Suicide and Maternal Mortality

Factors that Contribute to Neonatal Mortality at a Community Hospital

OBJECTIVES

The prevalence of intrauterine fetal demise (IUFD) in the United States is 5.74 per 1000 live births. In Maryland, the prevalence is 6.75 per 1000 and occurs nearly twice as frequently in Black than in white populations. At MedStar Franklin Square Medical Center (MFSMC), Electronic Medical Records (EMR) show that IUFDs are 2.5 times greater in Black than white women. This analysis aims to identify factors that contribute to this health disparity.

METHODS

We performed a retrospective chart review of deliveries at MFSMC between 2018 and 2020. Literature-supported variables were collected for all pregnancies that ended in IUFD. Using logistic regression models, these factors were analyzed to isolate predictors for IUFD and association with race. The same predictors were compared to those of women who delivered live infants during this period.

RESULTS

Without adjustment, the odds of having an IUFD are 2.21 times higher for Black mothers than for white mothers at MFSMC. No other unadjusted odds ratios between comorbid risk factors and the chance of IUFD were significant. After adjusting for diabetes, growth restriction, substance abuse, and hypertension, the odds of having an IUFD are 2.31 times higher for Black than white mothers.

CONCLUSIONS

Black mothers experience increased risk for IUFD, after controlling for other pertinent factors. This disparity should be addressed by reducing healthcare provider bias, increasing maternal health services, and providing comprehensive patient education.

Trends in prevalence and treatment of antepartum and postpartum depression in the United States: Data from the national health and nutrition examination survey (NHANES) 2007 to 2018

OBJECTIVES

(1) To assess the prevalence of depression and treatment rates in antepartum and postpartum women compared to a control group of reproductive-age women over a 12-year period, and (2) To determine demographic characteristics associated with depression.

METHODS

National Health and Nutrition Examination Survey data (2007-2018) were used. 5412 controls, 314 antepartum women, and 455 postpartum women were analyzed. Outcomes included depression prevalence, defined as moderate to severe depressive symptoms measured by Patient Health Questionnaire-9 (PHQ-9) scores ≥10 or self-reported antidepressant use; and treatment, defined as antidepressant prescription and/or mental health care services in the past 12 months. Multivariable logistic regression adjusted for age, insurance, race/ethnicity, education, and marital status estimated odds ratios and 95% confidence intervals.

RESULTS

Depression prevalence was 20.2% in controls (95% CI 18.5-21.9), 9.7% in antepartum (6.3-14.1), and 12.8% in postpartum women (9.3-17.1). Mental health care service utilization increased for postpartum women in 2017-2018 (22.0%, 10.6-37.7). In those with depression, control and postpartum groups had similar treatment rates (70%, p = 0.894) compared to antepartum women (51%, p = 0.051). Antidepressant use was the most common treatment reported in all groups. Those who were married or had private insurance had the lowest depression rates in their respective categories. After adjusting for confounders, antepartum and postpartum women had lower odds of depression compared to controls. When the outcome was PHQ-9 ≥ 10 alone, these associations persisted.

CONCLUSION

In a nationally representative sample, depression prevalence was lower in perinatal women compared to reproductive-age controls, and treatment rates were lowest in antepartum women with prevalent depression. Mental health care services may have increased for postpartum women due to the US Preventive Services Task Force 2016 recommendations, which endorsed psychotherapy for postpartum women. Even so, antidepressants were the most reported treatment among perinatal women, despite psychotherapy being the first-line recommended treatment for this population.

Cognitive behavioural therapy for intolerance of uncertainty: A study protocol for the prevention of postpartum anxiety

BACKGROUND

Mental health disorders are the most prevalent health complication experienced during pregnancy and the postpartum, with anxiety disorders being most common. Intolerance of uncertainty (IU) is a well-known feature of anxiety disorders and has recently been identified as a risk factor for the worsening of anxiety during the postpartum period. Cognitive Behavioural Therapy (CBT) is a first-line treatment for perinatal anxiety, and CBT specifically targeting IU in non-perinatal populations has demonstrated positive findings for reducing anxiety. As such, the objective of our study is to examine whether CBT targeting IU in pregnancy can reduce the risk of postpartum anxiety.

