Pregnancy in the severely mentally ill patient as an opportunity for global coordination of care

Norwegian community midwives' experience of interdisciplinary collaboration in care of pregnant women with vulnerabilities

AIM

The aim of this study was to investigate Norwegian community midwiveś(CMs) experience of collaboration when caring for pregnant women with vulnerabilities. We wanted to determine which professionals and services are considered important and with whom they have written agreements and good lines of communication. Furthermore, which tools are used in collaboration and if any background factors enhance collaboration.

BACKGROUND

Vulnerable pregnant women may require more than standard antenatal care, involving interdisciplinary collaboration. Outcomes can improve if vulnerable pregnant women are offered additional support. The introduction of multi-disciplinary teams in Norway has shown promising results, as in many other countries. A Norwegian report concluded that there is need for more research to improve the quality and availability of interdisciplinary care.

METHODS

A cross-sectional, descriptive study, using data from a questionnaire that approximately 700 CMs in Norway were invited to answer online from May-August 2020. Data were analysed using the statistical software SPSS 26.

RESULTS

One third (257) of the invited CMs participated in the survey. They reported that professionals involved in standard antenatal care, such as those at the maternity unit and PHNs, were the most important collaborative partners when caring for vulnerable pregnant women. The CMs reported poor communication with general practitioners, child welfare-, drug welfare- and mental health-services. The most frequent methods for accessing collaboration were phoning and electronically through patient record systems, while there was limited use of the personal care plan, patient coordination meetings and regular meetings with collaborative partners/services. CMs with more than ten years as a CM and "Early Start" training were more frequently involved in patient coordination meetings and counselling and debriefing sessions compared to inexperienced CMs who had not attended a special training program.

CONCLUSION

Experience and completed the Early Start education/training increased the use of interprofessional collaborating meetings including CMs. This study suggests interdisciplinary training programmes to improve collaboration, which are expected to benefit vulnerable pregnant women, their babies and families.

IMPLICATION FOR PRACTICE AND RESEARCH

We recommend education and training in both the educational system and among involved professionals in communities to improve collaboration in the care of vulnerable women. In order to measure the effectiveness of collaboration in the care of vulnerable pregnant women, both the targeted group and the collaborating professionals should be asked to provide feedback. More research on communication and collaboration is needed.

Reproductive Decision-Making Capacity in Women With Psychiatric Illness: A Systematic Review

BACKGROUND

Decision-making capacity can be affected by psychiatric illness. Women who have psychiatric illness who make decisions about their reproductive health may require evaluation of their decision-making capacity.

OBJECTIVE

This article aims to characterize existing literature about capacity evaluations in women with psychiatric illness making reproductive decisions.

METHODS

We conducted a systematic review searching PubMed, EMBASE, Ovid PsycINFO, and ClinicalTrials.gov databases through July 2020. Articles were evaluated for relevance to inclusion criteria, first by title and abstract screening then by reading the full text of articles. Our inclusion criteria were case reports and studies that involved women of childbearing age with psychiatric illness making obstetrical decisions for whom decision-making capacity was evaluated. We qualitatively analyzed our data by examining themes within the studies, such as the circumstances of the referral and characteristics of reproductive decision-making. We also collected information about the clinical circumstances, such as the clinical setting (e.g., inpatient or outpatient, in primarily psychiatric or obstetric care) and who made the determination of capacity.

RESULTS

We identified 18 articles, which included 22 distinct patient cases and 27 distinct obstetrical decisions. Decisions about termination of pregnancy were most common, which were 10 of 27 decisions. Decisions about timing and mode of delivery accounted for 7 and 5 decisions, respectively. The most common psychiatric diagnosis reported was schizophrenia, which was present in 8 patients. Major depression and bipolar disorder were also frequently reported, present in 3 and 5 patients, respectively.

CONCLUSION

Patients who make health care decisions must have decision-making capacity. A patient with psychiatric illness does not inherently lack capacity, and in fact, most patients with psychiatric illness have decision-making capacity. Psychiatric illness, however, can add complexity to obstetrical medical decision-making. Reasons for this complexity include the involvement of many stakeholders, the often time-sensitive nature of these decisions, and the potentially unpredictable course of psychiatric illness. Successful management of these cases involves multidisciplinary collaboration, the use of preventative ethics through advanced care planning, and identification of a guardian or surrogate decision-maker when a patient is determined to lack decision-making capacity or for a patient who has capacity through advanced care planning.

PROSPERO REGISTRATION NUMBER

CRD42020143434.

Interpersonal nurse-patient relationship with a young schizophrenic pregnant woman

The objective of this study was to investigate elements of the personal and psychiatric history, as well as the challenges related to motherhood, of a young schizophrenic female, through person-centered therapeutic interaction. The investigation had an exploratory scope, undertaken in a teaching hospital and data were collected during nondirective interaction on the part of the nurse with a young schizophrenic woman who had been treated in the institution for 10 years. Thematic analysis of the content was undertaken, with emphasis on the nuclei of meaning, identification of the themes and definition of the categories. The patient, called L. in this study, was 30 years old, had a two-year-old child and was three months pregnant when data were collected. Her trajectory was characterized by doubts, fears and uncertainties. The episodes of hospitalization, the coexistence with other patients, and the medications promoted insight into the symptoms, and acceptance of the diagnosis. The main challenge was experiencing pregnancy and the puerperium concomitantly with the psychiatric treatment. The interpersonal relationship established evidenced that, the young woman felling understood and that her needs were attended, overcame several difficulties she had reported and felt fulfilled and integrated into her social environment.

Pedagogical Implications of Partnerships Between Psychiatry and Obstetrics-Gynecology in Caring for Patients with Major Mental Disorders

OBJECTIVE

Because there are no formal reviews, the authors set out to identify and describe programs that serve female patients with major mental disorders by integrating mental health care with services in obstetrics and gynecology and to describe the pedagogical implications of those programs.

METHOD

The authors searched PubMed for all articles describing a program in which psychiatry was formally integrated with obstetric or gynecological services, other than standard consultation-liaison programs, in the care of patients with major mental disorders. The search terms used included interdisciplinary, interprofessional, integrated, collaborative care, psychiatry, and obstetrics-gynecology or psychosomatic obstetrics-gynecology.

RESULTS

The authors found six distinct integrated programs. These included family planning clinics that were integrated into inpatient psychiatry services; inpatient and outpatient psychiatry services for pregnant mentally ill women in close collaboration with obstetric services; a day hospital for pregnant women with psychiatric disorders in an obstetric setting; an interdisciplinary training site providing care for predominantly depressed, low-income, and minority women; a primary care HIV service for women integrated with departments of obstetrics-gynecology and psychiatry; and an obstetrics-gynecology clinic-based collaborative depression care intervention for socially disadvantaged women. Residents' involvement was described in four of the programs.

CONCLUSIONS

These innovative and integrated programs potentially enhance the care of vulnerable and culturally diverse women with major mental disorders. The authors discuss how these programs may contribute to the education of residents in psychiatry and obstetrics-gynecology.