Within the sample of 17 women who had experiences of the mental health-care pathway, three women (trust B 3629, trust A 1834, trust A 2943) who had experienced a historical case of depression and/or anxiety and were not experiencing a current episode had a self-reported positive experience of the care pathway for that episode. This included both a mild case and a severe case that required urgent psychiatric care. One of the women had a history of anxiety only (trust A 2943) and is now having additional checks for reassurance even though she does not have a currently identified episode of anxiety or depression.

Nine of the 17 women had a current case of depression identified either by their HP or as a result of the woman telling their HP as part of their routine care. All nine women had a history of depression with or without anxiety.

Two of the women reported having had a very positive care experience for their mental health problems (trust B 1653, trust C 2288). These experiences included one woman (trust B 1653) who was extremely resistant to any offer of help initially, particularly the antidepressants offered by her GP. The exemplary practice of her MWs and particularly her HV throughout the 12-month postnatal period resulted in the woman receiving regular additional home-based support and being personally accompanied to attend a mother and baby group for the first time. At the 12-month BaBY PaNDA study interview, the woman reported taking antidepressants and receiving support from a breastfeeding counsellor in addition to receiving ongoing visits from her HV. The other woman who reported a highly positive experience of her mental health-care pathway has been experiencing depression since age 11/12 years and had conceived her baby through IVF having tried for 5 years (trust C 2288). This woman has an excellent relationship with her female GP, who manages her symptoms very carefully with medication and monthly appointments. The woman also has a referral in place to give her direct access to community care services if and when she feels she needs them.

The remaining four women had a mixed experience of their treatment and management of their mental health problems (trust C 1489, trust A 1851, trust B 2912, trust A 2699). In all cases, the women reported the variation in experience in relation to different HPs and their personal approach, commitment and type of support they offer. Care from MWs and HVs appears to be preferred over the GP in many cases owing to the nature of the support, which tends to be focused more on talking, advice and links to support groups than on the use of antidepressants. Not all MWs and HVs are, in the views of some of the women, interested or supportive, however. In one case, it was a mental health worker who was the key HP to determining a positive and effective mental health-care pathway for one woman (trust A 1851). The woman noted the excellent relationship she had with this mental health worker as the reason why the counselling sessions were effective on this occasion.

Two of these four women had taken the decision to make an appointment and seek treatment or support for their symptoms at the request of their husband (trust B 2912, trust A 1851). One woman had a negative experience of counselling in the past and had stopped attending her sessions. She felt her emotional well-being was not being monitored as closely as she might need given her history of depression and anxiety, and the abnormal growth rate of her foetus resulting in a planned early induction:

I think it would be helpful to, you know, even if they weren’t these exact questions, you know, just for midwives to kinda check in on how you’re feeling. I mean they’re probably a bit desensitised to it all because obviously they’ve heard everything possible, but I think, I think there’s an emphasis on how the baby’s doing which is, which yeah, it should be, but I think sometimes the mother’s kind of forgotten a little bit so long as the baby’s OK.

Trust A 1851

Both women ultimately felt the treatment was effective, although one woman believed it was the support from her friends while her husband was away that improved her symptoms, rather than the antidepressants from her GP (trust B 2912).

The BaBY PaNDA assessment identified one woman with a history of depression as having a current episode of depression and anxiety at both 20 weeks prenatally and 12 months postnatally (trust A 2699). This woman participated in three in-depth study interviews to discuss her care pathway at 20 weeks prenatal and 3–4 and 12 months postnatal. The woman reports that the HP screens her informally at every check given her mental health history, family history and natural tendency to be self-doubting and anxious. She has also experienced two miscarriages between her first child and this fourth pregnancy, birth and motherhood:

I think with my history of depression and with like my mum and my grandma, they did, every time I went for a check-up, they did ask, you know, ‘How’s your mood? Do, have you ever been feeling low?’ . . . I’m not a very confident person as well, which doesn’t help. I’m not one that can walk up to somebody and start a conversation sometimes, it depends on the people I suppose really.