METHODS

This protocol paper outlines a proof-of-concept randomised clinical trial assessing the effectiveness of a newly developed CBT for IU (CBT-IU) protocol to reduce the risk of postpartum anxiety. Pregnant individuals identified at increased risk for postpartum anxiety (defined as a baseline score of 64 or greater on the Intolerance of Uncertainty Scale) will be randomised to receive CBT-IU or care as usual (CAU) during pregnancy and will be followed through the postpartum period (6-12 weeks). The CBT-IU protocol is a weekly, six session treatment, which includes psychoeducation, behavioural experiments, imaginal exposure, and problem-solving to target IU.

DISCUSSION

To our knowledge, this will be the first study to investigate the efficacy of a CBT protocol aimed at reducing the risk of developing postpartum anxiety. Establishing this protocol as a potentially preventative strategy will offer a new option to improve the mental health and well-being of mothers and their infants.

CLINICAL TRIAL REGISTRATION

Trial Number is NCT05691140 and accessible at https://clinicaltrials.gov/study/NCT05691140.

Targeted Research and Treatment Implications in Women With Depression

Women with a history of traumatic experience, particularly adversity encountered during childhood, have an increased risk of developing depression. The authors review the biological mechanisms associating trauma with depression, including the role of the hypothalamic-pituitary-adrenal axis. Additionally, the psychosocial and cultural considerations associating traumatic experience with depression are discussed, and current gaps in knowledge about biological mechanisms, psychosocial factors, and cultural aspects relating trauma to depression that remain to be addressed are described. Women with a history of trauma are also at increased risk for engaging in suicidal behaviors, including suicidal ideation and attempts. Increased suicidality in women with a history of trauma has been observed in various populations, including among victims of intimate partner violence, female veterans, refugees, and individuals who identify as lesbian, gay, bisexual, transgender, queer or questioning, or other. Although associations between trauma and suicidality have been well documented, limited research has examined the impact of age or reproductive stage, an important area for future research. A wide range of biological, psychosocial, and cultural factors that can increase the risk for suicidality across the lifespan in women are described, and how they may be included when completing clinical assessments for women is highlighted. Machine learning, and its use in risk and outcome prediction of depression in women across reproductive stages toward individualized psychiatric services, is introduced, with future directions reviewed.

Impact of postpartum physical activity on maternal depression and anxiety: a systematic review and meta-analysis

OBJECTIVE

To examine the influence of postpartum exercise on maternal depression and anxiety.

DESIGN

Systematic review with random effects meta-analysis and meta-regression.

DATA SOURCES

Online databases up to 12 January 2024, reference lists, recommended studies and hand searches.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and non-randomised interventions of any publication date or language were included if they contained information on the Population (postpartum people), Intervention (subjective or objective measures of frequency, intensity, duration, volume, type, or mode of delivery of exercise), Comparator (no exercise or different exercise measures), and Outcome (postpartum depression, anxiety prevalence, and/or symptom severity).

RESULTS

A total of 35 studies (n=4072) were included. Moderate certainty evidence from RCTs showed that exercise-only interventions reduced the severity of postpartum depressive symptoms (19 RCTs, n=1778, SMD: -0.52, 95% CI -0.80 to -0.24, I2=86%, moderate effect size) and anxiety symptoms (2 RCTs, n=513, SMD: -0.25, 95% CI -0.43 to -0.08, I2=0%, small effect size), and the odds of postpartum depression by 45% (4 RCTs, n=303 OR 0.55, 95% CI 0.32 to 0.95, I2=0%) compared with no exercise. No included studies assessed the impact of postpartum exercise on the odds of postpartum anxiety. To achieve at least a moderate reduction in the severity of postpartum depressive symptoms, postpartum individuals needed to accumulate at least 350 MET-min/week of exercise (eg, 80 min of moderate intensity exercise such as brisk walking, water aerobics, stationary cycling or resistance training).

CONCLUSIONS

Postpartum exercise reduced the severity of depressive and anxiety symptoms and the odds of postpartum depression.

