17 February 2023, Singapore - Singapore’s first set of Guidelines on perinatal mental health was launched today at the MCHRI¹ Asia Pacific Maternal and Child Health Conference and IPRAMHO International Meeting 2023 in KK Women’s and Children’s Hospital (KKH).

The Guidelines, unveiled by Dr Janil Puthucheary, Senior Minister of State, Ministry of Health and Ministry of Communications and Information, casts the spotlight on the rising incidence of maternal depression, and the urgent need to address the issue.

“In KKH, we saw a 47 per cent increase in patients who screened positive for postnatal depression between April 2019 to March 2020 and April 2021 to March 2022. This increase during the COVID-19 pandemic mirrors patterns seen in other countries². It is a major concern as it impacts not just the mother but also the child. Evidence^{3, 4, 5, 6} has proven that anxiety and depression in the mother can lead to adverse consequences. Mothers who are mentally vulnerable are unable to function normally, or bond with their infants, and in severe cases, may be at risk of suicide. For the child, maternal depression can impact his or her brain development, and may affect his or her temperament, behaviour and readiness for school,” said Associate Professor Helen Chen, Head and Senior Consultant, Department of Psychological Medicine, KKH, and Chairperson, Workgroup for the Guidelines.

In Singapore, postnatal depression affects one in 14 women while antenatal depression affects one in eight women⁷ pre-COVID-19. The pandemic has contributed to the rising incidence of maternal depression.

“There is an urgent need to address the situation, as Singapore moves into an endemic phase. The key to preventing these negative effects is early screening, prompt attention for anxiety and depression, preferably even before the women is pregnant. This is integral to what KKH and MCHRI hopes to achieve, to optimise the continuum of care from pregnancy to childbirth, infancy to adulthood. We are building on the foundation to improve our population health for mothers in Singapore,” added Associate Professor Chen.

A Healthier SG, starting from every woman

Developed by KKH-led IPRAMHO⁸, Singapore’s first set of Guidelines for Perinatal Mental Health details clinical recommendations for women before, during and after childbirth to impact positive long-term outcomes.

Some of the key recommendations for the Guidelines for Perinatal Mental Health include:

Preconception

• Increasing awareness and availability of advice on preconception mental health
• Optimising preconception mental health with a holistic approach with lifestyle changes and medication use

• Early screening and assessment
• Optimising care, treatment and support for women with antenatal depression

• Early screening and assessment
• Optimising care, treatment and support for women with postnatal depression

• Increasing accessibility to mental health support for women who have experienced severe medical trauma, and those with mental health needs during their pregnancy
• Tailoring mental healthcare needs for adolescents and women with special needs
• Promoting higher caregiver quality for perinatal and infant mental health needs

“Since 2017, IPRAMHO has been launching programmes to address the burgeoning metabolic challenge in the maternal and child health landscape. This set of Guidelines looks at a different aspect - perinatal mental health from preconception through to postnatal. This is an area that has been overlooked, and require more awareness and guidance for patients and healthcare professionals. More importantly, this continues our work in developing a holistic approach to shaping the future of women and children and transform national health, for our generation and many generations to come,” said Professor Tan Kok Hian, Head and Senior Consultant, Perinatal Audit and Epidemiology Unit, KKH, and Lead Principal Investigator of IPRAMHO.

The development of the Guidelines was spurred by the findings from two recent surveys by IPRAMHO. The first survey involving 600 antenatal and postnatal women found that mental health education was poor despite the high prevalence of antenatal and postnatal anxiety as well as depression⁹. 62 per cent did not receive assessments or education on mental health from healthcare professionals, and only one in six women cited that they would seek help from healthcare professionals if they were experiencing mental health symptoms.

Not surprising, a second survey involving 53 doctors revealed that more than 90 per cent of patients rarely report mental health concerns or symptoms during the antenatal or postnatal periods.¹⁰ More than half of the doctors also admitted that they seldom initiate a discussion about mental health with their patients, while the majority of the doctors were not confident or only “somewhat” confident about providing advice on perinatal mental health. (Refer to Annex B for details of the surveys)

The Singapore Perinatal Mental Health Guidelines is part of a series of guidelines designed by IPRAMHO, a main programme by MCHRI, to transform national health in Singapore.

The Guidelines will be made available to healthcare professionals through the College of Obstetricians & Gynaecologists Singapore.

