Building a Strong Village to Support Mothers

Human capital is the prime resource of our little red dot, especially in light of falling birth rates. The potential of each child must thus be preciously guarded, beginning from within the womb.

Supporting antenatal maternal mental health

The seminal translational birth cohort study "Growing Up in Singapore Towards healthy Outcomes" started in 2008 and has since provided robust evidence demonstrating the impact of maternal health on child health outcomes. One key area is on how maternal antenatal depression and anxiety can impact the developing brain of the foetus in utero,^1,2 and how their influences continue postnatally with resultant negative impact on child neurodevelopment and child health outcomes.³ Children from lower-income families are more vulnerable to these influences, with maternal antenatal depression having a greater impact on their school readiness by four years of age.⁴

Recognising the critical need to safeguard human potential while the COVID-19 pandemic upturned our lives, an inter-agency task force for the Child and Maternal Health and Well-being Strategy and Action Plan was set up in 2021 to ensure comprehensive support for women preparing for motherhood, and to optimise child health outcomes and well-being. This provided much- needed resourcing to move upstream towards active screening for antenatal depression with early intervention at KK Women's and Children's Hospital (KKH), with the initiation of the Psychological Resilience in Antenatal Management programme in late 2022.⁵

Expanding postnatal mental healthcare

Concurrently, this increased focus on child and maternal health supported the wider movement of enabling the primary health sector to screen for postnatal depression during well-child visits, coupled with early intervention for mild to moderate cases through the Family Nexus Programme. This programme involved SingHealth Polyclinics (SHP) and was an extension of the community maternal mental health services developed following the successful pilot of the Integrated Maternal and Child Wellness Hub at SHP-Punggol from 2019 to early 2022. ⁶ Simultaneously, we supported the development of the National Healthcare Group Polyclinics' Enhanced Maternal Baby Toddler and Child Surveillance programme, with similar aims of screening and providing early primary care intervention for postnatal depression through training and consultancy advice.

Over the past decade and a half, we have learnt that early detection through opportunistic screening integrated into obstetric care and primary health well-child visits is a valid, effective and sustainable approach. ^7,8,9 This is in line with the World Health Organization's recommendations to embed maternal mental health services within reproductive and child health programmes, ¹⁰ and to ensure equity so that diverse populations have access to care.

Learning from our patients

Sharing our experiences and advocating for maternal mental health are crucial aspects of building a strong network for mothers and infants. We have learnt this from the generosity of the women we have cared for, who participated in our research studies at KKH's Women's Mental Wellness Service over the past 17 years. When struggling with the challenges of becoming a mother, self-doubt and shame can be difficult emotions that patients grapple with. Yet, they were willing to participate in the research projects and in so doing, allowed us to analyse their experiences so that we could better understand what local women needed, and what worked well for them.

The theme for World Mental Health Day on 10 October 2023 was "Mental health is a universal human right". Our approach of protecting human potential through building a strong network for maternal mental health will enable us to be more inclusive of the children of the future, recognising the foetus in the womb as a potential member of our community. We have also learnt from our mothers-to-be that low-dose antidepressant therapy can be beneficial for antenatal depression, particularly for those with pre-existing depression and who are of advanced age,¹¹ alongside a case management model that ensures continuity of care and safety even for at-risk patients.¹²

Providing holistic care in supportive counselling

Our patients have also taught us the importance of building trusting relationships between treatment providers and patients, providing empathic support while patients learn to accept the changes in their lives, and engaging patients' partners in the treatment process.¹³ These aspects can be embedded in supportive counselling,¹⁴ which we offer as an intervention modality in KKH's Postnatal Depression Intervention Programme.¹⁵

The counselling approach is translatable and scalable beyond psychiatric specialist services. The nursing team at SHP-Punggol showed the efforts of primary healthcare nurses to attend to new mothers with empathy and care, and to provide opportunistic guidance in self-care, breastfeeding and care of the infant.

Another strong partnership of collaboration and training over the past decade was with MindCare, a community mental health service under Allkin Singapore (formerly AMKFSC Community Services). This provided an alternative resource for women who otherwise were reluctant to engage in tertiary services.

Unifying community mental healthcare

In Singapore's healthcare system, patients are able to access care through different channels, and the three healthcare clusters operate in different ways that align with their institutional resourcing and processes. Thus, there was a need to communicate clear recommendations for best practices in perinatal mental healthcare. This would allow women of childbearing age to be assured of standards of care that can help optimise outcomes for the well- being of themselves and their children. A public health approach was taken so that the guidelines would be readable by any professional who would have contact with an expectant or recently delivered woman, or even one planning pregnancy.

Our KKH workgroup developed the Singapore Perinatal Mental Health Guidelines, which were launched at the SingHealth Duke-NUS Maternal and Child Health Research Institute's Asia Pacific Maternal and Child Health Conference, and Integrated Platform for Research in Advancing Maternal and Child Health Outcomes International Meeting in February 2023.¹⁶ Efforts to disseminate information and advance knowledge must continue to facilitate mental health literacy about perinatal depression and anxiety.¹⁷

Developing beyond conventional borders

In tandem with recognising the impact of maternal mental health on infants, our team has been building our expertise in perinatal infant mental health over the past six years. Following a Health Manpower Development Plan training visit by a leading expert, we developed the Supporting Resilience and Empowering Mums programme which lasted from 2017 to 2019. The programme offered home-based mother-infant therapy for mothers suffering from postnatal depression and concomitant mother-infant bonding disorders.¹⁸ Additionally, the programme supported the training and supervision of Clarity Singapore, a community mental health partner. This enabled us to build an even wider network, as Clarity Singapore has become a key resource for the private sector, especially for women who decline psychiatric services.

