Maternal Mortality and Mental Health: Challenges and Solutions

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Maternal Mortality andMental HealthChallenges
and Solutions

• Dr Alain Gregoire
• South East Regional Psychiatric Assessor, CEMACH
• Consultant/Hon. Senior Lecturer in Perinatal
  Psychiatry, Southampton

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Maternal Mortalityand Mental Health

• Perinatal mental health relevance to maternity
  services and primary care
• Why Mothers Die psychiatric causes
• Key recommendations
• Policy context
• Relevance to mental health services
• Specialist perinatal psychiatric services

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Perinatal Mental Health Relevance to Maternity
Services

• Depression is the most common major complication
  of the postnatal period
• Psychosis is one of the most severe complications
  of the postnatal period
• Significant impact on healthcare behaviour
• Lasting effects on maternal and child physical
  and mental health
• Maternal and child mortality

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Perinatal Mental Health Relevance to Primary Care

• Short and long term effects on woman, child and
  family
• High cost to NHS, social services and society
• Predictable, preventable, detectable, treatable

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Maternal Mortalityand Mental Health

• Perinatal mental health relevance to maternity
  services and primary care
• Why Mothers Die psychiatric causes
• Key recommendations
• Policy context
• Relevance to mental health services
• Specialist perinatal psychiatric services

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Why Mothers Die 2000-2002 psychiatric causes

• Suicide, substance misuse, misattributed physical
  causes, accidents, misadventure
• 28 suicides reported
• ONS linkage over 50 suicides/open verdicts
• 60 psychiatric related deaths overall
• Half were in 3 months before and after birth
• 2/3 violent means 4 infanticides
• 2 homicides

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Letter from a woman to her mother written shortly
before killing her child and herself

• Dear mom,
• Just a quick note with Johns school
  photograph, I have sent you the large one, its
  really good, hay? Boy how his blonde hair shows
  up in this photo, plus he is wearing blue which
  he always looks good in. I miss you mom, I am
  very depressed and feeling very alone. You have
  no life here. I only see Neil and George and the
  rest just pass through. Goodness I wish I could
  come back to you mom I am so tired of all this. I
  just want to be part of a family again,
• Take care Mom hope you like the photo,
• Love you Mom,
• Love..

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Why Mothers Die 2000-2002 psychiatric causes

• Leading overall cause of death of women in
  pregnancy and postnatally in the UK
• Key themes
• Poor identification of past history (50)
• Poor identification of risk (50 of above)
• Poor communication of both by psychiatric
  services, GPs, maternity
• Misattribution of physical illness to psychiatric
  causes (32)
• All but 2 did not receive specialist care

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Why Mothers Die 2000-2002 psychiatric causes

• 87 white, no social class association
• 54 severe illness
• 50 had past history of severe illness, 25 of
  psychiatric admission
• 50 in contact with psychiatric services
• Only 2 had any contact with specialist perinatal
  services
• Only 5 had previous postnatal history

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Maternal Mortality and Mental Health

• Perinatal mental health relevance to maternity
  services and primary care
• Why Mothers Die psychiatric causes
• Key recommendations
• Policy context
• Relevance to mental health services
• Specialist perinatal psychiatric services

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Why Mothers Die 2000-2002 Key Recommendations

• Guidelines in all maternity services for
  detection and management of risk of illness
• Routine enquiry about past history at booking
• Training for maternity service professionals
• Specialist perinatal psychiatric services,
  including specialist mother baby units,
  available to all women who need them

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Maternal Mortalityand Mental Health

• Perinatal mental health relevance to maternity
  services and primary care
• Why Mothers Die psychiatric causes
• Key recommendations
• Policy context
• Relevance to mental health services
• Specialist perinatal psychiatric services

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Policy context

• NSF Mental Health
• NIHCE Antenatal Care
• Womens Mental Health into the Mainstream
• Psychiatric Inpatient Care Safety, Privacy,
  Dignity
• Childrens NSF
• NIHCE Antenatal and Postnatal Mental Health (2006)

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Maternal Mortalityand Mental Health

• Perinatal mental health relevance to maternity
  services and primary care
• Why Mothers Die psychiatric causes
• Key recommendations
• Policy context
• Relevance to mental health services
• Specialist perinatal psychiatric services

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Bipolar Disorder and Puerperal Psychosis

• Postpartum is the highest period of risk for
  psychosis (21 fold)
• 2-4 /1000 deliveries
• Confusion, delusions, hallucinations, severe
  disturbance of function
• Untreated bipolar illness 50 relapse in
  pregnancy 70 relapse postpartum
• 50 risk of recurrence in 1 year