Trust A 2699 (20 weeks prenatally, 3–4 postnatally and 12 months postnatally)

The woman started to open up to her MW over time as they built up a relationship during the prenatal period. The HV also asked her how she was feeling from her first contact just after the birth of her baby but, as time went by, the woman felt the appointments were rushed and quick checks of the baby’s health only. This led her to say everything was fine. The woman also felt that her consultant discussed her coming off antidepressants too soon. Again, she felt the consultant was in a rush and she felt pressured not to get into a discussion:

Sometimes I think, with some doctors, you can just walk into the room and you can feel, like you can just completely open up to them, whereas some doctors you can’t, and, which is why I always try to stick to the same doctor, but I mean obviously sometimes you can’t ‘cos they’re quite popular or what have you, but, yeah, I do sort of, I believe, in a way, that if it’d have been sort of like me usual doctor, I maybe would have said, well you know, I’ve had days where I’ve been like, I can’t be bothered to do anything typa thing.

Trust A 2699

Another case (as detailed below) illustrates failures in the screening/case-finding and care pathway process, which resulted in a lack of care provision for a woman who was admitting to self-harming (trust A 1148). This woman, who has a history of depression and anxiety, was identified as having a current episode of moderate depression in her BaBY PaNDA assessments at 20 weeks prenatal and 3–4 months postnatal. The woman has one child already and found the pregnancy difficult with the condition of hyperemesis, persistent severe vomiting, ultimately requiring a hospital admission. She was worried about the effect this would have on her baby as well as distress at leaving her older child while in hospital. Although the woman was pleased her MW was focused on the baby throughout the pregnancy, she felt there was no assessment of whether or not she needed additional support during the pregnancy. The birth of her second child was induced resulting in a birth by forceps with an epidural. The baby experienced health issues following the birth culminating in an operation at 7 weeks to remove a lump caused by a blocked gland. Although the HV did frequently screen the woman for depression using the EPDS case-finding instrument, the woman felt the HV was only interested in the baby and did not offer any options for support.

I mean the questions were asked. I can’t dismiss that, but nothing was acted on, just doing this ten point check, OK you’re on borderline, we’ll do it again next time, that’s basically all that happened. There wasn’t anything there to say, right, well this is how it is and this is how you’re feeling, this is how, what things we can do and things like that, there, there’s just no . . .

Trust A 1148

The mother reported in her in-depth interview for the BaBY PaNDA study at 3–4 months postnatally that she was self-harming, having hit the wall and scraped her knuckles on purpose. She told the HV she was not coping but, in the view of the woman, the HV appeared to be only focused on the score of the repeated EPDS case-finding assessments.

I told her, and I said, ‘you know, I, I don’t think I’m coping very well.’ And she said, ‘Oh you’re borderline, I can offer you help but I don’t need to bring on any, anything extra.’ What does that mean, I don’t know. So it was, it was left at that.

Trust A 1148

The woman’s GP also carried out an informal screen for depression at the 6-week check and offered her CBT. The long waiting list for CBT and the need to follow it up herself when feeling so down with the depression resulted in no progress for this core treatment option.

. . . when I was at the doctor’s, it was the six week check, we did touch on it [depression] and he did mention this other form of not counselling but another method of working, but it was going to be a long drawn out affair, waiting weeks for the appointment so to be fair, I didn’t follow it up and they never asked again and, I just felt, I did ask for help but it wasn’t there, so what’s the point? . . . Depression’s horrible. In one sense you feel alone, particularly when, you know, you, you feel as though you’re asking for help and you’re not getting it. It’s weird, just being in that situation you just, you don’t know what to do and you just want to hide away in a little hole and just want to go away and leave me alone, but then you want the help. It’s a merry go round.

Trust A 1148

A further five women were identified as having a current episode of depression by the CIS-R reference standard within one of the BaBY PaNDA study assessments. None of these women were referred by their GP onto the mental health-care pathway for further assessment or treatment as a result of the BaBY PaNDA assessment (their GPs would have been sent a letter from the BaBY PaNDA team advising them of their depression outcome).