Women's experiences of attempted suicide in the perinatal period (ASPEN-study) - a qualitative study

BACKGROUND

Suicide is a leading cause of maternal death during pregnancy and the year after birth (the perinatal period). While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK [1], the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth [2]. Qualitative research into perinatal suicide attempts is crucial to understand the experiences, motives and the circumstances surrounding these events, but this has largely been unexplored.

AIM

Our study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt.

METHODS

Through iterative feedback from a group of women with lived experience of perinatal mental illness and relevant stakeholders, a qualitative study design was developed. We recruited women and birthing people (N = 11) in the UK who self-reported as having undertaken a suicide attempt. Interviews were conducted virtually, recorded and transcribed. Using NVivo software, a critical realist approach to Thematic Analysis was followed, and themes were developed.

RESULTS

Three key themes were identified that contributed to the perinatal suicide attempt. The first theme 'Trauma and Adversities' captures the traumatic events and life adversities with which participants started their pregnancy journeys. The second theme, 'Disillusionment with Motherhood' brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women's mental health. The third theme, 'Entrapment and Despair', presents a range of factors that leads to a significant deterioration of women's mental health, marked by feelings of failure, hopelessness and losing control.

CONCLUSIONS

Feelings of entrapment and despair in women who are struggling with motherhood, alongside a background of traumatic events and life adversities may indicate warning signs of a perinatal suicide. Meaningful enquiry around these factors could lead to timely detection, thus improving care and potentially prevent future maternal suicides.

Adapting brief problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence in rural Ethiopia

OBJECTIVE

To adapt an evidence-based psychological intervention for pregnant women experiencing depressive symptoms and intimate partner violence (IPV) in rural Ethiopia.

METHOD

We conducted a desk review of contextual factors in Sodo, Ethiopia, followed by qualitative interviews with 16 pregnant women and 12 antenatal care (ANC) providers. We engaged stakeholders through participatory theory of change (ToC) workshops, to select the intervention and articulate a programme theory. We used "ADAPT" guidance to adapt the intervention to the context, before mapping potential harms in a "dark logic model".

RESULTS

Brief problem-solving therapy developed for South Africa was the most contextually relevant model. We adapted the delivery format (participants prioritised confidentiality and brevity) and training and supervision (addressing IPV). Consensus long-term outcomes in our ToC were ANC providers skilled in detecting and responding to emotional difficulties and IPV, women receiving appropriate support, and emotional difficulties improving. Our dark logic model highlighted the risk of more severe IPV and mental health symptoms not being referred appropriately.

CONCLUSION

Although intervention adaptation is recommended, the process is rarely reported in depth. We comprehensively describe how contextual considerations, stakeholder engagement, programme theory, and adaptation can tailor psychological interventions for the target population in a low-income, rural setting.

An exploration of service use pattern changes and cost analysis following implementation of community perinatal mental health teams in pregnant women with a history of specialist mental healthcare in England: a national population-based cohort study

BACKGROUND

The National Health Service in England pledged >£365 million to improve access to mental healthcare services via Community Perinatal Mental Health Teams (CPMHTs) and reduce the rate of perinatal relapse in women with severe mental illness. This study aimed to explore changes in service use patterns following the implementation of CPMHTs in pregnant women with a history of specialist mental healthcare in England, and conduct a cost-analysis on these changes.

METHODS

This study used a longitudinal cohort design based on existing routine administrative data. The study population was all women residing in England with an onset of pregnancy on or after 1st April 2016 and who gave birth on or before 31st March 2018 with pre-existing mental illness (N = 70,323). Resource use and costs were compared before and after the implementation of CPMHTs. The economic perspective was limited to secondary mental health services, and the time horizon was the perinatal period (from the start of pregnancy to 1-year post-birth, ~ 21 months).

RESULTS

The percentage of women using community mental healthcare services over the perinatal period was higher for areas with CPMHTs (30.96%, n=9,653) compared to areas without CPMHTs (24.72%, n=9,615). The overall percentage of women using acute care services (inpatient and crisis resolution teams) over the perinatal period was lower for areas with CPMHTs (4.94%, n=1,540 vs. 5.58%, n=2,171), comprising reduced crisis resolution team contacts (4.41%, n=1,375 vs. 5.23%, n=2,035) but increased psychiatric admissions (1.43%, n=445 vs. 1.13%, n=441). Total mental healthcare costs over the perinatal period were significantly higher for areas with CPMHTs (fully adjusted incremental cost £111, 95% CI £29 to £192, p-value 0.008).

CONCLUSIONS

Following implementation of CPMHTs, the percentage of women using acute care decreased while the percentage of women using community care increased. However, the greater use of inpatient admissions alongside greater use of community care resulted in a significantly higher mean cost of secondary mental health service use for women in the CPMHT group compared with no CPMHT. Increased costs must be considered with caution as no data was available on relevant outcomes such as quality of life or satisfaction with services.

Intimate partner violence across pregnancy and the postpartum and the relationship to depression and perinatal wellbeing: findings from a pregnancy cohort study

PURPOSE

To compare the prevalence of emotional and physical intimate partner violence (IPV) across pregnancy and the first year postpartum in those with and without clinical depression and assess the association between maternal childhood trauma, current stressful life events and depression and IPV over the perinatal period.

METHODS

Data were obtained from 505 pregnant women from the Mercy Pregnancy and Emotional Wellbeing Study (MPEWS), a cohort study with data collected across pregnancy until 12 months postpartum. Maternal antenatal depression was measured using the Structured Clinical Interview for DSM-IV (SCID-IV) with repeat measurement of perinatal depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS). Trauma was measured using the Childhood Trauma Questionnaire, and experiences of physical and emotional intimate partner violence using items in the Stressful Life Events Scale.

RESULTS

Women experiencing IPV across the perinatal period were significantly more likely to score over 13 on the EPDS (p < .001) at each timepoint in pregnancy and the postpartum and physical IPV was associated with clinical depression. Further, a history of childhood trauma and current additional stressful life events were significantly associated with reporting current IPV in the perinatal period.

CONCLUSIONS

This study confirmed the risk factors of childhood trauma and current stressful life events for reporting experiences of IPV in the perinatal period. Furthermore, women experiencing IPV reported higher depressive symptoms, providing evidence supporting the value of assessing those women who screen higher on the EPDS for IPV. Together these findings also support trauma informed care across pregnancy and the postpartum.

Community perinatal mental health teams and associations with perinatal mental health and obstetric and neonatal outcomes in pregnant women with a history of secondary mental health care in England: a national population-based cohort study

BACKGROUND

Women with a pre-existing severe mental disorder have an increased risk of relapse after giving birth. We aimed to evaluate associations of the gradual regional implementation of community perinatal mental health teams in England from April, 2016, with access to mental health care and with mental health, obstetric, and neonatal outcomes.

METHODS

For this cohort study, we used the national dataset of secondary mental health care provided by National Health Service England, including mental health-care episodes from April 1, 2006, to March 31, 2019, linked at patient level to the Hospital Episode Statistics, and birth notifications from the Personal Demographic Service. We included women (aged ≥18 years) with an onset of pregnancy from April 1, 2016, who had given birth to a singleton baby up to March 31, 2018, and who had a pre-existing mental disorder, defined as contacts with secondary mental health care in the 10 years immediately before pregnancy. The primary outcome was acute relapse, defined as psychiatric hospital admission or crisis resolution team contact in the postnatal period (first year after birth). Secondary outcomes included any secondary mental health care in the perinatal period (pregnancy and postnatal period) and obstetric and neonatal outcomes. Outcomes were compared according to whether a community perinatal mental health team was available before pregnancy, with odds ratios (ORs) adjusted for time trends and maternal characteristics (adjORs).

FINDINGS

Of 807 798 maternity episodes in England, we identified 780 026 eligible women with a singleton birth, of whom 70 323 (9·0%) had a pre-existing mental disorder. A postnatal acute relapse was found in 1117 (3·6%) of 31 276 women where a community perinatal mental health team was available and in 1745 (4·5%) of 39 047 women where one was unavailable (adjOR 0·77, 95% CI 0·64-0·92; p=0·0038). Perinatal access to any secondary mental health care was found in 9888 (31·6%) of 31 276 women where a community perinatal mental health team was available and 10 033 (25·7%) of 39 047 women where one was not (adjOR 1·35, 95% CI 1·23-1·49; p<0·0001). Risk of stillbirth and neonatal death was higher where a community perinatal mental health team was available (165 [0·5%] of 30 980 women) than where it was not (151 [0·4%] of 38 693 women; adjOR 1·34, 95% CI 1·09-1·66; p=0·0063), as was the risk of a baby small for gestational age (2227 [7·2%] of 31 030 women vs 2542 [6·6%] of 38 762 women; adjOR 1·10, 1·02-1·20; p=0·016), whereas preterm birth risk was lower (3167 [10·1%] of 31 206 women vs 4341 [11·1%] of 38 961; adjOR 0·86, 0·74-0·99; p=0·032).

INTERPRETATION

The regional availability of community perinatal mental health teams reduced the postnatal risk of acute relapse and increased the overall use of secondary mental health care. Community perinatal mental health teams should have close links with maternity services to avoid intensive psychiatric support overshadowing obstetric and neonatal risks.

