Chapter 69 Maternal mental health and psychological problems
After reading this chapter, you will:
Introduction
There is recognition that despite improvements in the understanding, detection and treatment of pregnancy-related mental health disorders, many women will not seek help and try to cope with their illness, hiding their unhappiness from their caregivers and family. Women still fear discrimination and long-term repercussions if they reveal a previous emotional disturbance or psychiatric illness (MIND 2001, Robinson 2002). This remains the case despite the fact that one in four people will experience mental health problems at some time during their lifetime. Up to 50% of all women are thought to have suffered some form of emotional disturbance during their lives and the risk is much higher amongst women who are socially excluded (MIND 2001).
A global perspective of women’s mental health
Depression is a serious public health issue and it is estimated by the World Health Organization to be the greatest burden of disease and cause of premature death worldwide by 2020 (WHO 2000). In this authoritative report, WHO propose that women are twice as likely as men to be diagnosed with depression and that violence and self-inflicted injuries will also feature as a characteristic of women’s mental health.
Saltman (1991) identified that one of the reasons for the high rates of women’s psychological and mental morbidity is the focus on mortality. Whilst mortality overall is reduced, there has been little progress in the understanding and redressing of factors that contribute to mental illness. Another primary concern in understanding the mental wellbeing of women is suicide and its determinants (DH 1999). In global studies of women in their peak reproductive years, ages 15–44, it was shown that suicide was second only to tuberculosis as a cause of death. Murray & Lopez (1996) found that in 1990, 180,000 women in China alone committed suicide and 87,000 women in India died by self-immolation.
Further research has shown that there are strong inverse relationships with poverty, social position, ethnic background, marital support and access to healthcare (Bartley & Owen 1996). Being a participant in decisions about healthcare and life choices has a significant impact upon psychological and mental wellbeing, during and outside of pregnancy; a sense of control is critical to wellness.
Health and social behaviours may have an impact upon wellbeing, with tobacco usage and drug and alcohol misuse being common in women with anxiety and depressive disorders (DH 2003). Understanding the dependency that such behaviours provoke is critical for midwives to support positive pregnancy outcomes.
Violence against women
Whether by their intimate partners or men not known to them, violence is probably the most prevalent and certainly the most representative gender-based cause of depression in women. In studies of the effect upon women in war-torn communities, it was revealed that rape, torture and murder were by far the most common weapon in the entrapment and subjugation of women and their children (WHO 2000). The impact of these crimes leads to a range of mental health illnesses; depression, self-harm and trauma.
Violence and abuse of women consistently features in mental health and physical morbidity. Abusive behaviour, particularly in an intimate relationship, has a detrimental impact on the woman; fear, lack of freedom, humiliation and threat of harm all contribute to deny women’s Human Rights (WHO 1997) (Ch. 23).
Women are more likely than men to suffer abuse throughout their lifetime, particularly rape, sexual assault and child sexual abuse. Research has consistently shown that between 20% and 30% of women have been sexually abused as a child, compared with 10% of male children (DH 2003). This report indicates that 1 in 10 women have experienced some form of sexual victimization, including rape, and that ‘strangers’ are only responsible for 8% of rapes. Sexual abuse particularly experienced as a child has considerable significance for childbearing women, physically during the birth and psychologically throughout childbirth and parenting (Gutteridge 2001).
Pregnancy, childbirth and mental health
There is an increased risk of mental illness associated with childbirth, mostly in the postpartum period, but problems may also be present before or during pregnancy. Many of the factors associated with postnatal mental illness, such as lack of a confiding relationship, lack of support, marital tension, socioeconomic problems and a previous psychiatric history, are present during pregnancy (O’Hara & Zekoski 1988, O’Hara et al 1991, Romito 1989) and so depression may occur both in pregnancy and in the postpartum period (Evans et al 2001, Green & Murray 1994, Watson et al 1984). There appears to be a positive correlation between women who lack positive maternal role models and the development of anxiety-based depressive disorders during pregnancy and the postnatal period (Gutteridge, unpublished data, 1998).
Whilst there is deepening awareness of postnatal depression and psychotic illness following childbirth, there is relatively little published work on the incidence of, and morbidity associated with, antenatal depression. This is despite the fact that depressed mood in pregnancy has been associated with poor attendance at antenatal clinics, substance misuse, low birthweight and preterm labour (Hedegaard et al 1993, Pagel et al 1990). Whereas it was once thought that pregnancy was a protective factor against depression, Watson et al (1984) found that in 24% of cases of detected postnatal depression, symptoms were present during pregnancy.
There is now clear evidence that psychopathological symptoms in pregnancy have physiological consequences for the fetus (Teixeira et al 1999). A cohort study of depressed mood during pregnancy and after childbirth concluded that research and clinical efforts towards recognizing and treating antenatal depression must be improved (Evans et al 2001). The Confidential Enquiry into Maternal Deaths (Lewis 2004) recommends better detection and management of psychiatric disorders antenatally, to reduce the mortality rate. Services must be designed to meet the needs of all women, and a crucial part of the service should address the mental health needs of women.
Who is ‘at risk’?
Many women experience mixed reactions to their pregnancy, with transient feelings of anxiety and fear; they should be reassured that this is normal and be encouraged to discuss these feelings openly (Ch. 12). The incidence of detected mental illness in the first trimester of pregnancy is thought to be as high as 15%, with only 5% of these women having suffered from previous episodes of mental illness. In the second and third trimesters of pregnancy, the incidence of new episodes of mental illness is less, only about 5%.