Other guidelines launched by IPRAMHO include the Integrated Activity Guidelines for Early Childhood (under seven years) and Children and Adolescents (seven to 18 years) which were launched in 2022 and 2021 respectively, Guidelines for Pregnant Women focusing on the management of gestational diabetes, and physical activity, were launched in 2018 and 2020 respectively, and Guidelines for Perinatal Nutrition, in 2019.

¹SingHealth Duke-NUS Maternal and Child Health Research Institute
²Lobel M, Preis H, Mahaffey B, Schaal NK, Yirmiya K, Atzil S, Reuveni, Balestrieri M, Penengo C, Colli C, Garzitto M, Driul L, llska M, Brandt-Salmeri A, Kolodziej-Zaleska A, Caparros-Gonzalez RA, Amiel Castro R, Marca-Ghaemmaghami PL, Meyerhoff H. Common model of stress, anxiety, and depressive symptoms in pregnant women from seven high-income Western countries at the COVID-19 pandemic onest. ScienceDirect. 2022 Dec. https://doi.org/10.1016/j.socscimed.2022.115499.
³Rifkin-Graboi A, Bai J, Chen H, Hameed WB, Sim LW, Tint MT, Leutscher-Broekman B, Chong YS, Gluckman PD, Fortier MV, Meaney MJ, Qiu A. Prenatal maternal depression associates with microstructure of right amygdala in neonates at birth. Biol Psychiatry. 2013 Dec 1;74(11):837-44. doi: 5.1016/j.biopsych.2013.06.019. Epub 2013 Aug 19. PMID: 23968960.
⁴Rifkin-Graboi A, Meaney MJ, Chen H, Bai J, Hameed WB, Tint MT, Broekman BF, Chong YS, Gluckman PD, Fortier MV, Qiu A. Antenatal maternal anxiety predicts variations in neural structures implicated in anxiety disorders in newborns. J Am Acad Child Adolesc Psychiatry. 2015 Apr;54(4):313-21.e2. doi: 1016/j.jaac.2015.01.013. Epub 2015 Jan 30. PMID: 25791148.
⁵Soe NN, Wen DJ, Poh JS, Li Y, Broekman BF, Chen H, Chong YS, Kwek K, Saw SM, Gluckman PD, Meaney MJ, Rifkin-Graboi A, Qiu A. Pre- and Post-Natal Maternal Depressive Symptoms in Relation with Infant Frontal Function, Connectivity, and Behaviors. PLoS One. 2016 Apr 13;11(4):e0152991. doi: 10.1371/journal.pone.0152991. PMID: 27073881; PMCID: PMC4830615.
⁶Law EC, Aishworiya R, Cai S, Bouvette-Turcot AA, Broekman BFP, Chen H, Daniel LM, Gluckman PD, Shek LPC, Tay SKH, Chong YS, Koh GC, Meaney MJ. Income disparity in school readiness and the mediating role of perinatal maternal mental health: a longitudinal birth cohort study. Epidemiol Psychiatr Sci. 2021.
⁷Chee YIC, Lee DTS, Chong YS, Tan LK, Ng TP, Fones CSL. Confinement and other psychosocial factors in perinatal depression: a transcultural study in Singapore. J Affect Disord 2005;89:157-66.
⁸Integrated Platform for Research in Advancing Maternal and Child Health Outcomes is one of the main programmes by MCHRI.
⁹Quah PL, Poo ZX, Chen H, Razali NS, Chai SMH, Tan MH, Chua TE, Sng BL, Tan LK, Tan KH. Perinatal Mental Health: Knowledge, Attitudes, Perceptions and Practices Among Perinatal Women (I-MUM). APMCH021, Asia Pacific Maternal & Child Health Conference 2023 & Integrated Platform for Research in Advancing Maternal and Child Health Outcomes (IPRAMHO) International Meeting. 17 & 18 February 2023. KK Women’s and Children’s Hospital Singapore.
¹⁰Quah PL, Chen H, Tan LK, Tan KH. Perinatal Mental Health: Knowledge, Attitudes, Perceptions and Practices Among Doctors (I-DOC). APMCH020. Asia Pacific Maternal & Child Health Conference 2023 & Integrated Platform for Research in Advancing Maternal and Child Health Outcomes (IPRAMHO) International Meeting. 17 & 18 February 2023. KK Women’s and Children’s Hospital Singapore.