Zuranolone for Postpartum Depression After Highly Lethal Suicide Attempt: Two Case Illustrations and a Narrative Literature Review

BACKGROUND

In the United States, suicide is one of the leading causes of death in the first year postpartum, possibly accounting for up to 20% of deaths. The Food and Drug Administration recently approved 2 fast-acting medications, brexanolone and zuranolone, for the treatment of postpartum depression (PPD), which shares many clinical features with postpartum suicidality.

OBJECTIVE

Determining the efficacy of zuranolone in the treatment of severe PPD in the context of highly lethal suicide attempts.

METHODS

We describe 2 illustrative cases of zuranolone treatment of PPD after a gunshot suicide attempt. Following treatment, both women demonstrated a rapid reduction in depressive symptoms and readiness for safe discharge. We also conducted a review of the literature on suicide attempts associated with PPD.

RESULTS

Our case series demonstrated that zuranolone may effectively treat PPD with rapid-onset highly lethal suicide attempts.

CONCLUSIONS

Postpartum suicidality is complex and often emerges rapidly. We advocate for more research on fast-acting novel treatments, such as zuranolone and brexanolone, for PPD and postpartum suicidality.

Association between gut microbiota and perinatal depression and anxiety among a pregnancy cohort in Hunan, China

BACKGROUND

Perinatal depression and anxiety pose significant risks to maternal health and may lead to suicide. The gut microbiota may play a crucial role in perinatal depression and anxiety. However, the relationship between the alterations in gut microbiota and perinatal depression and anxiety remains unclear. This study aimed to investigate the dynamic changes of gut microbiota over various perinatal stages and their associations with perinatal depression and anxiety symptoms, especially suicide ideation.

METHODS

A total of 177 pregnant and 19 postpartum women were recruited in this study, with 48 of them participating longitudinally. Maternal depression and anxiety symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), 9-item Patient Health Questionnaire (PHQ-9), and 7-item Generalized Anxiety Disorder Scale (GAD-7). Fecal samples collected during the perinatal period were analyzed using 16S rRNA gene sequencing.

RESULTS

Significant changes in microbial diversity and multi-taxonomic levels were observed during pregnancy. The random forest regression model showed significant associations of some gut microbial features with depression and anxiety symptoms. Several genera were significantly associated with gestation age and perinatal depression and anxiety, such as Akkermansia, Bifidobacterium and Streptococcus. In addition, Erysipelotrichaceae_UCG-003 and Eubacterium_hallii_group were positively associated with suicidal ideation. The glycine biosynthesis pathway might act as a mediator between Eubacterium_hallii_group and suicidal ideation (ab = 3.27, p < 0.05).

CONCLUSION

The gut microbiota undergoes a programmed shift during pregnancy, which may play a critical role in perinatal depression and anxiety. Our findings underscore the impact of certain bacterial genera and metabolic pathways on perinatal mental health, which may help to develop new diagnostic tools and targeted interventions to reduce perinatal mental disorders and improve the outcomes for both mothers and infants.

The continuity relationship makes caring for women with anxiety and depression easier, but it is also a heavy responsibility

BACKGROUND

Perinatal depression and anxiety, experienced by about 20 % of women, are a risk factor for associated morbidities for mothers and babies, including risk of suicide and preterm birth. Traditionally this group of women have not been able to access midwifery continuity of care despite the known benefits.

AIM

This study aims to explore the experiences of midwives providing continuity of care to women with perinatal mental health disorders and women's experiences of receiving care in a continuity of care model.

METHODS

We used a mixed methods design incorporating a qualitative exploratory study using a qualitative descriptive approach [1] to understand midwives experiences. We also explored the women's experience of receiving continuity of care and observed mothers interacting with their babies. The quantitative data was collected using the Parenting Interactions with Children Checklist of Observations (PICCOLO) [2], described in detail below, to measure these interactions.

RESULTS

Two overarching themes were generated: Continuity is protective, with subthemes Safe in their hands, Healing from previous trauma and Sustaining breastfeeding; and Having exceptional care deserves equitable access, with sub-themes Having your choices respected, Having a meaningful birth experience, Providing exceptional care requires support.