FUNDING

The National Institute for Health and Care Research.

Mother-infant interaction and infant development in women at risk of postpartum psychosis with and without a postpartum relapse

BACKGROUND

This study aimed to investigate mother-infant interaction and infant development in women at-risk of postpartum psychosis (PP), with and without a postpartum relapse.

METHODS

103 women (and their offspring) were included, 43 at-risk-of-PP because of a diagnosis of bipolar disorder, schizoaffective disorder or previous PP, and 60 with no current/previous mental illness or family history of PP. Of the at-risk women, 18 developed a psychiatric relapse within 4 weeks after delivery (AR-unwell), while 25 remained symptom-free (AR-well). Mother-infant interaction was assessed using the CARE-Index at 8 weeks' and 12 months' postpartum and infant development using the Bayley-III at 12 months' postpartum.

RESULTS

Women at-risk-of-PP as a group, regardless of whether they developed a psychiatric relapse within 4 weeks after delivery, had less synchronous mother-infant interactions and had infants with less optimal cognitive, language, motor and socio-emotional development than healthy controls. In particular, boys of at-risk women had the lowest scores in cognitive, language and motor development and in mother-infant interaction, while girls of the at-risk women had the lowest scores in socio-emotional development. The synchrony in the dyad predicted infant cognitive and language development. There was no evidence for a difference in mother-infant interaction nor in infant development between the AR-unwell and AR-well groups.

CONCLUSIONS

These results suggest that, while there is a lack of evidence that an early postpartum relapse in women at-risk-of-PP could represent a risk for the infant per se, maternal risk for PP may be associated with less optimal mother-infant interaction and infant development.

A consensus statement on perinatal mental health during the COVID-19 pandemic and recommendations for post-pandemic recovery and re-build

Introduction

The COVID-19 pandemic posed a significant lifecourse rupture, not least to those who had specific physical vulnerabilities to the virus, but also to those who were suffering with mental ill health. Women and birthing people who were pregnant, experienced a perinatal bereavement, or were in the first post-partum year (i.e., perinatal) were exposed to a number of risk factors for mental ill health, including alterations to the way in which their perinatal care was delivered.

Methods

A consensus statement was derived from a cross-disciplinary collaboration of experts, whereby evidence from collaborative work on perinatal mental health during the COVID-19 pandemic was synthesised, and priorities were established as recommendations for research, healthcare practice, and policy.

Results

The synthesis of research focused on the effect of the COVID-19 pandemic on perinatal health outcomes and care practices led to three immediate recommendations: what to retain, what to reinstate, and what to remove from perinatal mental healthcare provision. Longer-term recommendations for action were also made, categorised as follows: Equity and Relational Healthcare; Parity of Esteem in Mental and Physical Healthcare with an Emphasis on Specialist Perinatal Services; and Horizon Scanning for Perinatal Mental Health Research, Policy, & Practice.

Discussion

The evidence base on the effect of the pandemic on perinatal mental health is growing. This consensus statement synthesises said evidence and makes recommendations for a post-pandemic recovery and re-build of perinatal mental health services and care provision.

Impact of Parental Mental Health and Poverty on the Health of the Next Generation: A Multi-Trajectory Analysis Using the UK Millennium Cohort Study

PURPOSE

Exposure to parental mental ill-health and poverty in childhood impact health across the lifecourse. Both maternal and paternal mental health may be important influences, but few studies have unpicked the complex interrelationships between these exposures and family poverty for later health.

METHODS

We used longitudinal data on 10,500 children from the nationally representative UK millennium cohort study. Trajectories of poverty, maternal mental health, and secondary caregiver mental health were constructed from child age of 9 months through to 14 years. We assessed the associations of these trajectories with mental health outcomes at the age of 17 years. Population-attributable fractions were calculated to quantify the contribution of caregivers' mental health problems and poverty to adverse outcomes at the country level.

RESULTS

We identified five distinct trajectories. Compared with children with low poverty and good parental mental health, those who experienced poverty and poor primary or secondary caregiver mental health (53%) had worse outcomes. Children exposed to both persistent poverty and poor caregiver mental health were at markedly increased risk of socioemotional behavioural problems (aOR 4.2; 95% CI 2.7-6.7), mental health problems (aOR 2.5; CI 1.6-3.9), and cognitive disability (aOR 1.7; CI 1.1-2.5). We estimate that 40% of socioemotional behavioural problems at the age of 17 were attributable to persistent parental caregivers' mental health problems and poverty.

DISCUSSION

More than half of children growing up in the UK are persistently exposed to either one or both of poor caregiver mental health and family poverty. The combination of these exposures is strongly associated with adverse health outcomes in the next generation.

Sex differences in experiences of multiple traumas and mental health problems in the UK Biobank cohort

PURPOSE

Experiences of reported trauma are common and are associated with a range of mental health problems. Sex differences in how reported traumas are experienced over the life course in relation to mental health require further exploration.

METHODS

157,358 participants contributed data for the UK Biobank Mental Health Questionnaire (MHQ). Stratified Latent Class Analysis (LCA) was used to analyse combinations of reported traumatic experiences in males and females separately, and associations with mental health.

RESULTS

In females, five trauma classes were identified: a low-risk class (58.6%), a childhood trauma class (13.5%), an intimate partner violence class (12.9%), a sexual violence class (9.1%), and a high-risk class (5.9%). In males, a three-class solution was preferred: a low-risk class (72.6%), a physical and emotional trauma class (21.9%), and a sexual violence class (5.5%). In comparison to the low-risk class in each sex, all trauma classes were associated with increased odds of current depression, anxiety, and hazardous/harmful alcohol use after adjustment for covariates. The high-risk class in females and the sexual violence class in males produced significantly increased odds for recent psychotic experiences.

CONCLUSION

There are sex differences in how reported traumatic experiences co-occur across a lifespan, with females at the greatest risk. However, reporting either sexual violence or multiple types of trauma was associated with increased odds of mental health problems for both males and females. Findings emphasise the public mental health importance of identifying and responding to both men and women's experiences of trauma, including sexual violence.

Receiving threatening or obscene messages from a partner and mental health, self-harm and suicidality: results from the Adult Psychiatric Morbidity Survey

PURPOSE

Threatening or obscene messaging is repeated, unwanted texts, emails, letters or cards experienced by the recipient as threatening or obscene, and causing fear, alarm or distress. It is rarely examined as an aspect of intimate partner violence. We describe the prevalence of exposure to threatening/obscene messaging from a current or ex-partner; characteristics of victims; and associations with other forms of violence and abuse, mental disorder, self-harm, and suicidality.

METHODS

Cross-sectional probability-sample survey of the general population in England aged 16 + . Multivariable regression modelling tested associations between receipt of threatening/obscene messaging and current common mental disorder, past-year self-harm and suicidality.

RESULTS

Threatening/obscene messages were received from a current/ex-partner by 6.6% (95%CI: 5.9-7.3) of adults who had been in a relationship; 1.7% received these in the past year. Victims were more likely to be female, under 35, single or divorced, socioeconomically disadvantaged, and to have experienced other forms of sexual and partner violence and abuse. Those who received threatening/obscene messages in the past year were more likely to experience common mental disorder (adjusted odds ratio 1.89; 1.01-3.55), self-harm (2.31; 1.00-5.33), and suicidal thoughts (2.00; 1.06-3.78).

CONCLUSION

Threatening/obscene messaging commonly occurs in the context of intimate partner violence. While often occurring alongside sexual and physical violence, messaging has an additional association with mental disorder and suicidality. Routine enquiry in service settings concerning safety, including those working with people who have escaped domestic violence, should ask about ongoing contact from previous as well as current partners. This should include asking about messaging, as well as other forms of potentially technology-enabled abuse which may become increasingly common.

Past-year intimate partner violence perpetration among people with and without depression: an individual participant data (IPD) meta-mediation analysis

PURPOSE

To investigate whether (1) depression is associated with increased risk of past-year intimate partner violence (IPV) perpetration, disaggregated by sex, after controlling for potential confounders; (2) observed associations are mediated by alcohol misuse or past-year IPV victimisation.

METHODS

Systematic review and individual participant data (IPD) meta-mediation analysis of general population surveys of participants aged 16 years or older, that were conducted in a high-income country setting, and measured mental disorder and IPV perpetration in the last 12 months.

RESULTS

Four datasets contributed to meta-mediation analyses, with a combined sample of 12,679 participants. Depression was associated with a 7.4% and 4.8% proportion increase of past-year physical IPV perpetration among women and men, respectively. We found no evidence of mediation by alcohol misuse. Among women, past-year IPV victimisation mediated 45% of the total effect of depression on past-year IPV perpetration. Past-year severe IPV victimisation mediated 60% of the total effect of depression on past-year severe IPV perpetration. We could not investigate IPV victimisation as a mediator among men due to perfect prediction.

CONCLUSIONS

Mental health services, criminal justice services, and domestic violence perpetrator programmes should be aware that depression is associated with increased risk of IPV perpetration. Interventions to reduce IPV victimisation might help prevent IPV perpetration by women. Data collection on mental disorder and IPV perpetration should be strengthened in future population-based surveys, with greater consistency of data collection across surveys, as only four studies were able to contribute to the meta-mediation analysis.

Problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence: A randomised, controlled feasibility trial in rural Ethiopia

Evidence for the feasibility of brief psychological interventions for pregnant women experiencing intimate partner violence (IPV) in rural, low-income country settings is scarce. In rural Ethiopia, the prevalence of antenatal depressive symptoms and lifetime IPV are 29% and 61%, respectively. We aimed to assess the feasibility and related implementation outcomes of brief problem-solving therapy (PST) adapted for pregnant women experiencing IPV (PST-IPV) in rural Ethiopia, and of a randomised, controlled feasibility study design. We recruited 52 pregnant women experiencing depressive symptoms and past-year IPV from two antenatal care (ANC) services. Consenting women were randomised to PST-IPV (n = 25), 'standard' PST (not adapted for women experiencing IPV; n = 12) or enhanced usual care (information about sources of support; n = 15). Masked data collectors conducted outcome assessments nine weeks post-enrolment. Addis Ababa University (#032/19/CDT) and King's College London (#HR-18/19-9230) approved the study. Fidelity to randomisation was impeded by strong cultural norms about what constituted IPV. However, recruitment was feasible (recruitment rate: 1.5 per day; 37% of women screened were eligible). The intervention and trial were acceptable to women (4% declined initial screening, none declined to participate, and 76% attended all four sessions of either active intervention). PST-IPV was acceptable to ANC providers: none dropped out. Sessions lasting up to a mean 52 minutes raised questions about the appropriateness of the model to this context. Competence assessments recommended supplementary communication skills training. Fidelity assessments indicated high adherence, quality, and responsiveness but assessing risks and social networks, and discussing confidentiality needed improvement. Adjustments to optimise a future, fully powered, randomised controlled trial include staggering recruitment in line with therapist availability, more training on the types of IPV and how to discuss them, automating randomisation, a supervision cascade model, and conducting post-intervention outcome assessments immediately and three months postpartum. Registration: Pan African Clinical Trials Registry #PACTR202002513482084 (13/12/2019): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9601.

Child educational progress in Born in Bradford pregnancies affected by gestational diabetes and also exposed to maternal common mental disorders

Gestational diabetes and the maternal mental disorders of anxiety and depression have been implicated in adverse offspring neuro-behavioural outcomes but these exposures have only been studied in isolation. 1051 children whose mothers were diagnosed with gestational diabetes in UK's Born in Bradford cohort had linkage to maternal primary care records, providing diagnostic and treatment codes for depression and anxiety. Education record linkage provided results of the Early Years Foundation Stage Profile from the first year of school, aged five. Risk of not attaining a 'Good level of development' was analysed using multivariable Poisson regression within a generalised estimating equation framework. Multiple imputation was implemented for missing data. There was limited evidence of increased risk of failure to attain a 'good level of development' in those additionally exposed to maternal mental disorders (adjusted RR 1.21; 95% CI 0.94, 1.55). However, there was more evidence in children of Pakistani maternal ethnicity (adjusted RR 1.36; 95% CI 1.04, 1.77) than White British; this may have been driven by English not being the primary language spoken in the home. Therefore there may be groups with GDM in whom it is particularly important to optimise both maternal physical and mental health to improve child outcomes.

Obstetric and neonatal outcomes in pregnant women with and without a history of specialist mental health care: a national population-based cohort study using linked routinely collected data in England

BACKGROUND

Pregnant women with pre-existing mental illnesses have increased risks of adverse obstetric and neonatal outcomes compared with pregnant women without pre-existing mental illnesses. We aimed to estimate these differences in risks according to the highest level of pre-pregnancy specialist mental health care, defined as psychiatric hospital admission, crisis resolution team (CRT) contact, or specialist community care only, and the timing of the most recent care episode in the 7 years before pregnancy.

METHODS

Hospital and birth registration records of women with singleton births between April 1, 2014, and March 31, 2018 in England were linked to records of babies and records from specialist mental health services provided by the England National Health Service, a publicly funded health-care system. We compared the risks of adverse pregnancy outcomes, including fetal and neonatal death, preterm birth, and babies being born small for gestational age (SGA; birthweight <10th percentile), and composite indicators for neonatal adverse outcomes and maternal morbidity, between women with and without a history of contact with specialist mental health care. We calculated odds ratios adjusted for maternal characteristics (aORs), using logistic regression.

FINDINGS

Of 2 081 043 included women (mean age 30·0 years; range 18-55 years; 77·7% White, 11·4% South Asian, 4·7% Black, and 6·2% mixed or other ethnic background), 151 770 (7·3%) had at least one pre-pregnancy specialist mental health-care contact. 7247 (0·3%) had been admitted to a psychiatric hospital, 29 770 (1·4%) had CRT contact, and 114 753 (5·5%) had community care only. With a pre-pregnancy mental health-care contact, risk of stillbirth or neonatal death within 7 days of birth was not significantly increased (0·45-0·49%; aOR 1·11, 95% CI 0·99-1·24): risk of preterm birth (<37 weeks) increased (6·5-9·8%; aOR 1·53, 1·35-1·73), as did risk of SGA (6·2- 7·5%; aOR 1·34, 1·30-1·37) and neonatal adverse outcomes (6·4-8·4%; aOR 1·37, 1·21-1·55). With a pre-pregnancy mental health-care contact, risk of maternal morbidity increased slightly from 0·9% to 1·0% (aOR 1·18, 1·12-1·25). Overall, risks were highest for women who had a psychiatric hospital admission any time or a mental health-care contact in the year before pregnancy.

INTERPRETATION

Information about the level and timing of pre-pregnancy specialist mental health-care contacts helps to identify women at increased risk of adverse obstetric and neonatal outcomes. These women are most likely to benefit from dedicated community perinatal mental health teams working closely with maternity services to provide integrated care.

FUNDING

National Institute for Health Research.

A mixed methods systematic review exploring infant feeding experiences and support in women with severe mental illness

There are many benefits of breastfeeding to women and their infants but meeting the recommended 6 months of exclusive breastfeeding is likely to be more challenging for women with severe mental illness (SMI). This is the first systematic review that aims to examine evidence of (a) infant feeding outcomes in women with SMI and the factors associated with this, (b) the experiences of infant feeding and infant feeding support for women with SMI, (c) interventions for supporting infant feeding among these women and (d) health care professionals' attitudes toward supporting infant feeding in women with SMI. Mixed methods systematic review was carried out using the principles of Joanna Briggs Institute's (JBI) 'convergent integrated' methodology. CINAHL, PsycINFO, Medline and MIDIRS were used to search literature between 1994 and 2022. The quality of selected articles was assessed using JBI critical appraisal tools and thematic synthesis was undertaken to obtain findings. Eighteen papers were included in the final review. Women with SMI were less likely to initiate and continue breastfeeding than women without SMI. Several challenges with breastfeeding were highlighted, and while these were often linked to women's mental health difficulties, inconsistent advice from health care professionals and poor support with breastfeeding further compounded these challenges. This review highlights that policy and practice need to take into account the individual challenges women with SMI face when planning, initiating and maintaining breastfeeding. Education and training for health care professionals are needed to enable them to provide tailored infant feeding support to women with SMI, which reflects their individual needs.

Development and Validation of a Prediction Tool for Reoffending Risk in Domestic Violence

Importance

Current risk assessment tools for domestic violence against family members were developed with small and selected samples, have low accuracy with few external validations, and do not report key performance measures.

Objective

To develop new tools to assess risk of reoffending among individuals who have perpetrated domestic violence.

Design, Setting, and Participants

This prognostic study investigated a national cohort of all individuals arrested for domestic violence between 1998 and 2013 in Sweden using information from multiple national registers, including National Crime Register, National Patient Register, Longitudinal Integrated Database for Health Insurance and Labour Market Studies Register, and Multi-Generation Register. Data were analyzed from August 2022 to June 2023.

Exposure

Arrest for domestic violence.

Main Outcomes and Measures

Prediction models were developed for 3 reoffending outcomes after arrest for domestic violence: conviction of a new violent crime (including domestic violence), conviction of any new crime, and rearrest for domestic violence at 1 year, 3 years, and 5 years. The prediction models were created using sociodemographic factors, criminological factors, and mental health status-related factors, linking data from multiple population-based longitudinal registers. Cox proportional hazard multivariable regression was used to develop prediction models and validate them in external samples. Key performance measures, including discrimination at prespecified cutoffs and calibration statistics, were investigated.

Results

The cohort included 27 456 individuals (mean [SD] age, 39.4 [11.6] years; 24 804 men [90.3%]) arrested for domestic violence, of whom 4222 (15.4%) reoffended and were convicted for a new violent crime during a mean (SD) follow-up of 26.5 (27.0) months, 9010 (32.8%) reoffended and were convicted for a new crime (mean [SD] follow-up, 22.4 [25.1] months), and 2080 (7.6%) were rearrested for domestic violence (mean [SD] follow-up, 25.7 [30.6] months). Prediction models were developed with sociodemographic, criminological, and mental health factors and showed good measures of discrimination and calibration for violent reoffending and any reoffending. The area under the receiver operating characteristic curve (AUC) for risk of violent reoffending was 0.75 (95% CI, 0.74-0.76) at 1 year, 0.76 (95% CI, 0.75-0.77) at 3 years, and 0.76 (95% CI, 0.75-0.77) 5 years. The AUC for risk of any reoffending was 0.76 (95% CI, 0.75-0.77) at 1 year and at 3 years and 0.76 (95% CI, 0.75-0.76) at 5 years. The model for domestic violence reoffending showed modest discrimination (C index, 0.63; 95% CI, 0.61-0.65) and good calibration. The validation models showed discrimination and calibration performance similar to those of derivation models for all 3 reoffending outcomes. The prediction models have been translated into 3 simple online risk calculators that are freely available to use.

