Mental health and childbirth

Learning Outcomes

After studying this chapter you should be able to:

Knowledge relating to mental disorders

Demonstrate an awareness of the range of possible mental health disorders in the perinatal period
Understand the importance of identification of mental health history and working in a proactive and preventative way with women at risk of illness
Identify of symptoms of mental illness in the perinatal period
Understand and manage risk in the perinatal period
Understand the risk of misattribution in the perinatal period
Describe the principles of prescribing in the perinatal period
Discuss capacity issues in perinatal mental illness

Clinical competencies

Take an adequate mental health history
Make a clinical management plan for someone with a mental health diagnosis
Assess and manage physical health for those with a mental health diagnosis
Assess, communicate and manage risk in the perinatal period

Professional skills and attitudes

Develop of active listening skills
Develop professional curiosity about the mental wellbeing of all expectant and new mothers
Understand the barriers women with mental health disorders may have and can experience in health care
Show leadership in respectful and inclusive use of language, attitude and decision-making when offering care to those at risk of or experiencing poor mental health

Understanding the importance of good maternal mental health is expected core knowledge of every obstetrician. Knowledge of adult mental health, infant mental health, psychopharmacology, embryology, psychology, endocrinology, medicolegal frameworks and pregnancy- and postnatal-specific mental health issues is necessary.

This chapter is designed to be a practical introductory guide to achieve a better understanding of common mental health problems which women can experience during and after pregnancy. The role of the obstetrician is prevention, detection, early intervention, assessing risk and providing safe, evidence-based care.

Mental health disorders can be debilitating and can affect both mother and child. Untreated they are a common cause of morbidity and are one of the leading causes of maternal deaths. One hundred sixty-one women died from mental health–related causes between 2009 and 2013. This represents a rate of 3.7 deaths from mental health–related causes during or up to 1 year after the end of pregnancy per 100,000 maternities in the UK and Ireland for 2009–2013 (95% CI 3.2–4.4) (MBRACCE-UK).

Poor maternal mental health increases the risk to the infant of poorer health during infancy and childhood, the possibility of speech and language delay or lower educational attainment (Avon Longitudinal Study of Parents and Infants).

It is important to recognize that measures which improve the mental health of mothers can directly improve the life chances of the next generation.

Midwives and obstetricians are uniquely placed to support women to stay mentally well throughout their pregnancies and to identify emerging mental health issues quickly and ensure access to appropriate treatment. To do this effectively, it is crucial to take a holistic view of the needs of women in your care, respecting strengths, preferences, attitudes and cultural heritage of women. Women with mental health histories will bring a range of views, opinions and wishes to decisions with regard to their pregnancy, birth and postnatal period. Women, including women with mental health issues, need to have access to accurate, understandable and comprehensive information in order to help them consider their options and make informed decisions.

No one expects an obstetrician or midwife to be a mental health expert. You are not expected to know about every diagnosis, every therapy or every treatment in mental health. You are not expected to diagnose a disorder or initiate treatment. However, an obstetrician needs to be able to take an adequate history and assess current mental health and to ensure women have access to high-quality information, further assessment and treatment if required. Health care systems vary. Within the system in which you work, it is necessary to have measures in place for women to be able to access accurate information, advice and treatment. Primary care, reliable online resources, the voluntary sector, midwives, health visitors, counselling and therapy services all have a part to play. For those women with the most complex or serious mental health issues, access to a specialist mental health service (preferably a perinatal mental health service) is recommended.

The role of the obstetrician as relates to mental illness and childbirth

In antenatal clinic or at a postnatal review, there are three specific questions to consider in relation to mental illness

Does the expectant mother have a history of mental illness?
Does the expectant mother have any current symptoms of a mental illness or disorder?
Does the expectant mother use any treatment for a mental illness or disorder?

Taking a basic mental health history

As in any branch of medicine, your role is to take an adequate history and perform the necessary examination. Taking a basic mental health history is an expected competency of an obstetrician ( Box 14.1 ).

Box 14.1

A basic mental health history

Suggested questions

1.
Have you had any issues with your mental health in the past?
2.
How many episodes have you had?
3.
(For multiparous women) What was your mental health like during/after your previous pregnancies?
4.
Can you tell me a bit more about what that was like for you when things were at their worst?
5.
Were you given a diagnosis? What was it?
6.
What treatment did you receive?
7.
Did the treatment you received work?
8.
What else helped with your mental health?
9.
Did you ever need hospital care? Did you accept hospital care or was admission under the Mental Health Act?
10.
Have you ever felt life was not worth living?
11.
Have you ever thought about or tried to end your life? Can you say a bit more about that?
12.
Do you use medication or are you engaged in treatment or receive ongoing support for your mental health? Can you describe these?
13.
If not using medication (and you have used it previously), when did you stop and why?
14.
Does anyone else in your family have a diagnosis of significant mental illness?
15.
Are you worried about mental health in this pregnancy or after childbirth?
16.
How are things currently with your mental health?
17.
Is there anything I haven’t asked you about in relation to your mental health that you think I should have or that you think it’s important for me to know?

