Young women are the most vulnerable to postpartum mental illness: A retrospective cohort study in UK primary care

Identification of mothers with mental health problems is accidental: perceptions of health care providers on availability, access, and support for maternal mental health care for adolescent mothers in Malawi

BACKGROUND

Integration of maternal mental health into primary health care is considered a strategy to improve access to mental health support in low- and middle-income countries (LMICs). Health care workers' (HCWs) and traditional practitioners' (traditional healers, herbalists, traditional birth attendants, spiritual healers, prophets, and community health volunteers) perceptions of the availability and management of adolescent mothers' maternal mental health care were explored in rural Malawi. Recognizing and identifying the barriers associated with access to maternal mental health support is essential to improving the mental health of adolescent mothers.

METHODS

A descriptive qualitative design (DQ) was used to explore HCWs' and traditional practitioners' perceptions of maternal mental health services for adolescent mothers. In-depth interviews were conducted with HCWs (n = 6), and three focus group discussions were conducted with 30 community-based traditional practitioners. Participants were purposefully recruited because they provide formal or informal health services to adolescent mothers during the postnatal period at Mitundu Rural Hospital and its catchment area in Lilongwe District, in Malawi. Interviews were analyzed using reflective thematic analysis and inductive thinking.

RESULTS

Thematic analysis found four themes to describe access to maternal mental health care for adolescent mothers. Participant perceptions were themed around health system challenges and how cultural background and beliefs influence access to mental health care and support. The themes were: (1) Inadequate staff development; (2) Limited resources (medication and infrastructure); (3) Limited policy and guidelines implementation; and (4) Cultural background and belief influence on help-seeking. HCWs suggested improving pre-service and in-service training to improve mental health assessment of mothers, while traditional practitioners wanted to increase their awareness of mental health issues.

CONCLUSION

Participants emphasized that multifaceted factors influenced access to mental health support. These factors affect the assessment, treatment, and support of adolescent mothers and help-seeking by mothers. Therefore, strengthening the healthcare system and empowering providers with the knowledge and skills to recognize at-risk mothers and provide timely support is essential.

Postpartum Psychosis: A Proposed Treatment Algorithm

Background

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

Methods

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

Objective

To provide a treatment algorithm for the management of PPP based on available evidence.

Results

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

Conclusion

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.Reprinted from J Psychopharmacol 2023; 37:960-970, with permission from Sage Journals. Copyright © 2023.

Postpartum psychosis: A proposed treatment algorithm

BACKGROUND

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

METHODS

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

OBJECTIVE

To provide a treatment algorithm for the management of PPP based on available evidence.

RESULTS

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

CONCLUSION

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.

Postnatal depression and its social-cultural influences among adolescent mothers: A cross sectional study

In rural Malawi, adolescent mothers represent 31% of pregnancies. While some adolescent mothers experience motherhood as an exciting, positive, and affirming experience, for others, it may increase their risk of postnatal depression (PND). Social norms and culture contribute to adolescent mothers' experiences and may influence their mental health. However, there is limited research around the prevalence of PND and its cultural influences among adolescent mothers. A cross-sectional survey was administered from 7th September 2021 to 31st March 2022. Three hundred and ninety-five adolescent postnatal mothers aged ≤19 were conveniently recruited at Mitundu hospital in Lilongwe, Malawi. The Edinburgh Postnatal Depression Scale was used to assess depression. A cutoff point of ≥ 10 was employed to categorize probable PND. Binary logistic regression was used to determine the predictors of depression. The mean age of participants was 17 (SD 1.157). and 43.6% (n = 172) presented with PND (EPDS scores ≥10). When all factors were considered in a binary logistic model, adolescents who had ever experienced intimate partner violence (IPV) were 13.6 times more likely to report PND after controlling for age and other predictors compared to those without an experience of IPV (aOR 13.6, p = 0.01, 95% CI 2.10-88.9). Participants whose families did not decide for them (regarding their care) were 2.3 times more likely to present with PND than those whose families decided for them (aOR 2.3 p = 0.03, 95% CI 1.04-5.2). Adolescent mothers who had interacted with their health worker were less likely to report PND than those who had no interaction with the health worker (aOR 0.4 P0.02, CI 0.17-0.67). Social and cultural factors can impact mental health of adolescent mothers. It is recommended that targeted and integrated interventions are developed, implemented. and evaluated. There is a need to improve policy and practice to better support adolescent mothers postnatally.

Self-harm risk in pregnancy: recurrent-event survival analysis using UK primary care data

BACKGROUND

Perinatal self-harm is of concern but poorly understood.

AIMS

To determine if women's risk of self-harm changes in pregnancy and the first postpartum year, and if risk varies by mental illness, age and birth outcome.