Conclusions and Relevance

This prognostic study developed scalable, evidence-based prediction tools that could support decision-making in criminal justice systems, particularly at the arrest stage when identifying those at higher risk of reoffending and screening out individuals at low risk of reoffending. Furthermore, these tools can enhance treatment allocation by enabling criminal justice services to focus on modifiable risk factors identified in the tools for individuals at high risk of reoffending.

A survey and stakeholder consultation of Independent Domestic Violence Advisor (IDVA) programmes in English maternity services

BACKGROUND

Healthcare-based Independent Domestic Violence Advisors (hIDVA) are evidence-based programmes that provide emotional and practical support to service users experiencing domestic abuse. hIDVA programmes are found to improve health outcomes for service users and are increasingly delivered across a range of healthcare settings. However, it is unclear how hIDVA programmes are implemented across maternity services and the key facilitators and barriers to their implementation. The aim of this study was to identify; how many English National Health Service (NHS) Trusts with maternity services have a hIDVA programme; which departments within the Trust they operate in; what format, content, and variation in hIDVA programmes exist; and key facilitators and barriers of implementation in maternity services.

METHODS

A national survey of safeguarding midwives (Midwives whose role specifically tasks them to protect pregnant women from harm including physical, emotional, sexual and financial harm and neglect) within all maternity services across England; descriptive statistics were used to summarise responses. A World Café event (a participatory method, which aims to create a café atmosphere to facilitate informal conversation) with 38 national key stakeholders to examine barriers and facilitators to hIDVA programme implementation.

RESULTS

86/124 Trusts (69%) with a maternity service responded to the survey; 59(69%) of respondents reported that they had a hIDVA programme, and 47(55%) of the hIDVA programmes operated within maternity services. Key facilitators to implementation of hIDVA programmes included training of NHS staff about the hIDVA role and regular communication between Trust staff and hIDVA staff; hIDVA staff working directly from the Trust; co-creation of hIDVA programmes with experts by experience; governance and middle- and senior-management support. Key barriers included hIDVA staff having a lack of access to a private space for their work, insecure funding for hIDVA programmes and issues with recruitment and retention of hIDVA staff.

CONCLUSIONS

Despite hIDVA programmes role in improving the health outcomes of service users experiencing domestic abuse, increased funding and staff training is needed to successfully implement hIDVA staff in maternity services. Integrated Care Board commissioning of acute and mental health trust services would benefit from ensuring hIDVA programmes and clinician DVA training are prioritised.

Self-harm in pregnancy and the postnatal year: prevalence and risk factors

BACKGROUND

Self-harm in pregnancy or the year after birth ('perinatal self-harm') is clinically important, yet prevalence rates, temporal trends and risk factors are unclear.

METHODS

A cohort study of 679 881 mothers (1 172 191 pregnancies) was conducted using Danish population register data-linkage. Hospital treatment for self-harm during pregnancy and the postnatal period (12 months after live delivery) were primary outcomes. Prevalence rates 1997-2015, in women with and without psychiatric history, were calculated. Cox regression was used to identify risk factors.

RESULTS

Prevalence rates of self-harm were, in pregnancy, 32.2 (95% CI 28.9-35.4)/100 000 deliveries and, postnatally, 63.3 (95% CI 58.8-67.9)/100 000 deliveries. Prevalence rates of perinatal self-harm in women without a psychiatric history remained stable but declined among women with a psychiatric history. Risk factors for perinatal self-harm: younger age, non-Danish birth, prior self-harm, psychiatric history and parental psychiatric history. Additional risk factors for postnatal self-harm: multiparity and preterm birth. Of psychiatric conditions, personality disorder was most strongly associated with pregnancy self-harm (aHR 3.15, 95% CI 1.68-5.89); psychosis was most strongly associated with postnatal self-harm (aHR 6.36, 95% CI 4.30-9.41). For psychiatric disorders, aHRs were higher postnatally, particularly for psychotic and mood disorders.

CONCLUSIONS

Perinatal self-harm is more common in women with pre-existing psychiatric history and declined between 1997 and 2015, although not among women without pre-existing history. Our results suggest it may be a consequence of adversity and psychopathology, so preventative intervention research should consider both social and psychological determinants among women with and without psychiatric history.

Intimate partner violence perpetration and mental health service use in England: analysis of nationally representative survey data

BACKGROUND

Intimate partner violence perpetration (IPVP) is associated with psychiatric disorders, but an association with mental health service use has not been fully established and is relevant for policy. Mental health service contact by perpetrators of intimate partner violence presents an opportunity for reducing harmful behaviours.

AIMS

To examine the association between IPVP and mental health service use.

METHOD

Analysis of national probability sample data from the 2014 Adult Psychiatric Morbidity Survey, testing for associations between lifetime IPVP and mental health service use. We assessed the impact of missing data with multiple imputation and examined misreporting using probabilistic bias analysis.

RESULTS

The prevalence of reported lifetime IPVP was similar for men (8.0%) and women (8.6%). Before adjustments, IPVP was associated with mental health service use (odds ratio (OR) for any mental health service use in the past year for men: 2.8 (95% CI: 1.8-4.2), for women: 2.8 (95% CI: 2.1-3.8)). Adjustments for intimate partner violence victimisation and other life adversities had an attenuative influence. Associations remained on restricting comparisons with those without criminal justice involvement (OR for any mental health service use in the past year for men: 2.9 (95% CI: 1.7-4.8), for women: 2.3 (95% CI: 1.7-3.2)).

CONCLUSION

The strong association of IPVP with mental health service use is partly attributable to the concurrent presence of intimate partner violence victimisation and other life adversities. Efforts to improve the identification and assessment of IPVP in mental health services could benefit population health.

Help-seeking for Intimate Partner Violence and Abuse: Experiences of Serving and Ex-serving UK Military Personnel

Purpose

Intimate Partner Violence and Abuse (IPVA) is as a major health concern globally. The prevalence of IPVA perpetration and victimisation has been found to be higher in military compared to civilian populations. Of concern, help-seeking for other psychosocial difficulties among military communities has been shown to be both limited and challenging, and military personnel could face additional or amplified barriers to help-seeking for IPVA than their civilian counterparts. This study aimed to use qualitative methods to explore the experiences of, and barriers to, help-seeking for IPVA victimisation and perpetration among UK military personnel.

Methods

Thematic analysis was conducted on 40 one-to-one semi-structured interviews with military personnel (29 male, 11 female).

Results

Four superordinate themes were derived, thematically organised according to different levels of the social ecological model: Military cultural factors; Support service factors; Interpersonal factors; and Individual factors. At a military cultural level, participants described difficulties in help-seeking for IPVA resulting from widespread stigma and hypermasculine attitudes in military communities, minimisation of violence, perceived pressure from chain of command, and fear of consequences of reporting. At a support-service level, participants' negative views or experiences and lack of awareness of services were also significant in deterring help-seeking. At an interpersonal level, participants recounted how relationships with military colleagues, their partner and their family could be both instrumental or a hindrance to help-seeking for IPVA. At an individual level, lack of insight into IPVA and different forms of abuse were suggested through minimisation of violence and described to contribute to delay in help-seeking. Shame, compounded by multi-layered stigma present at each social ecological model level, was a key reason for delaying or avoiding help-seeking.

Conclusions

The findings indicate the added challenges in help-seeking for IPVA experienced by military personnel and highlight a need for a whole systems approach to improve the provision of support for IPVA in the military serving and ex-serving community to instil meaningful change.

Maternal Benzodiazepines and Z-Drugs Use during Pregnancy and Adverse Birth and Neurodevelopmental Outcomes in Offspring: A Population-Based Cohort Study

INTRODUCTION

The use of benzodiazepines and/or z-drugs in women of childbearing age has increased.

OBJECTIVE

The aim of the study was to evaluate whether gestational benzodiazepine and/or z-drug exposure is associated with adverse birth and neurodevelopmental outcomes.

METHODS

A population-based cohort including mother-child pairs from 2001 to 2018 in Hong Kong was analysed to compare gestationally exposed and nonexposed children on the risk of preterm birth, small for gestational age, autism spectrum disorder (ASD), and attention-deficit/hyperactivity disorder (ADHD) through logistic/Cox proportional hazards regression with a 95% confidence interval (CI). Sibling-matched analyses and negative control analyses were applied.