During the COVID-19 pandemic, the transition to telehealth allowed us to continue our work with perinatal women and their infants.¹⁹ Despite the physical distancing, opportunities arose for meaningful reflection during teleconsultations, which helped mothers shift towards positions of greater confidence in their maternal competencies.

We have since embedded the mother-infant relational focused approach into the supportive counselling provided by KKH's team of clinical counsellors. Though without formal training in infant mental health expertise, our team is forging ahead together as we learn through journal reviews, peer sharing and case discussions held within our Baby Matters special interest group.

Conclusion

This has been our approach to building a strong village to support mothers in their childbearing journey, particularly those from socially disadvantaged families. We invite one and all to join us in any way possible – as doctors, husbands, mothers, friends, employers, colleagues – because in doing so, we are building the village that will support us in the future.

1. Rifkin-Gabroi A, Bai J, Chen H, et al. Prenatal maternal depression associates with microstructure of right amygdala in neonates at birth. Biol Psychiatry 2013; 74(11):837-44.
2. Qiu A, Tuan TA, Ong ML, et al. COMThaplotypes modulate associations of antenatal maternal anxiety and neonatal cortical morphology. Am J Psychiatry 2015; 172(2):163-72.
3. Soe NN, Wen DJ, Poh JS, et al. Pre- and Post-natal Maternal Depression Symptoms in Relation with Infant Frontal Function, Connectivity, and Behaviors. PLoS One 2016; 11(4):e01529911.
4. Law EC, Aishworiya R, Cai S, et al. Income disparity in school readiness and the mediating role of perinatal maternal mental health: a longitudinal birth cohort study. Epidemiol Psychiatr Sci 2021; 30:e6.
5. Hassan Y, Chua TE, Chua CMY, Chen H. Psychological Resilience in Antenatal Management (PRAM): Universal Screening for Antenatal Population. In: SingHealth Duke-NUS. Available at: https://bit.ly/4a1D0bc. Accessed 6 March 2024.
6. Tsang LPM, Ng DCC, Chan YH, Chen HY. Caring for the mother-child dyad as a family physician. Singapore Med J 2019; 60(10):497-501.
7. Chen H, Bautista D, Ch'ng YC, et al. Screening for postnatal depression in Chinese-speaking women using the Hong Kong translated version of the Edinburgh Postnatal Depression Scale. Asia Pac Psychiatry 2013; 5(2):E64-72.
8. Lee TM, Bautista D, Chen HY. Understanding How Postnatal Depression Screening and Early Intervention Work in the Real World - A Singaporean Perspective. Ann Acad Med Singap 2016; 45(10):466-70.
9. Sim CSM, Chen H, Chong SL, et al. Primary health level screening for postpartum depression during well-child visits: Prevalence, associated risk factors, and breastfeeding. Asian J Psychiatry 2023; 87:103701.
10. World Health Organization. Guide for integration of perinatal mental health in maternal and child health services. Geneva: World Health Organization, 2022.
11. Chua TE, Allen JC, Ang L, et al. Patterns and predictors of treatment outcome for antenatal major depression. Singapore Med J 2017; 58(11):642-8.
12. Ch'ng YC, Wang J, Chen H. Perinatal Case Management— Caring for Mothers as They Care for Babies. J Paediatr Obst Gyn 2010; 225-32.
13. Ong LL, Ch'ng YC, Chua TE, Chen HY. A cross- sectional survey of what patients find most therapeutic in perinatal mental healthcare in Singapore. Asian J Psychiatr 2019; 43:57-9.
14. Fam J, Chen H, Wang J. Supportive counseling for postpartum depression in Asian mothers. Asia Pac Psychiatry 2011; 3(2):61-6.
15. Chen H. Addressing Maternal Mental Health Needs in Singapore. Psychiatr Serv2011; 62(1):102.
16. Chen H, Chua TE, Lee TMY, et al. Consensus statement on Singapore perinatal mental health guidelines on depression and anxiety. Ann Acad Med Singap 2023; 52(9):467-75.
17. Poo ZX, Quah PL, Chen H, et al. Knowledge, Attitude and Perceptions Around Perinatal Mental Health Doctors in an Obstetrics and Gynaecology Academic Department in Singapore. Cureus 2023; 15(5):e38906.
18. Loh AHY, Ong LL, Yong FSH, Chen HY. Improving mother-infant bonding in postnatal depression − The SURE MUMS study. Asian J Psychiatr2023; 81:103457.
19. Hong LF, Chua TE, Koh LPD, Yong FSH, Chen HY. Perinatal mental telehealth: a Singaporean experience born in COVID-19. Singapore Med J 2022; 63(10):628-9.