METHOD

This was a retrospective cohort study of 2 666 088 women aged 15-45 years from the 1 January 1990 to 31 December 2017 linked to 1 102 040 pregnancies and their outcomes, utilising the Clinical Practice Research Datalink and Pregnancy Register. We identified self-harm events and mental illness (depression/anxiety/addiction/affective/non-affective psychosis/eating/personality disorders) from clinical records and grouped women's age into 5-year bands. They calculated the rate of self-harm during discrete non-perinatal, pregnant and postpartum periods. We used a gap-time, stratified Cox model to manage multiple self-harm events, and calculated the unadjusted and adjusted hazard ratios (adjHR) of self-harm associated with pregnancy and the postpartum compared with non-perinatal periods. Pre-planned interactions tested if risk varied by mental illness, age and birth outcome.

RESULTS

The analysis included 57 791 self-harm events and 14 712 319 person-years of follow-up. The risk of self-harm shrank in pregnancy (2.07 v. 4.01 events/1000 person-years, adjHR = 0.53, 95% CI 0.49-0.58) for all women except for 15- to 19-year-olds (adjHR = 0.95, 95% CI 0.84-1.07) and the risk reduced most for women with mental illness (adjHR = 0.40, 95% CI 0.36-0.44). Postpartum, self-harm risk peaked at 6-12 months (adjHR = 1.08, 95% CI 1.02-1.15), at-risk groups included young women and women with a pregnancy loss or termination.

CONCLUSIONS

Maternity and perinatal mental health services are valuable. Family planning services might have psychological benefit, particularly for young women.

Postpartum hemorrhage and postpartum depressive symptoms: A retrospective cohort study

BACKGROUND

Many psychological and obstetrical factors contribute to the development of postpartum depression. However, little is known about how postpartum hemorrhage (PPH) influences postpartum depressive symptoms. This study explored the relationship between PPH and postpartum depressive symptoms in the Chinese population.

METHODS

A retrospective cohort study was conducted at the Baoan Maternal and Child Health Hospital in Shenzhen, China, from January 2016 to June 2020. The Edinburgh Postnatal Depression Scale was used to assess postpartum depressive symptoms. A multivariate logistic regression model was used to estimate the odds ratios (ORs) with 95% confidence intervals (95% CIs) between PPH and risk of postpartum depressive symptoms.

RESULTS

Of the 7734 respondents, 293 (3.8%) and 7441 were in the PPH and control groups, respectively. Puerperal women with PPH were more likely to screen positive for postpartum depressive symptoms than those without PPH (16.4% vs. 11.7%, p = .016). Adjusting for other covariates, women with PPH still had higher risk of postpartum depressive symptoms (OR = 1.68, 95% CI: 1.16-2.42). Stratification analyses revealed no interaction between PPH and maternal age, prepregnancy body mass index, mode of delivery, and fetal sex in developing depressive symptoms (p for interaction > .05).

CONCLUSIONS

PPH may increase the risk of postpartum depressive symptoms. Therefore, women with PPH should be actively screened for depressive symptoms in the immediate postpartum period.

Effectiveness of psychosocial support provided by midwives and family on preventing postpartum depression among first-time adolescent mothers at 3-month follow-up: A randomised controlled trial

AIMS AND OBJECTIVES

To evaluate the effectiveness of a midwife-family provided social support programme (MFPSS programme) for first-time adolescent mothers on preventing postpartum depression (PPD) at 3-month postpartum.

BACKGROUND

Adolescent mothers with lack of social support are a high-risk group for increasing the development of PPD. Interventions designed to promote social support and provided to mothers following childbirth have a more effective role in preventing PPD.

DESIGN

The Consolidated Standards of Reporting Trials (CONSORT) guidelines for a single-blinded randomised controlled trial were conducted.

METHODS

Forty-two adolescent mothers were randomly assigned to 4-week MFPSS programme plus routine care (n = 21) and routine care only (n = 21). PPD was measured using the Edinburgh Postnatal Depression Scale (EPDS), rates and severity at baseline, post-test, 6-week and 3-month postpartum follow-ups. Repeated measures ANOVA and Cohen's d were used to analyse the data.

RESULTS

At the last follow-up, 20 (95.24%) participants remained in each group. Data were analysed based on 40 adolescent mothers. After the intervention, the mean EPDS scores in the intervention group were significantly lower than the same scores in the control group at post-test, 6-week and 3-month postpartum follow-ups. Similarly, the rates and severity of PPD in the intervention group were also lower than the control group at post-test, 6-week and 3-month postpartum follow-ups.

CONCLUSION

Psychosocial support interventions designed to incorporate support from midwives and family members is an effective intervention for preventing PPD in first-time adolescent mothers and the preventive effect is sustained for up to 3-month postpartum.

RELEVANCE TO CLINICAL PRACTICE

Midwives or nurses could apply the MFPSS programme to nursing care for adolescent mothers and family members by adding health information about PPD and promoting social support.

CLINICAL TRIAL REGISTRATION

The trial was registered with Thai Clinical Trials Registry (TCTR). The trial registration number is TCTR 20190206004.