CONCLUSION

This study adds to current literature that indicates midwifery continuity of care as emotionally protective, which is particularly important for women with perinatal mental health conditions and may have ongoing positive effects that foster wellbeing. Experienced as providing 'exceptional' care, our findings demonstrate an urgent need to increase access to such models, and ensuring midwives have equally 'exceptional' training, support and referral pathways, to ensure their sustainability.

Postpartum dams exposed to a low-resource environment display neuroinflammation, elevated corticosterone, and anhedonia-like behavior

Women living in an impoverished environment after birth have an increased risk of developing postpartum depression (PP-Dep) and hypertension (PP-HTN). The mechanisms underlying these heightened risks are unknown and understudied. To examine the relation between reduced environmental resources, PP-Dep, and PP-HTN, postpartum rodent dams were exposed to the low-resource limited bedding and nesting (LBN) chronic stress model during weaning. Postpartum dams were divided into control (CTL) and experimental (LBN) groups, in which the experimental group experienced LBN. At 6 wks postpartum, blood pressure, sucrose preference tests (a proxy for anhedonia and depression), corticosterone, and markers of neuroinflammation were measured. We hypothesized that postpartum dams exposed to LBN will have increased corticosterone, neuroinflammation, depression-like behaviors, and HTN. Results show that postpartum dams exposed to an impoverished environment exhibit decreased sucrose preference, increased circulating corticosterone, and elevated neuroinflammation (∼150% increased TNF-α and astrocyte activation in the cerebrum). No changes in blood pressure were observed. However, there was a strong correlation between postpartum blood pressure and corticosterone and blood pressure and TNF-α levels. Importantly, this study provides insights into the pathology and development of PP-HTN and PP-Dep in the postpartum period, which will enable the discovery of novel therapeutic approaches.NEW & NOTEWORTHY Postpartum dams exposed to a low-resource environment experience anhedonia, elevated corticosterone, and neuroinflammation. Increases in corticosterone and neuroinflammation may contribute to the development of postpartum depression (PP-Dep) and postpartum hypertension (PP-HTN). Healthcare providers should consider asking questions about the social economic status and accessibility of resources for women after pregnancy. This study advocates for extended postpartum care beyond traditional care and better implementation of assessments for PP-Dep and PP-HTN.

CL Case Conference: Managing Substance Use and Agitation in Pregnancy

We present the case of a 29-year-old G1P0 female at 21 weeks of gestational age with stimulant use disorder, substance-induced psychosis, and agitation who is admitted to obstetrics and gynecology. During her hospitalization, consultation-liaison psychiatry plays an important role in managing her psychotropic regimen and determining appropriate safety precautions. Subject matter experts examine critical aspects of psychiatric care in pregnancy and liaising with obstetric services, including protocols for unit placement, suicide risk assessment, and medicolegal considerations such as involuntary commitment, medical decision-making capacity, and mandated reporting. Special attention is given to the management of agitation as an obstetric emergency, with detailed guidance on both nonpharmacologic and pharmacologic treatment strategies. We also discuss stimulant use disorder in pregnancy, including epidemiology, risk factors, potential treatment options, and barriers to receiving care.

Clinical Utility of Zuranolone for Postpartum Depression: A Narrative Review

Peripartum depression (PPD) affects approximately one in every eight birthing individuals. Despite a high prevalence, PPD is underdiagnosed and undertreated. Several PPD treatment options exist including psychotherapies, conventional serotonergic-based antidepressants and alternative and integrative medicine approaches. Rapid-acting neuroactive steroid-based antidepressants have been studied and approved in the United States (US) for the treatment of adult females with PPD. Zuranolone is the first US Food and Drug Administration approved oral antidepressant for adult females with PPD. This narrative review reports on the evidence for the clinical utility of zuranolone in PPD treatment. In double-blind, randomized, placebo-controlled, clinical trials, zuranolone demonstrated rapid, statistically significant and clinically meaningful improvements in depressive symptoms. Most common adverse events reported with zuranolone use were somnolence, dizziness, sedation, and headache. No clinically significant changes in vital signs, electrocardiogram or clinical lab parameters were observed. No loss of consciousness and no increase in suicidal ideation from baseline or deaths were seen in the studies. Secondary analyses demonstrated that zuranolone improves comorbid symptoms of anxiety and insomnia and some measures of health-related quality of life. Zuranolone relevant infant dose lactation data suggest that its use is compatible with breastfeeding, though future research is needed to measure potential adverse effects on the breastfed infant. Key aspects of clinical decision-making in patients with PPD are discussed.