Minor mental illness is more likely to occur in the first trimester of pregnancy in women who have marked neurotic traits in the premorbid personality. It also tends to occur in women who have a history of neurotic disorders and in those with social problems, such as marital tension. Other predisposing factors include a history of previous abortion and the possibility of the present pregnancy being terminated (Wilson et al 1996). Women with a poor obstetric history or those who have undergone extensive infertility treatment may exhibit signs of increased anxiety in early pregnancy.
The onset of minor mental illness later in pregnancy, usually during the third trimester, is less common than in the first trimester. When it occurs at this stage in pregnancy, however, the risk of the woman developing postnatal depression is increased (Forman et al 2000).
The midwife’s role in the antenatal period
There is growing emphasis on the development of the public health role of the midwife, with promotion of mental wellbeing representing an area where the midwife can make a valuable contribution (DH 2007). The midwife has a responsibility to provide holistic care, meeting the physical, psychological and emotional needs of all women. There should be an emphasis on promoting emotional and psychological wellbeing for all women, not just those perceived to be at risk. Ideally, all women should be treated with sensitivity during pregnancy and enabled during meetings with the midwife to reveal and discuss any issues that may predispose them to impaired mental health.
A midwife has a special relationship in a woman’s lifetime; s/he has a privileged position in which s/he is able to ask direct and intrusive questions regarding a woman’s fertility and sexual history. This is a trusting and a confiding relationship in which the midwife begins to feature strongly in a woman’s life history (Ch. 12), entrusting her body to the midwife and allowing her to care for her developing fetus.
Kirkham (2000) acknowledges the exclusivity of this relationship and identifies themes such as trust, friendship, purpose and the place of self within this dynamic context (Ch. 12). In no other professional relationship is there such a potential for influencing change than between midwife and childbearing woman.
Some women will live within a culture where there is no recognition of minor depressive illness or anxiety states (Wilson et al 1996). Any attempt to enquire whether the woman is symptomatic may be restricted by other family members who associate impaired mental health only with major psychotic illness to which there is shame and stigma attached (Oates 2001). The midwife should recognize that presentations of ongoing minor physical disorders and concerns about the pregnancy may be the only way the woman can express her feelings. To ensure that all women receive adequate support and help, independent, trained interpreters should be available for women whose first language is not English and every attempt must be made to see the woman unaccompanied.
Assessment
Taking a comprehensive history at the beginning of pregnancy is vital to assess risk, review and plan care around any deterioration of mental and psychological health. Emotional lability during pregnancy is expected; however, the midwife should make ongoing assessments throughout. NICE (2007:6) recommend a universal and continuous enquiry approach:
First health contact visit
Although NICE (2007) do not specifically advise against using screening tools such as the Edinburgh Postnatal Screening Scale (EPDS) (see below) or the Hospital Anxiety and Depression Scale (HADS) or the Patient Health Questionnaire-9 (PHQ-9), caution is advised (see website). Assessment tools should only be used as part of a subsequent evaluation for the routine monitoring of outcomes and only by appropriately trained health professionals (NICE 2007).
It is essential that an accurate history is taken and any reported current or past mental illness is adequately investigated and assessed. This should be done with extreme sensitivity to eradicate any fears the woman may have of discrimination (Robinson 2002). If the woman is under the care of a GP, psychiatrist, community psychiatric nurse or psychologist, attempts should be made to work collaboratively within this team to ensure the woman’s whole needs are met.
Women with a history of single episodes of major mental illness in the past but who have been well for some time are usually advised by their psychiatrist to stop their medication before conception and remain off the medication particularly in the first trimester (NICE 2007). An assessment should be made by a specialist service, usually consisting of a perinatal psychiatrist and specialist midwife/mental health nurse.
Whilst there is no significant risk of relapse during pregnancy for this group of women, there is a marked risk of developing a puerperal psychosis during the first 3 months after delivery (Cox 1986). Measures should be put in place to monitor and assess for deterioration postnatally (Bick et al 2002). This should be in collaboration with specialist perinatal psychiatric services.
Risk of suicide
The Confidential Enquiry into Maternal Deaths (Lewis 2004 & 2007) using the Office for National Statistics (ONS) linkage data indicates that suicide is the current leading cause of maternal death (indirect category). There is a misconception that women who live within socially deprived situations suffer a greater risk of mental health problems; in contrast, CEMACH highlighted that the following characteristics were risk indicators:
Therefore, the suicide profile of childbearing women is significantly disparate to that of the non-pregnant population. The risk of deterioration is significantly elevated in the last trimester of pregnancy and the first 12 weeks postpartum, when both suicide and infanticide should be considered. Though rare, most cases of infanticide where there is evidence of serious maternal mental illness will be associated with a suicide attempt or successful suicide (Marks & Kumar 1993).
CEMACE (previously CEMACH) recommend that women with a history of severe depression or psychotic disorder be referred to a specialist perinatal mental health team and an appropriate care plan developed, aiming to support the woman through pregnancy and minimize the risk of severe postnatal disorder (Oates 2004). Where a woman is under the care of a psychiatrist when pregnancy is diagnosed, there should be careful liaison between the obstetrician, midwife and mental health team to ensure that the woman’s care is seamless and holistic, and that appropriate management plans are made to maximize the outcome for mother and baby. This is especially relevant when deciding upon the woman’s ongoing and future drug regimen. Additionally, Oates (2000) recommends care is best delivered under the auspices of a managed network approach, whereby those women who are at greatest risk of relapse receive care from specialist service providers.