RESULTS

When comparing gestationally exposed with gestationally nonexposed children, the weighted odds ratio (wOR) was 1.10 (95% CI = 0.97-1.25) for preterm birth and 1.03 (95% CI = 0.76-1.39) for small for gestational age, while the weighted hazard ratio (wHR) was 1.40 (95% CI = 1.13-1.73) for ASD and 1.15 (95% CI = 0.94-1.40) for ADHD. Sibling-matched analyses showed no association between gestationally exposed children and their gestationally nonexposed siblings for all outcomes (preterm birth: wOR = 0.84, 95% CI = 0.66-1.06; small for gestational age: wOR = 1.02, 95% CI = 0.50-2.09; ASD: wHR = 1.10, 95% CI = 0.70-1.72; ADHD: wHR = 1.04, 95% CI = 0.57-1.90). Similarly, no significant differences were observed when comparing children whose mothers took benzodiazepines and/or z-drugs during pregnancy to children whose mothers took benzodiazepines and/or z-drugs before but not during pregnancy for all outcomes.

CONCLUSIONS

The findings do not support a causal relationship between gestational benzodiazepines and/or z-drugs exposure and preterm birth, small for gestational age, ASD, or ADHD. Clinicians and pregnant women should carefully balance the known risks of benzodiazepines and/or z-drugs use against those of untreated anxiety and sleep problems.

Adverse outcomes associated with recorded victimization in mental health electronic records during the first UK COVID-19 lockdown

PURPOSE

The impact of COVID-19 pandemic policies on vulnerable groups such as people with mental health problems who experience violence remains unknown. This study aimed to investigate the prevalence of victimization recorded in mental healthcare records during the first UK lockdown, and associations with subsequent adverse outcomes.

METHODS

Using a large mental healthcare database, we identified all adult patients receiving services between 16.12.2019 and 15.06.2020 and extracted records of victimisation between 16.03.2020 and 15.06.2020 (first UK COVID-19 lockdown). We investigated adverse outcomes including acute care, emergency department referrals and all-cause mortality in the year following the lockdown (16.06.2020- 01.11.2021). Multivariable Cox regressions models were constructed, adjusting for socio-demographic, socioeconomic, clinical, and service use factors.

RESULTS

Of 21,037 adults receiving mental healthcare over the observation period, 3,610 (17.2%) had victimisation mentioned between 16.03.2020 and 15.06.2020 (first UK COVID-19 lockdown). Service users with mentions of victimisation in their records had an elevated risk for all outcomes: acute care (adjusted HR: 2.1; 95%CI 1.9-2.3, p < 0.001), emergency department referrals (aHR: 2.0; 95%CI 1.8-2.2; p < 0.001), and all-cause mortality (aHR: 1.5; 95%CI 1.1-1.9; p = 0.003), when compared to service users with no recorded victimisation. We did not observe a statistically significant interaction with gender; however, after adjusting for possible confounders, men had slightly higher hazard ratios for all-cause mortality and emergency department referrals than women.

CONCLUSION

Patients with documented victimisation during the first UK lockdown were at increased risk for acute care, emergency department referrals and all-cause mortality. Further research is needed into mediating mechanisms.

Caregiving and mental health needs in the significant others of women receiving inpatient and home treatment for acute severe postpartum mental illness

To examine the mental health and caregiving needs of significant others (including partners, parents, friends) to women who received acute psychiatric care either as inpatients or at home during the perinatal period. Cross-sectional survey of 98 significant others of 279 women who participated in a quasi-experimental cohort study of services for mothers with acute severe postpartum mental health diagnoses. Significant others completed an adapted General Health Questionnaire-12 (GHQ) and Involvement Evaluation Questionnaire (IEQ) to indicate their mental health needs and service use as well as caregiving activities. The mean age of significant others was 38.9 years (range 24-69). 81.6% were male and 81.6% were intimate partners to the women. High levels of unmet mental health needs were detected in significant others, with a majority (51.0%) having a score > 2 on the GHQ-12 indicating caseness for a psychiatric disorder. In those with GHQ-12 caseness indicated, few were receiving help for their difficulties: 22.5% received support from their general practitioner, and 14.3% received help from a social worker, psychologist, psychiatrist or outpatient department. 18.4% received medication for GHQ-12 symptoms. The median sumscore of IEQ surveying caregiving activities in significant others was 18/108. We did not find evidence of differences in GHQ-12 or IEQ scores for significant others to women who received inpatient care versus care at home. Significant others to women with acute severe postpartum psychiatric illness have high levels of unmet mental health needs during the weeks after women are discharged from acute care. Services need to address these needs to optimise outcomes for the whole family.

Pregnant women and health workers' perspectives on perinatal mental health and intimate partner violence in rural Ethiopia: a qualitative interview study

BACKGROUND

Mental health conditions are common during the perinatal period and associated with maternal, foetal, and neonatal morbidity and mortality. There is an established bidirectional relationship between mental health conditions and intimate partner violence (IPV), including during and after pregnancy. Mean lifetime prevalence of physical, sexual or emotional IPV exposure among women in rural Ethiopia is estimated to be 61% and may be even higher during the perinatal period. We aimed to explore the perspectives of women and antenatal care (ANC) health workers on the relationship between all types of IPV and perinatal mental health, to inform the adaptation of a psychological intervention for pregnant women experiencing IPV in rural Ethiopia.

METHODS

We conducted in-depth qualitative interviews with 16 pregnant women and 12 health workers in the Gurage zone of the Southern Nations, Nationalities and People's Region of Ethiopia, between December 2018 and December 2019. We conducted thematic analysis of English-translated transcripts of audio-recorded Amharic-language interviews.

RESULTS

Participants contextualised IPV as the primary form of abusive treatment women experienced, connected by multiple pathways to emotional and bodily distress. Patriarchal norms explained how the actions of neighbours, family, community leaders, law enforcement, and government agents in response to IPV often reinforced women's experiences of abuse. This created a sense of powerlessness, exacerbated by the tension between high cultural expectations of reciprocal generosity and severe deprivation. Women and health workers advocated a psychological intervention to address women's powerlessness over the range of difficulties they faced in their daily lives.

CONCLUSIONS

Women and health workers in rural Ethiopia perceive multiple, interconnected pathways between IPV and perinatal emotional difficulties. Contrary to expectations of sensitivity, women and health workers were comfortable discussing the impact of IPV on perinatal mental health, and supported the need for brief mental health interventions integrated into ANC.

Perinatal mental health and COVID-19: Navigating a way forward

The COVID-19 pandemic and its aftermath have increased pre-existing inequalities and risk factors for mental disorders in general, but perinatal mental disorders are of particular concern. They are already underdiagnosed and undertreated, and this has been magnified by the pandemic. Access to services (both psychiatric and obstetric) has been reduced, and in-person contact has been restricted because of the increased risks. Rates of perinatal anxiety and depressive symptoms have increased. In the face of these challenges, clear guidance in perinatal mental health is needed for patients and clinicians. However, a systematic search of the available resources showed only a small amount of guidance from a few countries, with a focus on the acute phase of the pandemic rather than the challenges of new variants and variable rates of infection. Telepsychiatry offers advantages during times of restricted social contact and also as an additional route for accessing a wide range of digital technologies. While there is a strong evidence base for general telepsychiatry, the particular issues in perinatal mental health need further examination. Clinicians will need expertise and training to navigate a hybrid model, flexibly combining in person and remote assessments according to risk, clinical need and individual patient preferences. There are also wider issues of care planning in the context of varying infection rates, restrictions and vaccination access in different countries. Clinicians will need to focus on prevention, treatment, risk assessment and symptom monitoring, but there will also need to be an urgent and coordinated focus on guidance and planning across all organisations involved in perinatal mental health care.

Intimate Partner Violence and Abuse: A Qualitative Exploration of UK Military Personnel and Civilian Partner Experiences

Purpose

The prevalence of Intimate Partner Violence and Abuse (IPVA) perpetration and victimisation has been found to be higher in serving and ex-serving military samples compared to civilians. Despite this, there is a lack of qualitative research exploring the IPVA experiences of couples in which one or both partners are serving or have served in the military. This qualitative study aimed to explore IPVA experiences within the UK military community from the perspective of serving and ex-serving military personnel and civilian partners of UK military personnel.

Method

One-to-one telephone interviews were conducted with 40 serving and ex-serving military personnel (29 male, 11 female) and 25 female civilian partners. Data was analysed using thematic analysis.

Results

Four superordinate themes were derived: (1) patterns and directions of IPVA, (2) types of IPVA, (3) perceived drivers of IPVA and (4) perceived impact of IPVA. The findings point to frequent bidirectional abuse in part driven by poor communication and emotion regulation, whilst also highlighting the experiences of severe IPVA victimisation of civilian partners by military personnel motivated by power and control. Perceived drivers of both IPVA perpetration and victimisation include military factors borne of military culture or training, alcohol and mental health difficulties.

Conclusion

These results highlight the role of cultural norms, as well as the role of emotion dysregulation, poor communication skills and mental health difficulties in explaining and perpetuating abuse within ecological theoretical frameworks of violence among couples within which one or both partners are serving or ex-serving military personnel.

Quantifying the contribution of poverty and family adversity to adverse child outcomes in the UK: evidence from the UK Millennium Cohort Study

BACKGROUND

Adolescent health is poor in the UK, with higher prevalence of adverse outcomes in adolescents exposed to family adversities that cluster with poverty from early life. However, little evidence exists to quantify the contribution of these exposures to poor child health in the UK to inform policy. The aim of this study was to estimate the proportion of child physical, mental, cognitive, and behavioural outcomes that could be prevented if exposure to poverty and family adversity during childhood were eliminated.

