An audit of pregnant women with severe mental illness referred during the first 2 years of a new perinatal mental health service

Pregnancy intention in relation to maternal and neonatal outcomes in women with versus without psychiatric diagnoses

BACKGROUND

Studies have identified adverse maternal and neonatal outcomes for women with psychiatric disorders. Additionally, psychiatric disorders may pose an increased risk for unintended pregnancies (UPs) which in turn may also impact negatively on outcomes. The present study aims to compare the incidence of UPs in women with versus without current/past psychiatric diagnoses and investigates whether psychiatric history modifies the relation between delivery outcomes in women with and without UPs.

METHODS

A retrospective cohort was compiled of women who gave birth in a large hospital in Amsterdam, the Netherlands. Women ≥18 years old with singleton pregnancies and birth registrations in the electronic patient file during January 1, 2015 to March 1, 2020 were included. Patient characteristics (including pregnancy intention and psychiatric history), maternal (gestational diabetes, mode of delivery) and neonatal outcomes (e.g., gestational age [GA], birthweight and Apgar scores) were registered by health care providers in hospital charts. Incidence of UPs was compared between women with versus without current/past psychiatric diagnoses. Maternal and neonatal outcomes were compared between women with versus without UPs with linear or logistic regression models adjusted for relevant confounders with an interaction term for UP with current/past psychiatric diagnoses.

RESULTS

We included 1219 women with and 1093 women without current/past psychiatric diagnoses. Current/past psychiatric diagnoses were significantly associated with UPs after adjustment for confounders (39.0% vs. 29.6%, OR 1.56, CI 1.23-2.00, p < 0.001). In sub-analyses, women with depressive (OR 1.67, CI 1.24-2.26, p = 0.001), personality (OR 2.64, CI 1.38-5.11, p = 0.004) and substance-related and addictive disorders (OR 4.29, CI 1.90-10.03, p = 0.001) had higher odds of UPs compared to women without current/past psychiatric diagnoses. Amongst women with UPs, current/past psychiatric diagnoses did not modify maternal or neonatal outcomes, except for GA at delivery as women with both UPs and current/past psychiatric diagnosis had a 2.21-day higher mean GA at delivery than women in the reference group (p-value interaction = 0.001).

CONCLUSIONS

Current/past psychiatric diagnoses are associated with a higher odd of UPs. In our sample, maternal and neonatal outcomes were comparable for women with and without UPs and these results were similar for women with and without current/past psychiatric diagnoses, except for GA at delivery. Although our study is limited by several factors, we found that women with current/past psychiatric diagnoses, irrespective of pregnancy planning status, do not have more adverse maternal or pregnancy outcomes. Increased efforts are needed to ensure that psychoeducation and conversations about pregnancy planning and UPs are available for women with current/past psychiatric diagnoses.

Long-term influence of unintended pregnancy on psychological distress: a large sample retrospective cross-sectional study

This study examined the associations between childbirth decisions in women with unintended pregnancies and long-term psychological distress. An online survey of women selected from a representative research panel was conducted in July 2021. Among participants who experienced an unintended pregnancy, the childbirth decision was categorized: (i) wanted birth, (ii) abortion, (iii) adoption, and (iv) unwanted birth. Participants who made childbirth decisions more than 1 year ago were included. ANCOVA was conducted with psychological distress (Kessler 6) as the dependent variable and education, marital status, years from the decision, age of the first pregnancy, economic situation at the unintended pregnancy, and the number of persons consulted at the unintended pregnancy as covariates. Logistic regression analysis was conducted for high distress (K6 ≥ 13) by adjusting the same covariates. A total of 47,401 respondents participated in the study. Women with an experience of unintended pregnancy experienced more than 1 year before the study were analyzed (n = 7162). Psychological distress was the lowest for wanted birth and increased for abortion, adoption, and unwanted birth. In the adjusted model, abortion was associated with lower distress scores than both adoption and unwanted birth. Compared to the wanted birth, adoption and unwanted birth showed significantly higher levels of distress (adjusted odds ratio [aOR] = 2.03 [95% CI 1.36-3.04], aOR = 1.64 [95% CI 1.04-2.58], respectively). Long-term effects on psychological distress differed according to the childbirth decisions in unintended pregnancy. Healthcare professionals should be aware of this hidden effect of unintended pregnancy experience on women's mental health.