To have a productive conversation with a woman about her mental health, you should consider whether you are at ease talking about mental health. Always use respectful language and open questioning and take notice of verbal and non-verbal cues in the conversation; actively listen; and allow adequate time.

In 2017, the Royal College of Obstetricians and Gynaecologists invited women to share their experiences. The themes were collated in their Women’s Voices Publication 2017 . They concluded:

’The current system relies too heavily on women coming forward and disclosing their own conditions. The lack of understanding of various perinatal mental health conditions means that, without women coming forward and disclosing, symptoms are being completely missed and are damaging women’s confidence in the system. A number of women reported how it was all too easy to evade healthcare professionals’ questions and hide symptoms. Many women are reluctant to talk about how they are feeling and about their history of mental health, and simple tick box “yes” and “no” questions do not encourage a dialogue that allows a woman to open up. This means that only those who are confident and able to speak up are doing so, leaving many vulnerable women to fall through the gaps.

A number of women highlighted incidents of failings by healthcare professionals, ranging from bad experiences of not being listened to after repeatedly asking for help to being told that they were being referred but with no support then ever materialising. Women felt frustrated that their concerns had not been taken seriously and many only had access to support once they had found a healthcare professional who was willing to listen.

A lot of respondents commented that they did not feel that they had had enough time with healthcare professionals to discuss their mental health, or that appointments had been rushed. Many of these commented that they felt had been due to an overstretched service, not because the healthcare professional did not care. Where conversations about mental health were being had, they were often not held in a personal or an open way, or felt like simple “tick box” exercises.’ Maternal Mental Health-Women’s Voices RCOG 2017

If you do enable a woman to disclose a mental health history or concern, it is important you and she have a shared understanding about what will happen with the information she has given. Making a plan undoubtedly involves including all those who work with her in the perinatal period.

Always ask for a woman’s consent to liaise with other health care professionals with whom she may be involved. Why?

’In at least 16 of the 57 women with a prior history of mental health problems, who died by suicide, there was evidence that significant aspects of the woman’s past psychiatric history were not communicated between primary care and maternity services. In several instances, maternity services had not been informed of a woman’s past psychiatric history and in some circumstances the GP was unaware that the women had booked for maternity care.’ Saving Lives, Improving Mothers’ Care 2015

Frequently, women report that because they were articulate, well groomed, in employment and/or in a committed relationship, health care professionals made assumptions that mental health issues would not be present, so did not ask, and an opportunity to intervene was lost.

Similarly other women from a range of socioeconomic and cultural backgrounds report they felt assumptions were made about their mental health, their resilience and their support network without any evidence to support these views.

It is important to be aware of unconscious bias with regard to mental health.

Unconscious bias happens by our brains making quick judgements and assessments of people and situations. Our biases are influenced by our background, cultural environment and personal experiences. We may not even be aware of these views or aware of their full impact or implication.

Making a mental health plan

Women with established mental health diagnoses need a mental health plan for their pregnancy, delivery and postnatal period which takes into account their mental health and the treatment (including medication) that they use for their mental health disorder.

Case study 1

Sarah is 24 years old and a PhD student in astrophysics. She has a diagnosis of bipolar affective disorder and used lithium since her last acute episode 2 years ago to good effect.

She stopped her lithium abruptly on discovering her pregnancy. The pregnancy was not planned.

She and her partner are happy to be expecting a baby. Sarah’s family lives overseas, and her partner’s family is local. They do not know anything about her past mental health.

Case study 2

Thelma is 29 years old and works in retail. She is in the first trimester of her first pregnancy. Thelma’s body mass index (BMI) is in the low/normal range and has fallen in the last 4 weeks. She has a history of anorexia nervosa and has had two hospital inpatient spells for treatment. Both admissions were involuntary under the Mental Health Act, and nasogastric (NG) feeding was administered on both occasions. She has been well for over a year, and this pregnancy was planned. She is horrified by her enlarging breasts and is dreading her body changing further. She admits to some temptation to restrict calories.

Case study 3

Angela is 34 years old and works as a local general practitioner. She knows several obstetricians in the department socially. Angela has had episodes of depression throughout her teenage years and early twenties. She discloses at 28 weeks she is low in mood, regrets being pregnant and feels resentful of the baby, as she blames it for her sore back and hips and her ongoing nausea. She is not sleeping well and sometimes thinks it is too hard to go on. She does not want you to share this information with anyone or to include it in her clinical record.

Case study 4

Selma is 30 years old, is 28 weeks’ pregnant and is attending her first antenatal contact. She has a diagnosis of schizophrenia and sees a community psychiatric nurse monthly. She lived in supported accommodation and has had frequent hospital admissions for her mental health. She says she is not currently taking any medication. She seems distracted and guarded in her responses. She asks some questions and makes some remarks which strike you as odd. ‘How do you know it’s a human baby?’ and ‘The baby is chosen and will protect me from the pain.’

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