Psychometric Properties of the Edinburgh Postnatal Depression Scale Among Rural-Dwelling U.S. Women

To decrease the high rates of mental health-related maternal morbidity and mortality among rural-dwelling women, it is critical to identify those experiencing postpartum depression (PPD) and provide necessary follow-up care. To effectively screen for PPD, clinicians must utilize instruments which account for context-specific factors and maintain validity across diverse populations. The Edinburgh Postnatal Depression Scale (EPDS) is the most commonly used depression screening tool in perinatal settings, but has not been validated for use within rural American settings. The aim of this study was to establish the psychometric properties of the EPDS and assess its validity for clinical use within a rural American context. In regards to construct validity, we found that a single-factor structure representing depression status was psychometrically sound and well explained by the items of the EPDS. The scale demonstrated strong criterion-related validity, where EPDS screening results were significantly correlated with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria used by providers to make differential depression diagnoses. The EPDS yielded acceptable reliability and internal consistency (Cronbach's alpha = 0.90) in measuring depression status among our rural-dwelling sample. This is the first study establishing validity of a PPD screening tool within a rural U.S. population.

An Integrative Review Exploring Womens' Experiences of Retraumatization Within Perinatal Services

INTRODUCTION

Evidence indicates that retraumatization has a detrimental effect for those women who are accessing perinatal services. One in five women worldwide has a history of childhood adversity. Between 18% and 34% of women experience trauma, which is a well-known risk factor for the onset of chronic mental health disorders. There is a lack of evidence on women's experiences on retraumatization in perinatal care settings and how to prevent retraumatization from occurring. The purpose of this study was to conduct an integrative review on women experiences of retraumatization to determine preventive measures within perinatal services.

METHODS

This integrative review followed Whittemore and Knafl's 5-stage framework as it allows for the inclusion and integration of diverse research methodologies into an overall synthesis of the evidence. A systematic search of 5 databases was conducted (Web of Science, MEDLINE, CINAHL, ASSIA, and PsychINFO) with no date, language, or geographical limits set due to the paucity of research published in this subject area. This review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Fifteen studies met the inclusion criteria and were included in the thematic synthesis. The review identified that participants across the studies had a history of child sexual abuse, sexual abuse, and rape. Three main themes plus subthemes were identified: (1) activating (subthemes: positions in labor, intimate procedures, communications with health care professionals, loss of control); (2) outcomes (subtheme: emotional responses); and (3) interventions reducing or preventing retraumatization (subthemes: role of the health care professional, screening for abuse and history of trauma).

DISCUSSION

Our findings demonstrate that women are experiencing retraumatization in perinatal services, and there is evidence of formalized approaches being applied in clinical settings to prevent retraumatization from occurring. This study is the first to examine the factors that contribute to retraumatization in perinatal services and make recommendations to reduce the harmful practices in place in perinatal care settings.

The Impact of Pregestational Diabetes on Maternal Morbidity and Mortality: Trends, Challenges, and Future Directions