METHODS

We used nationally representative birth cohort data from the UK Millennium Cohort Study to calculate population attributable fractions. Exposure trajectories were characterised using previously developed group-based multi-trajectory models of childhood adversities up to age 14 years, including low poverty and family adversity, persistent poverty, persistent parental alcohol use, persistent domestic violence and abuse, and persistent poverty and poor parental mental health trajectory; and we assessed the effect of these trajectories on adolescent outcomes using regression models. These models were used to calculate population attributable fractions by contrasting a hypothetical scenario in which all children were in a low poverty and family adversity trajectory with the real-world scenario.

FINDINGS

The identified exposure trajectories contributed substantially to the burden of childhood developmental problems. Compared with the low poverty and family adversity trajectory, the overall percentage of socioemotional behavioural problems at age 14 years attributable to persistent poverty and family adversity trajectories was 54% (95% CI 45-60). A percentage of 36·1% (95% CI 21·8-46·2) was reported for drug experimentation, 32·6% (18·8-40·7) for cognitive disability, and 27·4% (12·9-34·9) for obesity (appendix).

INTERPRETATION

Poverty and family adversity contribute to a substantial burden of adverse child health and developmental outcomes in the UK population.

FUNDING

The National Institute for Health Research (NIHR) Policy Research Programme, NIHR Applied Research Collaboration South London at King's College Hospital NHS Foundation Trust, and the UK Medical Research Council.

Effectiveness and cost-effectiveness of psychiatric mother and baby units: quasi-experimental study

BACKGROUND

Psychiatric mother and baby units (MBUs) are recommended for severe perinatal mental illness, but effectiveness compared with other forms of acute care remains unknown.

AIMS

We hypothesised that women admitted to MBUs would be less likely to be readmitted to acute care in the 12 months following discharge, compared with women admitted to non-MBU acute care (generic psychiatric wards or crisis resolution teams (CRTs)).

METHOD

Quasi-experimental cohort study of women accessing acute psychiatric care up to 1 year postpartum in 42 healthcare organisations across England and Wales. Primary outcome was readmission within 12 months post-discharge. Propensity scores were used to account for systematic differences between MBU and non-MBU participants. Secondary outcomes included assessment of cost-effectiveness, experience of services, unmet needs, perceived bonding, observed mother-infant interaction quality and safeguarding outcome.

RESULTS

Of 279 women, 108 (39%) received MBU care, 62 (22%) generic ward care and 109 (39%) CRT care only. The MBU group (n = 105) had similar readmission rates to the non-MBU group (n = 158) (aOR = 0.95, 95% CI 0.86-1.04, P = 0.29; an absolute difference of -5%, 95% CI -14 to 4%). Service satisfaction was significantly higher among women accessing MBUs compared with non-MBUs; no significant differences were observed for any other secondary outcomes.

CONCLUSIONS

We found no significant differences in rates of readmission, but MBU advantage might have been masked by residual confounders; readmission will also depend on quality of care after discharge and type of illness. Future studies should attempt to identify the effective ingredients of specialist perinatal in-patient and community care to improve outcomes.

Screening instruments for eating disorders in pregnancy: Current evidence, challenges, and future directions

Pregnancy is a vulnerable period for eating disorder (ED) occurrence and maternal EDs are associated with heightened risk of adverse pregnancy and infant outcomes. This highlights the need to identify pregnant women with past or current EDs in order to offer appropriate support. However, there is a knowledge and practice gap on screening pregnant women for EDs. Clinical guidance is lacking in international treatment guidelines, which is unsurprising given that no validated ED screening tool specifically designed for use in antenatal populations exists. Moreover, data on the effectiveness of general population screening tools for identifying EDs in pregnant women are scarce. This article provides a synthesis of current evidence, treatment guidelines, and data on the diagnostic accuracy for screening for EDs in antenatal samples from three studies with different screening approaches. We outline recommendations for future steps to tackle the knowledge and practice gap on screening for EDs in pregnant women, including next steps for the development of a pregnancy-specific ED screener and the use of general mental health screeners to detect EDs during pregnancy. Up-to-date, the jury is still out as how to best identify current or past EDs in pregnancy. More research is needed to assess the efficacy of using general mental health screeners versus ED-specific screening instruments to detect ED in pregnancy. Additionally, clinicians have to be trained on how to assess and manage EDs during pregnancy. PUBLIC SIGNIFICANCE: Identifying pregnant women with eating disorders (EDs) is a public health concern which can be addressed using multiple approaches, including implementation of general and specific assessments within routine antenatal care, and training of healthcare professionals.

Intimate partner violence and abuse experience and perpetration in UK military personnel compared to a general population cohort: A cross-sectional study

Background

Research exploring prevalence of, and factors associated with, increased risk of experiencing or perpetrating Intimate Partner Violence and Abuse (IPVA) in military communities is limited. This study aimed to describe IPVA prevalence in a military sample, explore the role of military-specific risk factors, and draw comparisons with a general population cohort.

Methods

We utilised data from a sample of military personnel participating in a cohort study of the health and wellbeing of UK military personnel who reported having an intimate relationship in the previous 12 months (n = 5557). To allow for comparison with civilian populations, participants from a general population cohort study in England (n = 6075) were matched on age and sex to the military cohort (n = 8093).

Findings

The 12-month prevalences of IPVA experience and perpetration in the military sample were 12.80% (95% CI 11.72–13.96%) and 9.40% (8.45–10.45%), respectively. Factors associated with both increased IPVA experience and perpetration included childhood adversity, relationship dissatisfaction, military trauma, and recent mental health and alcohol misuse problems. Compared to the civilian cohort, adjusted odds (95% CI) of IPVA experience and perpetration were higher in the military: 2.94 (2.15–4.01) and 3.41 (1.79–6.50), respectively.

Interpretation

This study found higher prevalences of IPVA experience and perpetration in the military compared to the general population cohort and highlighted both non-military and military factors associated with increased risk of both. Relationship dissatisfaction, military trauma and mental health difficulties mark key areas for IPVA prevention and management efforts to target.

Funding

Funded by the UK Ministry of Defence and National Institute of Health Research.

Cost-effectiveness of screening tools for identifying depression in early pregnancy: a decision tree model

Background

Although the effectiveness of screening tools for detecting depression in pregnancy has been investigated, there is limited evidence on the cost-effectiveness. This is vital in providing full information to decision makers. This study aimed to explore the cost-effectiveness of different screening tools to identify depression in early pregnancy compared to no screening.

Methods

A decision tree was developed to model the identification and treatment pathways of depression from the first antenatal appointment to 3-months postpartum using the Whooley questions, the Edinburgh Postnatal Depression Scale (EPDS) and the Whooley questions followed by the EPDS, compared to no screening. The economic evaluation took an NHS and Personal Social Services perspective. Model parameters were taken from a combination of sources including a cross-sectional survey investigating the diagnostic accuracy of screening tools, and other published literature. Cost-effectiveness was assessed in terms of the incremental cost per quality adjusted life years (QALYs). Cost-effectiveness planes and cost-effectiveness acceptability curves were produced using a net-benefit approach based on Monte Carlo simulations of cost-outcome data.

Results

In a 4-way comparison, the Whooley, EPDS and Whooley followed by the EPDS each had a similar probability of being cost-effective at around 30% for willingness to pay values from £20,000–30,000 per QALY compared to around 20% for the no screen option.

Conclusions

All three screening approaches tested had a higher probability of being cost-effective than the no-screen option. In the absence of a clear cost-effectiveness advantage for any one of the three screening options, the choice between the screening approaches could be made on other grounds, such as clinical burden of the screening options. Limitations include data availability and short time horizon, thus further research is needed.

Clinical trials registration

N/A

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08115-x.

Changes in the identification and management of mental health and domestic abuse among pregnant women during the COVID-19 lockdown: regression discontinuity study

BACKGROUND

Domestic violence and abuse (DVA) and mental illness during pregnancy have long-lasting and potentially serious consequences, which may have been exacerbated during the COVID-19 pandemic.

AIMS

To investigate how the UK COVID-19 lockdown policy influenced the identification of DVA and depressive symptoms during pregnancy in health services in South-East London in Spring 2020, using eLIXIR (Early-Life Data Cross-Linkage in Research) maternity and mental routine healthcare data.

METHOD

We used a regression discontinuity approach, with a quasi-experimental study design, to analyse the effect of the transition into and out of the COVID-19 lockdown on the rates of positive depression screens, DVA recorded in maternity and secondary mental health services, and contact with secondary mental health services during pregnancy.

RESULTS

We analysed 26 447 pregnancies from 1 October 2018 to 29 August 2020. The rate of DVA recorded in maternity services was low throughout the period (<0.5%). Within secondary mental health services, rates of DVA dropped by 78% (adjusted odds ratio 0.219, P = 0.012) during lockdown, remaining low after lockdown. The rate of women screening positive for depression increased by 40% (adjusted odds ratio 1.40, P = 0.023), but returned to baseline after lockdown lifted.

CONCLUSIONS

Rates of DVA identification in secondary mental health services dropped during and after lockdown, whereas overall rates of DVA identified in maternity services were concerningly low. Healthcare services must adopt guidance to facilitate safe enquiry, particularly in remote consultations. Further research is vital to address the longer-term impact on women's mental health caused by the increase in depression during the lockdown.