Psychiatric vulnerability and the risk for unintended pregnancies, a systematic review and meta-analysis

Background

Unintended pregnancies (UPs) are a global health problem as they contribute to adverse maternal and offspring outcomes, which underscores the need for prevention. As psychiatric vulnerability has previously been linked to sexual risk behavior, planning capacities and compliance with contraception methods, we aim to explore whether it is a risk factor for UPs.

Methods

Electronic databases were searched in November 2020. All articles in English language with data on women with age ≥ 18 with a psychiatric diagnosis at time of conception and reported pregnancy intention were included, irrespective of obstetric outcome (fetal loss, livebirth, or abortion). Studies on women with intellectual disabilities were excluded. We used the National Institutes of Health tool for assessment of bias in individual studies and the Grading of Recommendations Assessment, Development and Evaluation method for assessment of quality of the primary outcome.

Findings

Eleven studies reporting on psychiatric vulnerability and UPs were included. The participants of these studies were diagnosed with mood, anxiety, psychotic, substance use, conduct and eating disorders. The studies that have been conducted show that women with a psychiatric vulnerability (n = 2650) have an overall higher risk of UPs compared to women without a psychiatric vulnerability (n = 16,031) (OR 1.34, CI 1.08–1.67) and an overall weighed prevalence of UPs of 65% (CI 0.43–0.82) (n = 3881).

Interpretation

Studies conducted on psychiatric vulnerability and UPs are sparse and many (common) psychiatric vulnerabilities have not yet been studied in relation to UPs. The quality of the included studies was rated fair to poor due to difficulties with measuring the outcome pregnancy intention (use of various methods of assessment and use of retrospective study designs with risk of bias) and absence of a control group in most of the studies. The findings suggest an increased risk of UPs in women with psychiatric vulnerability. As UPs have important consequences for mother and child, discussing family planning in women with psychiatric vulnerabilities is of utmost importance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04452-1.

Preconception personality disorder and antenatal maternal mental health: A population-based cohort study

BACKGROUND

Prior anxiety and depression have been identified as risk factors for maternal perinatal mental health problems, but other preconception mental disorders have not been prospectively examined. This study investigated prospectively whether women with preconception personality disorder have increased rates of antenatal anxiety and/or depressive symptoms.

METHODS

244 women in a population cohort were assessed for personality disorder at age 24 using the Standardised Assessment of Personality. Five to twelve years later, women were screened with the Clinical Interview Schedule, Revised Anxiety Subscale and the Edinburgh Postnatal Depression Scale during the third trimester of 328 pregnancies.

RESULTS

Preconception personality disorder was associated with a three-fold increase in the odds of antenatal anxiety symptoms, which remained with adjustment for preconception background factors and preconception common mental disorder (adjusted OR 2.84, 95% CI 1.31-6.15). Preconception personality disorder was associated with doubled odds of antenatal depressive symptoms, however this was attenuated with adjustment for preconception background factors and preconception common mental disorder (adjusted OR 1.98, 95% CI 0.81-4.81).

LIMITATIONS

Our findings are restricted to pregnant women aged 29-35 years. Anxiety and depression may have been under-identified because they were assessed at a single antenatal time point. Residual confounding of the associations by preconception common mental disorder at other time points may have occurred.

CONCLUSIONS

Women with personality disorder are at heightened risk of anxiety symptoms in pregnancy, over and above risks associated with prior common mental disorder. This raises a possibility that pregnancy brings particular emotional challenges for women with personality disorders.

Engaging women at risk for poor perinatal mental health outcomes: a mixed-methods study

Risk factors for poor perinatal mental health are well known. Psychosocial assessment and depression screening during the perinatal period aim to identify women at risk for poor perinatal outcomes. Early intervention programmes are known to improve the mental health outcomes of women and infants. Key to any intervention is initial and ongoing engagement in the therapeutic process. This mixed-methods study reports the proportion of women who engage/do not engage with services and their characteristics, as well as the strategies clinicians use to engage women. Data were collected by reviewing medical records, interviewing perinatal and infant mental health (PIMH) clinicians, their managers, key stakeholders, and women service users. Analyses identified that most (71.3%) women referred engaged with the PIMH service. Themes related to non-engagement are 'time to rethink' and 'stigma'. Themes reflecting the engagement strategies used by PIMH clinicians are initial engagement: 'back to basics' and 'building trust', therapeutic engagement: 'making myself useful', engagement at discharge: 'woman or clinician led', and models that facilitate engagement.