Maternal mortality in the United States is on the rise, demonstrating a concerning trend that stands in stark contrast to the falling rates in other developed countries. A key challenge facing the improvement of maternal care is the mounting prevalence of chronic health conditions such as hypertension and diabetes, which are often linked to poor diet and sedentary lifestyle. Pregestational diabetes now impacts 1 to 2% of pregnancies, while gestational diabetes affects another 7.8%. Both type 1 and type 2 diabetes elevate the risk of severe maternal morbidity and mortality (SMM), including severe cardiac morbidity, hypertensive disorders of pregnancy, hemorrhage, infection, and mental health conditions. The increase in diabetes is thought to account for 17% of the increase in maternal mortality between 1997 and 2012. Another critical issue facing maternal care is the significant disparity in pregnancy outcomes among populations facing greater burdens of adverse social determinants of health, including socioeconomic characteristics, chronic stress, and systemic racism. For example, non-Hispanic Black women are 2.5 times more likely to die during pregnancy and the postpartum period than non-Hispanic White women. Vulnerable populations, often minorities, are also more likely to develop risk factors for SMM, such as type 2 diabetes. As pregestational diabetes is a particularly morbid condition in pregnancy, examining its complications and evidence-based treatments could significantly impact both maternal mortality rates and disparities in pregnancy outcomes in the United States. This review explores the relationship between pregestational diabetes and SMM, how the risk of SMM can be modified by disparities, and avenues for advancing care through future research. KEY POINTS: · Diabetes during pregnancy greatly increases the risk of SMM.. · Comprehensive care can improve outcomes in high-risk pregnancies with diabetes.. · Adverse social determinants of health worsen outcomes in pregnancies affected by diabetes.. · Improving diabetes care in pregnancy offers an opportunity to enhance maternal outcomes..

Perceptions of Lesotho nurse-midwives regarding post-partum depression management

BACKGROUND

 Effective post-partum maternal care is essential for the overall well-being of both the mother and the child. Postpartum depression (PPD) is a pervasive issue with profound implications for maternal health. However, a significant research gap exists concerning the perspectives of nurse-midwives on PPD within the context of Lesotho.

OBJECTIVES

 This study aimed to explore perceptions of nurse-midwives about PPD management at a tertiary care facility in Lesotho.

METHOD

 The study site was the Quthing Hospital, a government-funded healthcare facility situated in Lesotho's southernmost district, Quthing. Employing a constructivist paradigm, the research adopted a qualitative, exploratory, descriptive and contextual design. Using purposive sampling, nine nurse-midwives participated in individual interviews.

RESULTS

 Thematic analysis of the data resulted in three themes emerging namely: a lack of nurse midwifery empowerment, inadequate human and material resources and stigma on mental health issues.

CONCLUSION

 Nurse-midwives at a large tertiary care facility perceive PPD management through a multifaceted lens. Insights underscored the complexity of PPD and its ramifications for maternal care.Contribution: This study provides invaluable perspectives from nurse-midwives within a specific Lesotho context, laying the foundation for strategies to enhance PPD management and maternal mental healthcare.

Evaluation of depression at 6 and 12 months postpartum by examining depressive symptoms and self-harm ideation during the early postpartum period: Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study

Aim

The aim of this study was to evaluate depression at 6 and 12 months postpartum, using the Edinburgh Postpartum Depression Scale (EPDS) total score and its subitem regarding self-harm ideation (SHI) at 1 month postpartum.

Methods

A sample of 12,358 postpartum women answered the EPDS and questionaries at 1, 6, and 12 months postpartum longitudinally.

Results

For participants with postpartum depression (PPD; EPDS total score ≥9) and SHI (SHI sub-score ≥1) at 1 month postpartum, the risk of depression at 6 and 12 months postpartum (odds ratio [95% confidence interval] at 6 and 12 months postpartum: 20.03 [16.8-23.8] and 14.55 [12.3-17.2], respectively) was higher than for those with PPD but without SHI at 1 month postpartum (OR: 8.57 [7.36-10.0], and 6.24 [5.38-7.24], respectively). Additionally, SHI even without depressive symptoms at 1 month postpartum is also a risk for depression at 6 and 12 months postpartum. To support our longitudinal evaluation of depression at 6 and 12 months postpartum, these related factors were examined: traumatic events or relocations after the Great East Japan Earthquake, employment status, household income, personality traits, sleep status, psychological distress, and social networks. The result showed employment status, low household income and poor social networks were significantly associated with depression at 12 months postpartum but not at 6 months postpartum.

Conclusion

This study showed a high risk of depression at 6 and 12 months postpartum for those who had depressive symptoms with SHI at 1 month postpartum. Our findings may contribute to the precise evaluation of depression at 6 and 12 months postpartum while considering sleep status, psychological distress and social network during pregnancy.

