Up to 20% of women experience maternal mental health problems, but most jurisdictions lack policy for prevention, identification and treatment. To address this gap, a multi-stakeholder working group formed in Saskatchewan, Canada. As a result, the MotherFirst project emerged to create policies to improve the mental healthcare of mothers and to increase public and professional awareness. This paper critically analyzes the project using a policy cycle framework that can inform similar policy development. It explores the strengths of diverse partnerships, relationship building and public awareness campaigns, and the challenges that were encountered in the decision-making and implementation stages.

Maternal mental health problems include depression, anxiety disorders and psychosis. Depression is the leading cause of disability among women in their childbearing years (WHO 2010). Up to 20% of women may face serious depression or anxiety related to childbirth, meaning potential impact to over 76,000 Canadian families annually (CMHA 2012; Statistics Canada 2011). Maternal depression is diagnosed using the same criteria for major depressive disorder, but may also include specific symptoms such as a preoccupation with infant well-being, disinterest in the infant, fear of being left alone with the infant, or intrusiveness that prevents infant rest (APA 2000). Anxiety affects up to 24% of mothers (Heron et al. 2004); it includes panic disorder, obsessive compulsive disorder, post-traumatic stress disorder and generalized anxiety disorder (Levine et al. 2003). Psychosis affects approximately 0.1–0.2% of new mothers and is characterized by agitation, hallucinations, mood swings or abnormal perceptions that can lead to suicide and homicide (Brokington et al. 2002).

Untreated, maternal mental health problems pose serious emotional, physical and economic consequences for entire families. Mothers may have difficulty bonding with their infant, experience intense guilt and isolation, engage in risky behaviours (e.g., smoking, drinking), deliver prematurely and have obstetrical complications (Austin 2006; O'Keane and Scott 2005). Children of women who are depressed are at risk for preterm birth, low birth weight (Chung et al. 2001), less frequent and shorter duration of breastfeeding (Hellin and Waller 1992), and they may experience more growth, attachment, psychological, cognitive, behavioural or developmental problems (Murray and Cooper 2003). Moreover, their partners are 50% more likely to develop depression themselves (Goodman 2004), which can compound the effects (Kahn et al. 2004) and contribute to increased marital breakdown (Doheny 2008). Additionally, economic burden results from decreased work productivity (WHO 2003), increased healthcare costs (O'Brien et al. 2009) and long-term support costs (Stephens and Joubert 2001).

Despite the significance of maternal mental health problems, of all the Canadian provinces only British Columbia has implemented a comprehensive policy that targets awareness, identification and treatment (BC Reproductive Mental Health Program 2006). In Saskatchewan there were very few consistent or formal expectations or requirements to screen pregnant women or new mothers for mental health problems. While some support services and medical treatments are available, very few are specialized to address maternal mental health concerns (MotherFirst 2010).

This paper analyzes the opportunities and challenges of developing a maternal mental healthcare policy strategy. By comparing the prescribed steps of the policy cycle framework to the actual process, it is possible to gain insight into the opportunities and challenges of developing maternal mental health policy in a Canadian provincial setting. The lessons of the MotherFirst project can inform other jurisdictions wanting to develop policy to improve maternal mental health.

Design

To understand the purpose, actions and outcomes of the MotherFirst project, it is useful to contextualize the process within a broad policy cycle framework. Policy development is inherently complex, but for the sake of analytical clarity, it is possible to break it down into a step-by-step process. A policy cycle framework involves five interrelated stages: (a) agenda setting is about identifying and defining policy problems; (b) policy formulation is the development of potential policy solutions to address the specific problems; (c) decision-making involves selecting the most appropriate policy solutions; (d) implementation puts the policies into effect; and finally, (e) evaluation assesses the outcomes of such policies in practice (Howlett et al. 2009). Policy issues flow sequentially from inputs (or problems) to outputs (or policies) throughout these stages, reflecting an applied problem-solving process (Howlett et al. 2009) suitable for projects such as MotherFirst.

Results

Agenda setting

The MotherFirst project originated from concern expressed at the 2009 Unmasking Postpartum Depression conference in Regina, Saskatchewan. The conference focused on maternal mental health problems and brought together health professionals and women to share their experiences. Those who attended participated in small group sessions, where priorities of improved education, universal screening and accessible treatment became very clear. Subsequently, a working group was formed to develop the MotherFirst project to unify those concerns. This diverse group made it possible to define the problem collaboratively and identify how policy could be improved.

Within a few months, the group grew to 36 members. Many became involved through the conference, but there was also an active search to ensure the group was geographically, professionally and culturally representative. Each of the regional health authorities was represented, allowing input from across the province and bringing the varying needs and capacities of each region to the table. Major partnerships were forged with recognized provincial organizations such as the Saskatchewan Prevention Institute, KidsFirst (a program for socially vulnerable families), Healthline (provincial phone hotline) and the Health Quality Council, with further support and representation from major health professional associations and provincial organizations.

Of particular significance is the participation of Saskatchewan Ministry of Health staff, First Nations groups and women with lived experience with maternal mental health problems. Representation from the Ministry of Health was useful because it provided information, clarification and key communication with senior officials. Since First Nations women are at higher risk for maternal depression than women overall (Bowen et al. 2009), it was key to include First Nations communities and care providers to ensure a culturally relevant response.

Mothers who had struggled with maternal mental health problems were of absolute importance. They guided the process by offering first-hand insight of feeling misunderstood and inadequately supported by healthcare professionals, their families and their communities. These women were vital to identify effective policy that meets the needs of women and their families.