Perinatal mental health services in pregnancy and the year after birth: the ESMI research programme including RCT

Background

It is unclear how best to identify and treat women with mental disorders in pregnancy and the year after birth (i.e. the perinatal period).

Objectives

(1) To investigate how best to identify depression at antenatal booking [work package (WP) 1]. (2) To estimate the prevalence of mental disorders in early pregnancy (WP1). (3) To develop and examine the efficacy of a guided self-help intervention for mild to moderate antenatal depression delivered by psychological well-being practitioners (WP1). (4) To examine the psychometric properties of the perinatal VOICE (Views On Inpatient CarE) measure of service satisfaction (WP3). (5) To examine the clinical effectiveness and cost-effectiveness of services for women with acute severe postnatal mental disorders (WPs 1–3). (6) To investigate women’s and partners’/significant others’ experiences of different types of care (WP2).

Design

Objectives 1 and 2 – a cross-sectional survey stratified by response to Whooley depression screening questions. Objective 3 – an exploratory randomised controlled trial. Objective 4 – an exploratory factor analysis, including test–retest reliability and validity assessed by association with the Client Satisfaction Questionnaire contemporaneous satisfaction scores. Objective 5 – an observational cohort study using propensity scores for the main analysis and instrumental variable analysis using geographical distance to mother and baby unit. Objective 6 – a qualitative study.

Setting

English maternity services and generic and specialist mental health services for pregnant and postnatal women.

Participants

Staff and users of mental health and maternity services.

Interventions

Guided self-help, mother and baby units and generic care.

Main outcome measures

The following measures were evaluated in WP1(i) – specificity, sensitivity, positive predictive value, likelihood ratio, acceptability and population prevalence estimates. The following measures were evaluated in WP1(ii) – participant recruitment rate, attrition and adverse events. The following measure was evaluated in WP2 – experiences of care. The following measures were evaluated in WP3 – psychometric indices for perinatal VOICE and the proportion of participants readmitted to acute care in the year after discharge.

Results

WP1(i) – the population prevalence estimate was 11% (95% confidence interval 8% to 14%) for depression and 27% (95% confidence interval 22% to 32%) for any mental disorder in early pregnancy. The diagnostic accuracy of two depression screening questions was as follows: a weighted sensitivity of 0.41, a specificity of 0.95, a positive predictive value of 0.45, a negative predictive value of 0.93 and a likelihood ratio (positive) of 8.2. For the Edinburgh Postnatal Depression Scale, the diagnostic accuracy was as follows: a weighted sensitivity of 0.59, a specificity of 0.94, a positive predictive value of 0.52, a negative predictive value of 0.95 and a likelihood ratio (positive) of 9.8. Most women reported that asking about depression at the antenatal booking appointment was acceptable, although this was reported as being less acceptable for women with mental disorders and/or experiences of abuse. Cost-effectiveness analysis suggested that both the Whooley depression screening questions and the Edinburgh Postnatal Depression Scale were more cost-effective than with the Whooley depression screening questions followed by the Edinburgh Postnatal Depression Scale or no-screen option. WP1(ii) – 53 women with depression in pregnancy were randomised. Twenty-six women received modified guided self-help [with 18 (69%) women attending four or more sessions] and 27 women received usual care. Three women were lost to follow-up (follow-up for primary outcome: 92%). At 14 weeks post randomisation, women receiving guided self-help reported fewer depressive symptoms than women receiving usual care (adjusted effect size −0.64, 95% confidence interval −1.30 to 0.06). Costs and quality-adjusted life-years were similar, resulting in a 50% probability of guided self-help being cost-effective compared with usual care at National Institute for Health and Care Excellence cost per quality-adjusted life-year thresholds. The slow recruitment rate means that a future definitive larger trial is not feasible. WP2 – qualitative findings indicate that women valued clinicians with specialist perinatal expertise across all services, but for some women generic services were able to provide better continuity of care. Involvement of family members and care post discharge from acute services were perceived as poor across services, but there was also ambivalence among some women about increasing family involvement because of a complex range of factors. WP3(i) – for the perinatal VOICE, measures from exploratory factor analysis suggested that two factors gave an adequate fit (comparative fit index = 0.97). Items loading on these two dimensions were (1) those concerning aspects of the service relating to the care of the mother and (2) those relating to care of the baby. The factors were positively correlated (0.49; p < 0.0001). Total scores were strongly associated with service (with higher satisfaction for mother and baby units, 2 degrees of freedom; p < 0.0001) and with the ‘gold standard’ Client Service Questionnaire total score (test–retest intraclass correlation coefficient 0.784, 95% confidence interval 0.643 to 0.924; p < 0.0001). WP3(ii) – 263 of 279 women could be included in the primary analysis, which shows that the odds of being readmitted to acute care was 0.95 times higher for women who were admitted to a mother and baby unit than for those not admitted to a mother and baby unit (0.95, 95% confidence interval 0.86 to 1.04; p = 0.29). Sensitivity analysis using an instrumental variable found a markedly more significant effect of admission to mother and baby units (p < 0.001) than the primary analysis. Mother and baby units were not found to be cost-effective at 1 month post discharge because of the costs of care in a mother and baby unit. Cost-effectiveness advantages may exist if the cost of mother and baby units is offset by savings from reduced readmissions in the longer term.

Limitations

Policy and service changes had an impact on recruitment. In observational studies, residual confounding is likely.

Conclusions

Services adapted for the perinatal period are highly valued by women and may be more effective than generic services. Mother and baby units have a low probability of being cost-effective in the short term, although this may vary in the longer term.

Future work

Future work should include examination of how to reduce relapses, including in after-care following discharge, and how better to involve family members.

Trial registration

This trial is registered as ISRCTN83768230 and as study registration UKCRN ID 16403.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.

A qualitative study of minority ethnic women's experiences of access to and engagement with perinatal mental health care

Background

Approximately one in five women will experience mental health difficulties in the perinatal period. However, for a large group of women, symptoms of adverse perinatal mental health remain undetected and untreated. This is even more so for women of ethnic minority background, who face a variety of barriers which prevents them from accessing appropriate perinatal mental health care.

Aims

To explore minority ethnic women’s experiences of access to and engagement with perinatal mental health care.

Methods

Semi-structured interviews were conducted with 18 women who had been diagnosed with perinatal mental health difficulties and who were supported in the community by a specialist perinatal mental health service in South London, United Kingdom. Women who self-identified as being from a minority ethnic group were purposefully selected. Data were transcribed verbatim, uploaded into NVivo for management and analysis, which was conducted using reflective thematic analysis.

Results

Three distinct overarching themes were identified, each with two or three subthemes: ‘Expectations and Experiences of Womanhood as an Ethnic Minority’ (Shame and Guilt in Motherhood; Women as Caregivers; Perceived to Be Strong and Often Dismissed), ‘Family and Community Influences’ (Blind Faith in the Medical Profession; Family and Community Beliefs about Mental Health and Care; Intergenerational Trauma and Family Dynamics) and ‘Cultural Understanding, Empowerment, and Validation’ (The Importance of Understanding Cultural Differences; The Power of Validation, Reassurance, and Support).

Conclusion

Women of ethnic minority background identified barriers to accessing and engaging with perinatal mental health support on an individual, familial, community and societal level. Perinatal mental health services should be aware ethnic minority women might present with mental health difficulties in different ways and embrace principles of cultural humility and co-production to fully meet these women’s perinatal mental health needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04698-9.

Systematic review and meta-analysis of risk of gestational diabetes in women with preconception mental disorders

There is a well-established bidirectional association between Type 2 diabetes and mental disorder and emerging evidence for an increased risk of perinatal mental disorder in women with gestational diabetes (GDM). However, the relation between mental disorder prior to pregnancy and subsequent risk of GDM remains relatively unexplored. This is a systematic review and meta-analysis of the risk of GDM in women with a range of preconception mental disorders. Peer-reviewed literature measuring odds of GDM and preconception mood, anxiety, psychotic and eating disorders was systematically reviewed. Risk of bias was assessed using a checklist. Two independent reviewers were involved. 22 observational studies met inclusion criteria; most were retrospective cohorts from English speaking, high income countries. 14 studies were at high risk of bias. There was evidence for an increased risk of GDM in women with schizophrenia (pooled OR 2.44; 95% CI 1.17,5.1; 5 studies) and a reduced risk of GDM in women with anorexia nervosa (pooled OR 0.63; 95% CI 0.49,0.80; 5 studies). There was some limited evidence of an increased risk in women with bipolar disorder. There was no evidence for an association with preconception depression or bulimia nervosa on meta-analysis. There were insufficient studies on anxiety disorders for meta-analysis. This review indicates that there is not a significant risk of GDM associated with many preconception mental disorders but women with psychotic disorders represent a group uniquely vulnerable to GDM. Early detection and management of GDM could improve physical and mental health outcomes for these women and their children.

Development of type 2 diabetes in women with comorbid gestational diabetes and common mental disorders in the Born in Bradford cohort

OBJECTIVES

To compare, in a population of women with gestational diabetes mellitus (GDM), the time to diagnosis of Type 2 diabetes in those with and without common mental disorder (CMD) (depression and/or anxiety) during pregnancy.