Completing the cycle: The use of audit to develop a mental health service in times of austerity

BACKGROUND

A published audit demonstrated that a pilot psychiatric clinic failed to capture predicted numbers of women with severe and enduring mental illness.

METHODS

On the basis of recommendations from this audit, along with those from the Royal College of Psychiatrists and NICE guidelines, a more comprehensive psychiatric service was developed to meet this demand and therefore manage risk more effectively.

RESULTS

Over the course of a year, the new service attracted a higher rate of referrals of pregnant women with severe and enduring mental illness. The majority referral source continued to be midwifery-led.

CONCLUSIONS

Audit is a useful tool for evaluating and informing service development and helped us identify further improvements needed to deliver an effective mental health service.

Self-harm in postpartum depression and referrals to a perinatal mental health team: an audit study

There is a paucity of research on self-harm during pregnancy and the postpartum period despite suicide being a leading cause of death and high rates of mental disorder during this time. This audit describes a cohort of women referred to a new perinatal mental health team (PMHT) based in a large maternity hospital in the UK over a 12-month period. The audit was conducted in two stages. Stage one describes the clinical and socio-demographic characteristics of 225 pregnant women referred to the team after screening positive for a significant mental health history. Stage two determines the veracity of data on a subgroup of 73 pregnant women referred for previous postpartum depression (PPD), 58 % of whom disclosed an episode of self-harm with the 'intent to kill themselves' to the maternity staff when they first booked in for antenatal care. Previous PPD accounted for the largest majority of referrals (32 %) to the PMHT followed by depression (27 %) and self-harm (10 %). The majority of women (85 %) referred to the PMHT were engaged. Eight percent were so unwell at the point of referral they required an admission to the hospital. Attempted suicide in the subgroup of 73 women with previous PPD ranged from 24-49 %. The findings from this audit suggest that self-harm in PPD warrants further investigation.

Collaboration and integrated services for perinatal mental health: an integrative review

BACKGROUND

  An integrative review was undertaken to synthesise the research related to professionals' perceptions and experiences of working in collaborative and integrated models of perinatal care for women with mental health problems.

METHOD

  A search of the databases CINAHL, Medline, PubMed, Psychinfo and Scopus was conducted. Studies were limited to English language papers published from 2000 to 2010. Fourteen papers were included in the review.

RESULTS

  The overarching theme identified in the review related to the process of 'making it happen'. Eight key elements were identified as central components of this process: funding and resources for collaboration; shared vision, aims and goals; pathways and guidelines; continuity of care; building relationships and trust; role clarity; training and education of staff and support to work in new ways.

CONCLUSION

  Perinatal mental health is an emerging field that is particularly challenging as it requires professionals to work across disciplines and timeframes, where there is a risk of dichotomising care, compounding existing barriers to service uptake. Professionals need resources and to feel supported to change clinical practice and work in more collaborative ways. The voices of women and families are missing in the literature.

The rise and fall of a psychiatric antenatal clinic: development of a perinatal psychiatric service linked directly to the provision of antenatal care

Usual referral pathways to psychiatric services can miss opportunities for timely intervention in maternal perinatal psychiatric ill health. Psychiatric illness leading to suicide is a significant factor in at least 10% of maternal deaths. Despite Royal College of Psychiatry and National Institute for Health and Clinical Excellence recommendations for specialist provision of perinatal mental health services, this remains sporadic and insufficient. We set out to develop a new integrated antenatal-psychiatric direct referral pathway and present a year of experience using this service model. The psychiatric service was delivered from within the antenatal clinic setting with a direct health-care professional (HCP) led referral pathway between 2003 and 2004. The service comprised one session per week of a senior psychiatric specialist registrar and provided three new patients and two follow-up appointments per week. During this period, a total of 75 referrals to the service were made with 57 individuals attending for an appointment. There was a range of diagnoses among the women who attended, with only 24% meeting eligibility criteria for referral to secondary psychiatric services. The majority diagnosis was depression. More severely ill women were not referred to this clinic by obstetric HCPs. In conclusion, this model for developing and delivering a specialist perinatal psychiatric service using direct links to antenatal medical care was not successful despite requiring minimal funding. Nevertheless, it has been used to inform development of a new perinatal service in keeping with the Royal College of Psychiatrists' recommendations and incorporating enhanced training of HCPs responsible for the referral pathway.