MotherFirst members each brought unique expertise, were aware of the prevalence and severity of maternal mental health problems and recognized the inadequacy of existing care. This common perspective informed problem definition, which was a lack of consistent education, screening and treatment that stemmed from inadequate public policy. This problem definition was further supported by environmental scans of the policies of the Regional Health Authority in Saskatchewan, other Canadian provinces and international jurisdictions. Some regions have very nominal resources, while others have highly specialized programs. It was clear that Saskatchewan required improved policy to address maternal mental health problems.

Policy formulation

The mandate of the MotherFirst project, as informed by the problem definition, was to develop a comprehensive policy strategy and present it to the Saskatchewan government. The policies developed were based on published evidence and the practical experiences of project members through consultation. During the development of the policy recommendations, members met biweekly for five months via web conference. This routine enabled such diverse participants to meet regularly and make incremental progress towards an acceptable policy framework without travelling or leaving the workplace. Background materials were sent out before meetings to maintain the pace, and the web conference approach allowed members to review documents simultaneously while collaboratively revising the documents online as a group.

Education, screening and treatment were determined priority areas of policy development, reflected by the elements of the health promotion model: prevention, identification and treatment (WHO 2001). This model allowed the MotherFirst working group to identify opportunities to prevent and treat illness at the primary, secondary and tertiary levels, and provided a functional starting point for the MotherFirst policies. Primary prevention incorporates increased general public education; secondary prevention includes screening and identification; and tertiary prevention includes early intervention to restore health. Figure 1 depicts the policy priorities, recommendations and actions.

Decision-making

Decision-making proved to be a considerable challenge to the project despite the merit and popularity of the project. A positive response (i.e., recognition and commitment) from the Ministry of Health was required to improve maternal mental healthcare, but the ministry's decision was largely independent of the MotherFirst project. Because there was initially low government involvement, the MotherFirst project lobbied the government and used media to capture public attention.

In recognition of the essential role of the Ministry of Health, the MotherFirst Working Group employed all possible avenues to garner public, professional and political attention. Every opportunity was taken to promote maternal mental health as an important issue and create awareness of the MotherFirst project.

Particularly helpful to decision-making was the presence of mothers whose stories lent personal interest to the cause and garnered much public attention. Their candid recollections offered insight and captured the public's imagination by giving a personal voice to maternal mental health.

Ultimately, the MotherFirst project received a considerable amount of media coverage and a favourable response from the Ministry of Health. Project materials were widely distributed to the government, senior leadership of the Regional Health Authorities, women's and children's services, primary health and all First Nations communities, and the national Mental Health Commission. The public was engaged and, most importantly, the Ministry of Health ultimately endorsed the MotherFirst policy recommendations. Table 1 summarizes the activities to increase public, professional and political awareness.

Implementation

While the political endorsement of the MotherFirst policy recommendations is considered an achievement, its limitations are highlighted in the implementation stage. The Ministry of Health decided not to directly implement the MotherFirst policies through formal government means but rather asked the MotherFirst project to transition into an "implementation team" to support the health regions in adopting the recommendations. In response to this request, each member of the MotherFirst Working Group has gone back to their constituency to develop local Maternal Mental Health Groups to initiate changes in local healthcare services that address individual communities' unique needs. Each was offered support for professional training from the project lead, and educational materials were supplied. The wide-ranging experience of the group has generally facilitated effective collaboration with the health authorities.

The primary limitation of this implementation is the lack of specific funding. The Ministry of Health did not dedicate any funding to the project, which means it is not publicly funded, and regional health authorities must budget for the changes they make in consideration of all healthcare priorities. The MotherFirst project relies on the volunteered time of its members, as well as research and programming grants.

Despite these challenges, the Ministry's endorsement has encouraged the province's health regions to put the policies into practice. Through continued support by the MotherFirst project and growing public interest, it is possible for the recommendations to become standard practice throughout the province.

Evaluation

It is premature to monitor the results of the policy recommendations because they are still at different levels of implementation. A repeat environmental scan of the regional health policies will be conducted in 2013 to compare to the initial scan. This will identify any changes in policy and care services. Depending on data availability, it would also be useful to determine the change in maternal mental health education activities, as well as the prevalence of those screened and treated. Table 2 summarizes the activities, opportunities and challenges within each stage of the policy cycle framework.

Conclusions

The MotherFirst project illustrates the need for consistent and improved services and the potential to develop a community-based response to a serious and pervasive public health problem. By contextualizing the MotherFirst project within a policy cycle framework, our lessons learned can enlighten others who want to make similar policy improvements for maternal mental health.

MotherFirst: développement d'une stratégie pour la santé mentale maternelle en Saskatchewan

Résumé

Près de 20% des femmes éprouvent des problèmes de santé mentale liés à la maternité. Pourtant dans la plupart des provinces, il y a un manque de prévention, de dépistage et de traitement concernant ces problèmes. Pour corriger cette situation, on a créé un groupe de travail à intervenants multiples en Saskatchewan (Canada). De cette initiative est né le projet MotherFirst, qui vise à établir des politiques pour améliorer les soins de santé mentale maternelle et pour accroître la sensibilisation du public et des professionnels. Cet article propose une discussion critique du projet, effectuée à l'aide d'un cadre d'analyse sur les cycles de politiques, qui peut éclairer l'élaboration de ce type de politiques. L'article examine les points forts des divers partenariats, des relations entre acteurs et des campagnes de sensibilisation publique. Il examine également les défis rencontrés au cours de la prise de décision et pendant les étapes de mise en œuvre.

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