DESIGN AND SETTING

prospective study of the Born in Bradford cohort in Bradford, UK.

PARTICIPANTS

909 women diagnosed with GDM between 2007 and 2010, with linkage to their primary care records until 2017. The exposed population were women with an indicator of CMD during pregnancy in primary care records. The unexposed were those without an indicator.

OUTCOME MEASURES

Time to diagnosis of type 2 diabetes as indicated by a diagnosis in primary care records.

ANALYSIS

time to event analysis using Cox regression was employed. Multiple imputation by chained equations was implemented to handle missing data. Models were adjusted for maternal age, ethnicity, education, preconception CMD and tobacco smoking during pregnancy.

RESULTS

165 women (18%) were diagnosed with type 2 diabetes over a follow-up period of around 10 years. There was no evidence of an effect of antenatal CMD on the development of type 2 diabetes following GDM (adjusted HR 0.95; 95% CI 0.57 to 1.57).

CONCLUSIONS

Women with CMD were not at an increased risk of type 2 diabetes following GDM. This is reassuring for women with these co-morbidities but requires replication in other study populations.

Factors associated with re-admission in the year after acute postpartum psychiatric treatment

PURPOSE

To examine factors associated with being re-admitted in the year after discharge from acute postpartum psychiatric treatment.

METHODS

Secondary data analysis of information collected from mothers who were admitted to acute psychiatric services in the year after childbirth between 2013 and 2017. We carried out univariable analyses and multivariable hierarchical logistic regression to examine risk factors for women's re-admission to acute psychiatric care (inpatient or community crisis care) in the year following discharge.

RESULTS

Sixty-seven (24.1%) of 278 women were re-admitted in the year after discharge from acute care; the median number of days to re-admission was 86 (IQR 35-214), and women who were re-admitted accessed a median of two further acute services (IQR 1-3). In adjusted analyses, reporting a history of childhood trauma (aOR 1.02; 95% CI 1.00- 1.03, p = 0.036), a higher level of difficulties in the mother-infant bond (aOR 1.03; 95% CI 1.01-1.06, p = 0.009) and younger age (aOR 0.95; 95% CI 0.90-1.00, p = 0.066) were associated with re-admission.

CONCLUSION

This study confirms that the role of childhood adverse experiences on mental health is relevant for outcomes in women experiencing acute postpartum psychiatric episodes. Ongoing parent-infant bonding difficulties are also independently associated with re-admission. Perinatal mental health services therefore need to offer evidence-based interventions to address histories of trauma and to support parent-infant bonding to optimise mental health in women following discharge from acute psychiatric services. However, further research is needed to explore what other factors, not measured in our study, are also influential to re-admission.

The relationship between social support in pregnancy and postnatal depression

PURPOSE

Lack of social support is considered a potential risk factor for postnatal depression but limited longitudinal evidence is available. Pregnancy, when women have increased contact with healthcare services, may be an opportune time to intervene and help strengthen women's social networks to prevent feelings of depression postnatally, particularly for those at greatest risk. Our study examined the longitudinal relationship between social support in pregnancy and postnatal depression, and whether this is moderated by age or relationship status.

METHODS

We analysed data collected from 525 women from a diverse inner-city maternity population in England who were interviewed in pregnancy and again three months postnatally. Women provided sociodemographic information and completed self-report measures of depression (Edinburgh Postnatal Depression Scale) and social support (Social Provisions Scale).

RESULTS

Less social support in pregnancy was associated with postnatal depression, after adjusting for sociodemographic confounders and antenatal depression (Coef. = - 0.05; 95% CI - 0.10 to - 0.01; p = 0.02). There was weak evidence of a moderating effect of relationship status. Subgroup analysis showed a stronger relationship between social support in pregnancy and postnatal depression for women who were not living with a partner (Coef. =  - 0.11; 95% CI - 0.21 to - 0.01; p = 0.03) than for those who were (Coef. =  - 0.03; 95% CI - 0.09 to 0.02; p = 0.28). Sensitivity analysis using multiple imputations to account for missing data confirmed the main results.

CONCLUSIONS

Interventions that target social support in pregnancy have the potential to reduce depression postnatally. Future research should explore in greater detail which women would benefit most from which type of social support.

Mental health service use among pregnant and early postpartum women

PURPOSE

To explore the proportion and characteristics of women with a mental disorder who have contact with mental health services during pregnancy and the postnatal period in a maternity service in London.

METHODS

Data from the WEll-being in pregNancy stuDY (WENDY), a prospective cohort study, were used. Women were recruited at their first appointment for antenatal care and assessed for mental disorders using the Structured Clinical Interview DSM-IV Axis I/II Disorders for Research. Clinical, sociodemographic and psychosocial characteristics were collected. Mental health service use data were collected for the period from study entry to 3 months postpartum.

RESULTS

Two hundred women met diagnostic criteria for a mental disorder. Fifty-five (34%) of these had at least one contact with mental health services. Moderate depression (OR 7.44, CI 2.03-27.28, p < 0.01), severe depression (OR 10.5, CI 2.68-41.12, p < 0.01), past psychiatric hospital admission (OR 3.76, CI 1.05-13.44, p < 0.05), symptoms of anxiety (OR 3.95, CI 1.86-8.37, p < 0.001) and perceived low levels of social support (OR 0.43, CI 0.18-1.01, p = 0.05) were associated with an increased likelihood of contact with mental health services in univariate analyses. However, only moderate (OR 5.92, CI 1.31-26.78, p = 0.02) and severe depression (OR 6.04, CI 1.08-33.72, p = 0.04) remained significant in the multivariate regressions analyses.

CONCLUSION

Only a third of women with a diagnosable mental disorder at their first antenatal appointment had any contact with mental health services during pregnancy or up to 3 months postpartum. Further research is warranted to elicit perinatal women's views about the potential barriers to accessing professional mental health care.

Interventions to Reduce Intimate Partner Violence Perpetration by Men Who Use Substances: A Systematic Review and Meta-Analysis of Efficacy

INTRODUCTION

Despite the high prevalence of intimate partner violence (IPV) perpetration by men who use substances, limited evidence exists about how best to reduce IPV among this group.

METHOD

A systematic narrative review with meta-analysis determined the effectiveness of interventions to reduce IPV by men who use substances. Inclusion criteria were randomized and nonrandomized controlled trials; adult heterosexual male IPV perpetrators where at least 60% of participants were alcohol and/or drug users; the intervention targeted IPV with or without targeting substance use (SU); outcomes included perpetrator and/or victim reports of IPV, SU, or both. Methodological quality was assessed.

RESULTS

Nine trials (n = 1,014 men) were identified. Interventions were grouped into (1) integrated IPV and SU interventions (n = 5), (2) IPV interventions with adjunct SU interventions (n = 2), and (3) stand-alone IPV interventions (n = 2). Cognitive behavioral and motivational interviewing therapies were the most common approaches. Data from individual trials showed a reduction in SU outcomes in the short term (≤3months; n = 2 trials) and IPV perpetration at different time points (n = 3 trials) for interventions compared with treatment as usual (TAU). Meta-analysis with integrated IPV and SU interventions showed no difference in SU (n = 3 trials) or IPV outcomes (n = 4 trials) versus SU TAU.

CONCLUSIONS

Little evidence exists for effective interventions for male IPV perpetrators who use substances. Outcomes in integrated interventions were not superior to TAU in meta-analysis. Future trials should consider the nature of the relationship between IPV and SU in intervention design, duration of intervention, and type and timing of outcome measures. .

Maternal perceived bonding towards the infant and parenting stress in women at risk of postpartum psychosis with and without a postpartum relapse

BACKGROUND

Postpartum psychosis (PP) is the most severe psychiatric disorder associated with childbirth. However, there is little research on maternal bonding towards the infant and parenting stress in this clinical population.

METHODS

We investigated maternal bonding during pregnancy and post-partum in 75 women: 46 at risk of PP (AR), because of a DSM-IV diagnosis of bipolar disorder, schizoaffective disorder or previous PP, and 29 healthy controls. Of the AR women, 19 developed a psychiatric relapse within 4 weeks' post-partum (AR-unwell), while 27 remained symptom-free (AR-well). We investigated childhood maltreatment, parenting stress and psychiatric symptoms as potential predictors of maternal bonding.

RESULTS

In pregnancy, AR-unwell women reported a more negative affective experience towards their infants than AR-well women (d = 0.87, p = .001), while postnatally there was no significant difference in bonding. In contrast, AR women as a group reported a more negative affective experience than HC postnatally (d = 0.69, p = .002; d = 0.70, p = .010), but not antenatally. Parenting stress and psychiatric symptoms significantly predicted less optimal postnatal bonding (b = -0.10, t = -4.29, p < .001; b = -0.37, t = -4.85, p < .001) but only psychiatric symptoms explained the difference in bonding between AR and HC (b = -1.18, 95% BCa CI [-2.70,-0.04]).

LIMITATIONS

A relatively small sample size precluded a more in-depth investigation of underlying pathways.

CONCLUSION

This study provides new information on maternal bonding in women at risk of PP, and particularly in those that do and do not develop a postpartum relapse. The results suggest that improving maternal symptoms and parenting stress in the perinatal period in women at risk of PP could also have positive effects on bonding.