27 September 2022

The article below was written by Dr Caroline Pontvert, Consultant Perinatal Psychiatrist Dr Christy Pitfield, Principal Clinical Psychologist and Clinical lead Perinatal Mental Health Service, Central and North West London NHS FT HMP Bronzefield and originally published in the Faculty of Forensic Psychiatry's summer newsletter.

The NHS England defines the perinatal period as pregnancy and the first 12 months after childbirth. A woman will experience marked physiological and psychological changes during that time, therefore this is a period of increased vulnerability in regards to a woman’s physical and mental health outcomes.

In community samples, 20 percent of women will experience a perinatal mental health difficulty during this period (Howard & Khalifeh, 2020). The post-partum period is known to be the highest risk period for a woman's mental health (Kendell, 1987), with maternal suicide being the leading cause of death within a year after delivery (MBRRACE-UK, 2019).

It is well documented that the wellbeing of the mother is crucial to the development of her child’s emotional wellbeing, physical health and resilience and that this influences their long-term health and social outcomes.

The first ‘1001 critical days ’, spanning pregnancy and the first two years of a child’s life is considered a crucial period for infant health outcomes.

English female prisons & population

Women make up a small proportion of the UK prison population, approximately 5 percent (Corston, 2007).

Their routes into custody vary from men, women are more likely to be charged with non-violent offences. Women in prison have multiple and complex needs and have higher rates of mental health, physical health and substance misuse difficulties, compared with women in the community or men in prison.

They have higher rates of suicide and self- harm. For many women, entering custody means separation from their children. This has been found to be one of the most distressing aspects of their prison experiences.

Pregnant prisoners represent less than 2 percent of the women’s prison population (Review of operational policy on pregnancy, Mother and Baby Units and maternal separation, 2020 – MoJ). There are 12 female prisons in England, six with a Mother and Baby Unit (MBU) - 64 mothers and 70 babies can be accommodated. Babies can stay up to 18 month old. A MBU placement is granted via an independently chaired multidisciplinary Admissions Board based on the social, legal & criminal context of the woman and her psychological wellbeing, in agreement with Children’s Services.

Our service

Our Multidisciplinary team is based at HMP Bronzefield - with a 12 bed MBU - and operate an outreach model to HMP Send, HMP Downview and HMP East Sutton Park. It is a psychologically led service that adopts a trauma informed approach. The service is well embedded to the prison system and works closely with midwifery services. We assess all pregnant women identified during early days assessment (or any point), as they are deemed ‘high-risk’. We accept referrals for all women presenting mental health difficulties during the postnatal period, either on the MBU or those who have given birth and been separated from their baby.

Female prisoners in the perinatal period

Our early observations about the women we care for are:

- The pregnant women are usually on remand: which means they are at risk of discontinuity of care at one of the most vulnerable time of their life.

- There is a high number of adverse childhood experience in their histories: their clinical presentations are complex and they typically have diagnoses of Complex PTSD or personality disorders.

- Their traumatic experiences are not secluded to their childhood, they have been victims of numerous traumatic events across the lifespan: all of these experiences impact their capacity to develop meaningful, trusting relationships with professionals.

- Our population have complex perinatal loss histories: many have experienced miscarriages, stillbirths, infant death or a child being removed from their care. - The majority have histories of substance misuse.

- Many have long-standing untreated mental health difficulties.

We meet women at a time of their life in which they are very vulnerable, it is typical that the perinatal period reactivates previous trauma. However, our service is developed on the assumption - confirmed every day - that being in custody while pregnant or a new mother is a unique moment in these women's lives that can become a window of opportunity for them, with the right support, to access mental health care and parenting support.