1. Combining the strengths of UMIST and The Victoria University of Manchester ‘ Falling through the net’ Black and minority ethnic women and perinatal mental healthcare Dr Dawn Edge Research Fellow The University of Manchester 29-30 April 2009

2. Combining the strengths of UMIST and The Victoria University of Manchester Context PND ‘serious public health issue’ (WHO 2002) Psychosocial risk factors include: –material deprivation, lone parenthood Prevalence 15% Limited research suggests higher in Black women (Miranda et al 2005) 27% Black Caribbean women Manchester (Edge 2004) <10% accessed care

3. Combining the strengths of UMIST and The Victoria University of Manchester Study Aims To investigate factors that might account for low levels of diagnosis and treatment for PND among Black Caribbean women

4. Combining the strengths of UMIST and The Victoria University of Manchester Method Qualitative Study –Focus groups (n=73) –Individual interviews (n=11) Purposive Sample –Primary Care Health Professionals (n=42) Midwives, GPs, health visitors, 3 rd sector –Black Caribbean women (n=42) Recruitment via radio, local newspaper, churches Analysis –Framework Analysis (Ritchie & Spencer, 2003) –NVIVO-8 (QSR 2007)

5. Combining the strengths of UMIST and The Victoria University of Manchester Overview of Findings Service redesign Lack of screening ‘Colour-blind’

6. Combining the strengths of UMIST and The Victoria University of Manchester Findings (Health Professionals) Missed opportunities 1.Focus on physical care “Even though women may have had PND in the past, if they’ve got other more pressing medical problems … I think it tends to overshadow their PND or postnatal issues… One tends to focus rather heavily on the medical issues rather than the wider perspective.” (Hospital Doctor 1)

7. Combining the strengths of UMIST and The Victoria University of Manchester Findings Missed opportunities No routine screening – even for ‘high risk’ women (NICE 2007) “I am largely responsible for PHQ9 being introduced … when it comes to my own practice I very rarely get the PHQ9 out and get people to tick boxes. So umm, I would be lying if I said I used a formal structured questionnaire to get a clinical diagnosis, because I don’t.” (GP 1)

8. Combining the strengths of UMIST and The Victoria University of Manchester Findings Condition not taken seriously “Possibly we’re missing them [nervous laughter], I don’t know, but they don’t kill themselves. So, even if we’re missing them, we are managing them.” (GP 2) Lack of professional ‘ownership’ “If the mother appears to be ok, she’ll be home within twenty-four hours. Then they’re on to the community midwife... they don’t visit every day and then they’re transferred to the health visitor.” (Hospital Doctor 2)

9. Combining the strengths of UMIST and The Victoria University of Manchester Findings Impact of service redesign “We have terrible trouble with health visitors … because the health visitors are now sectorised, we have to liaise with about 12 different health visitors. It is just a nightmare! Deeply unsatisfactory! It’s not the health visitors’ fault – it’s the system.” (GP 1)

10. Combining the strengths of UMIST and The Victoria University of Manchester Findings ‘Colour blind’ approach “I would say that statement “We don’t see Black women” it’s perfectly true. I would see women sometimes and you could say to me afterwards, ‘what colour were they?’ I wouldn’t have a clue! I could tell you if they were Polish and didn’t speak English … it’s not colour that you actually see, it’s other issues … language is probably the big one” (Hospital Midwife 4)

11. Combining the strengths of UMIST and The Victoria University of Manchester Implications for Policy & Practice Policies –‘Tackling Health Inequalities’ (DH 2003) –‘Women’s mental health: into the mainstream’ (DH 2002) –‘Delivering Race Equality (DRE)’ by 2010 (DH 2005) Little impact on perinatal mental healthcare of BME women Practice Guidelines & instrumentation Impact of service redesign Training –Mental health & suicide (CEMACH 2008) –Cultural awareness

12. Combining the strengths of UMIST and The Victoria University of Manchester Conclusions Sub-optimal detection & treatment PND in ‘at risk’ women –Highlights gap between policy & practice –Applies to women in all ethnic groups Black women might be particularly vulnerable to deficiencies in provision Effective PND management requires –More robust implementation of existing guidelines –Strategies to address the full spectrum of need –Improved training for professionals –More coordinated, multi-agency approach

13. Combining the strengths of UMIST and The Victoria University of Manchester Acknowledgements FMHS Stepping Stones Award Prof F Creed Prof K Lovell Study participants

14. Combining the strengths of UMIST and The Victoria University of Manchester Contact Details Dr Dawn Edge 5.333 University Place The University of Manchester Oxford Road Manchester M13 9PL Tel: 0161 306 7650 Email: dawn.edge@manchester.ac.ukdawn.edge@manchester.ac.uk