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Depression

• High rates of depression in pregnancy (10-20)
  and postnatally (10-15)
• 50 of cases postnatally have started in
  pregnancy
• 3 fold incidence postnatally
• Severe 3
• Duration weeks-years
• Risk 40 if past depression
• Most cases undetected and untreated

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Schizophrenia

• Fertility probably increasing
• Prevalence 1
• Mental state worsens in pregnancy
• Increased risk of relapse in pregnancy probably
  postnatally
• Positive negative chronic symptoms in 70-80
• Poor contact with mental health and other
  services
• High risk of poor parenting outcomes

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Parental Effects of Mental Illness

• Personal suffering, illness disability.
• Poor antenatal self care.
• Impaired functioning.
• Social problems.
• Isolation/ poor support.
• Relationship problems Illness in partner.
• Impaired parenting.
• Dangerous behaviour Death.

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Child Effects of Mental Illness

• Raised foetal neonatal death
• More neurological malformations
• Increased obstetric complications
• Genetic risk
• Attachment problems
• Emotional behavioural problems
• Developmental/cognitive delay
• Isolation
• More accidents, neglect, abuse death

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Social Disadvantage

• Conflict with partner 90
• Physical abuse by partner 30
• Partner with substance abuse 25
• Long term debt 45
• Housing problems 45-85
• Hospitalised previous year 50

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Social Effects of Perinatal Mental Illness

• Transgenerational disadvantage, disability
  illness
• Main cause of death in new mothers
• Main cause of infanticide after 1st day
• Long term dependency on services
• Health costs
• MBU admission alone
• 15-25,000
• Social services costs m
• A major public health issue

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Manic depression? Good Lord, no. Manic
depression is completely beyond your price range.
NHS
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Prediction Psychosis

• Pregnancy lithium discontinuation ? 50 risk of
  recurrence
• History of bipolar disorder incidence of
  puerperal psychosis 40-70
• Schizophrenia 50 of infants taken into care
• Preconceptual advice
• Early antenatal detection of women with history
  of psychosis
• AN expert assessment of illness risks

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Prevention Psychosis

• No prophylaxis risk 50-70
• Lithium prophylaxis incidence
• 3/21 (Stewart et al 1991)
• 2/9 (Austin 1992)
• 1/14 (Cohen Sichel, 1995)
• Antipsychotic prophylaxis intensive FU
  incidence 0/11 (Gregoire, unpublished data)
• Agreed, communicated implemented plan
• prophylaxis intensive follow up

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Prediction Depression

• Previous depression ? PP prevalence 30-60
  (?effect of multiple previous)
• Other risk factors limited predictive power
• Antenatal depression, blues, highs
• Poor marital/ other support
• Chronic stressors
• Ambivalence re. Pregnancy
• Personality features?
• Awareness, advice, information

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Depression Prevention

• Recurrence rates
• Stop ADs in pregnancy 68
• (Wisner Wheeler 1994)
• AD prophylaxis 1/15 controls 5/8
• Double blind RCTs (Wisner et al 1998 2004)
• Nortriptyline 6/26 Placebo 6/25
• Sertraline 1/14 placebo 4/8
• Counselling, debriefing no evidence of effect
  but social support reduces risk
• Continue existing treatment
• Awareness, advice, support up to date info ?ADs

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Maternal Mortalityand Mental Health

• Perinatal mental health relevance to maternity
  services and primary care
• Why Mothers Die psychiatric causes
• Key recommendations
• Policy context
• Relevance to mental health services
• Specialist perinatal psychiatric services

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Specialist Perinatal Mental Health Services

• In all maternity services, available to all women
  who need them
• Specialist mother and baby inpatient facilities
  available for all women with child under one year
  who need admission
• Specialist consultant psychiatrist and community
  team

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Specialist Perinatal Mental Health Services Roles

• Develop and implement coordinated, integrated
  multiagency processes for
• Prediction and prevention antenatal booking
  screen ICP assessment prevention plans
• Early identification and prompt treatment advice
  and referral pathways rapid home assessment
  intensive home treatment inpatient MBUs
• Focus on needs of mother and child nursery nurse
  provision, mother infant video techniques
• Effective communication assessment and plan
  letters to women, copied to all written and
  video information
• Safety assessment and communication of risks and
  plan
• Staff education quarterly education, advice and
  support for midwives, h/vs regular events for
  GPs /obstetricians

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Conclusions

• Good clinical care demands
• Awareness, enquiry and action by all on mental
  illness and domestic violence issues and risks
• Routine provision of information
• Good multiagency care and communication
• Access to specialist perinatal psychiatric
  knowledge, skills and services in all settings
• Collaborative approaches
• Women and their families
• All agencies
• All services

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