Antenatal and child healthcare services

In Sweden, the antenatal and Child Health Services (CHS) have a long tradition, are free of charge and almost 100% of pregnant women and new parents with infants attend regular appointments. Antenatal care is mainly delivered by midwives and offers 8–11 recommended check-ups during pregnancy, and one postpartum appointment. The child healthcare programme is offered to all children between 0 and 5 years as well as parents, regardless of income or risk exposure. In recent decades there has been a shift from what used to be primarily somatic management concerns about pregnancy and postnatal care towards an increasingly public health and psychosocial perspective. The CHS team is led by a nurse, and includes a general practitioner or a paediatrician and, in almost all counties of Sweden, a psychologist. These psychologists work within the antenatal and child healthcare systems, offering regular consultation meetings with midwives and nurses and providing easy access for assessment and treatment to women with perinatal mental health problems.

Early identification

Much research in perinatal mental health has focused on postnatal depression, but in the past few years this perspective has broadened to include mental illness during pregnancy and a wide range of other mental disorders. Programmes that combine the systematic identification of postnatal depression with enhanced support have proven to be both clinically valuable and cost-effective (for a review see Howard et al ^{Reference Howard, Molyneaux and Dennis4}). Whether universal prenatal screening for depression is clinically effective and cost-effective is still under discussion. Some counties in Sweden are nevertheless implementing pilot projects. Antenatal screening for depression and other current or past mental health problems is by questionnaires or structured interviews.⁵ One county recently introduced a telephone call, 2 weeks after delivery, to ask about the mother's mental state. The effectiveness of these approaches in improving postnatal health is not yet established.

In 2010, the Swedish National Board of Health and Welfare recommended postnatal screening for depression using the Edinburgh Postnatal Depression Scale (EPDS), to be followed by person-centred counselling (so-called ‘listening visits’) by CHS nurses for all women with subthreshold or minor depression. This procedure is now implemented all over the country.⁶ National figures on postnatal screening rates are not available but in the three largest regions of Sweden, which include more than half of the population, about four out of five women took part in the screening visit 6–8 weeks postpartum during 2017. In the southern region, 87% of all new mothers were screened and 10% were followed up, half of them with ‘listening visits’ and the other half with a referral to psychologists or general practitioners.⁷ Despite these achievements, it has proved challenging to reach immigrant mothers, who are less likely to be offered counselling and less often agree to participate in screening; this group is at especially high risk of postnatal depression.^{Reference Shakeel, Sletner and Falk8}

Perinatal psychiatry

Women at risk of, or suffering from, severe mental disorders require rapid access to perinatal care from specialist psychiatric units. There is a need for multidisciplinary cooperation between psychiatry and antenatal/CHS and social services, but Sweden lacks specialised perinatal psychiatric services. Ideally, the management of perinatal mental disorders is provided by experts with appropriate knowledge. For example, psychiatric units specialising in affective disorders may be able to provide prophylactic lithium treatment to women with severe affective spectrum disorders, but this necessitates collaboration with both obstetric and paediatric services.^{Reference Forsberg, Adler and Römer Ek9}

Access to treatment and care for women with severe mental disorders still needs considerable improvement. A study on maternal suicides in Sweden found that 47% of the 103 women who died by suicide between 1980 and 2007 had had psychiatric disorders before their pregnancy (79% had bipolar disorder or psychosis, substance use disorders or a history of suicide attempts). But fewer than half the women's antenatal and obstetric records had taken note of that psychiatric history and in only 18% was there any record of prior suicide attempts. Although 30% had had at least one consultation for mental health problems within the antenatal care system, only 8% had received in- or out-patient psychiatric care.^{Reference Esscher, Essén and Innala10}

To increase access to psychiatric care during pregnancy, some obstetric and psychiatric clinics have initiated consultation-based cooperative activities. In one of these services, about 5% of pregnant women had been referred to a perinatal psychiatric liaison team during the past 10 years. Referrals originated mainly from antenatal and primary healthcare centres, but also from obstetric and specialist psychiatric services.^{Reference Blomdahl Wetterholm, Bendix and Pettersson11} A perinatal liaison team can both offer treatment and act as a gateway linking the different healthcare providers needed to manage pregnant women with severe mental disorders.

Providing equal access to healthcare for all the population in Sweden is challenging because of the low population density outside our few larger cities. During recent years, there have been efforts to improve local knowledge about perinatal psychiatric disorders through the publication of regional and national guidelines and multidisciplinary educational projects. Providing increased collaboration between psychiatric and primary healthcare providers, social services and obstetric services, such projects will be more rapidly implemented than the development of specialised perinatal psychiatric services. Mother and baby units do not yet exist in Sweden, but their formation is under discussion.

Priorities for research and service development

Our first priority is to ensure that there is rigorous assessment of the different screening protocols for risks to antenatal mental health. There should be national guidelines, based on scientific evidence, to complement the existing guidelines for screening in the postnatal period. Interventions for the prevention of postpartum depression tend to be more effective when targeting women at risk and also when offered early after delivery.^{Reference O'Connor, Senger and Henninger12} Current projects are using machine learning and deep learning techniques to develop algorithms that will allow us to identify women at high risk of postpartum depression with greater accuracy. Further research efforts should be encouraged.^{Reference Curry13}

Better organisation of perinatal mental healthcare services would improve collaboration between obstetric and psychiatric services, leading to more effective prophylaxis and treatment.^{Reference Forsberg, Adler and Römer Ek9} There is a need to lower maternal suicide rates in Sweden; we should increase detection of those at risk, provide individualised planning and quick access to psychiatric care.^{Reference Esscher, Essén and Innala10} Research priorities include discovering who is missing from existing screening programmes and we should plan interventions to address that problem.