondary mental health care in England: a national population-based cohort study. The Lancet Psychiatry, 11(3), 174-182.

Howard, L. M., Megnin-Viggars, O., Symington, I., & Pilling, S. (2014). Antenatal and postnatal mental health: summary of updated NICE guidance. Bmj, 349.

Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Graham, R., Mancher, M., Miller Wolman, D., Greenfield, S., & Steinberg, E. (Eds.). (2011). Clinical Practice Guidelines We Can Trust. National Academies Press (US).

NHS England. (2016). NHS England kickstarts programme to help 30,000 more new or expectant mums with serious mental illness. 

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