Challenges of Motherhood for Anesthesiologists: A Scoping Review

Despite advancements in gender representation, female anesthesiologists continue to encounter challenges in career advancement that may be further impacted by motherhood. This scoping review examines personal and systemic barriers and facilitators to career advancement for anesthesiologists facing infertility, pregnancy, and childcare. The review identified 22 relevant studies across five themes: the timing of pregnancy and parental leave, breastfeeding and lactation needs, childcare and gender norms, job reentry and career advancement opportunities, and work-life balance and physician well-being. Recommendations from these studies include establishing clear parental leave policies, providing adequate lactation spaces and protected break times, addressing gender disparities in leadership roles, and prioritizing physician well-being. To implement these recommendations effectively, institutions and departments should develop and disseminate role-specific policies that promote career advancement and satisfaction through equitable support of pregnant and parent anesthesiologists.

Suicide during pregnancy as a major contributor to maternal suicide among female sex workers in eight low- and middle-income countries: A community knowledge approach investigation

Studies indicate a high burden of mental health disorders among female sex workers (FSWs) in low- and middle-income countries (LMICs). Despite available data on suicidal ideation and suicide attempts among FSWs, little is known about suicide deaths in this hard-to-reach population. This study aims to examine the extent to which suicide is a cause of maternal mortality among FSWs, the contexts in which suicides occur, and the methods used. From January to October 2019, the Community Knowledge Approach method for identifying cause-specific deaths in communities was employed across eight LMICs (Angola, Brazil, the Democratic Republic of the Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa). A total of one thousand two hundred eighty FSWs provided detailed reports on two thousand one hundred twelve FSW deaths in the preceding 5 years, including 288 (13.6%) suicides, 178 (61.8%) of which were maternal. Of these maternal suicides, 57.9% occurred during pregnancy (antepartum), 20.2% within two months of delivery (puerperium), and 21.9% in the 2-12 months following delivery (postpartum). The highest proportion of suicides occurred in Nigeria, Kenya, and DRC in sub-Saharan Africa. A total of 504 children lost their mothers to suicide. Further research is needed to identify interventions for suicide risk among FSW mothers.

Perinatal women's views and experiences of discussing suicide in maternity care settings: A qualitative study

BACKGROUND

Suicide is a leading global cause of maternal death in the first year after birth. Limited research has explored which factors may support or prevent women from disclosing suicidality. This is important for informing appropriate approaches to identifying perinatal women who may require support.

AIMS

(i) explore perinatal women's views and experiences regarding the barriers, facilitators, and implications of identifying and disclosing suicidality in maternity care settings; and (ii) explore their perspectives on appropriate approaches for healthcare practitioners (HCPs) to take when asking about suicide during pregnancy or after birth.

METHODS

Twenty-one semi-structured interviews with perinatal women in the UK. Of these women, 17 had experienced self-reported perinatal mental health (PMH) problems and/or suicidality. Inductive thematic analysis was used to explore the data and identify themes.

RESULTS

Four themes, comprising 11 subthemes were identified. Barriers that affected women's willingness and capacity to disclose suicidality included: stigma, social expectations of motherhood, not recognising symptoms, not being asked about PMH and/or rushed appointments, lack of care continuity, and HCPs interpersonal skills. Important facilitators were the provision of PMH information and peer support. Women also suggested providing more choice in how PMH and suicide-related questions are administered (e.g., via a form and in-person) and for HCPs to frame these discussions sensitively.

CONCLUSIONS

Significant barriers impact perinatal women's disclosure of suicidality. Appropriate approaches for identifying suicidality in maternity contexts need to be developed that take account of these barriers and support women to feel safe, comfortable, and able to answer suicide-related questions honestly.

Thinking about the next generation: The case for a mentalization-informed approach to perinatal and intergenerational mental health

BACKGROUND

There has been substantial progress made across multiple disciplines to emphasize the importance of perinatal mental health both for parents and offspring. This focuses on what has been termed the 'First 1000 Days' from conception to the child's second birthday. We argue that our understanding of this issue can go further to create an intergenerational approach to mental health. Despite the existence of theoretical frameworks and practical approaches to implementation, there are gaps in the understanding of perinatal and intergenerational mental health including which psychological mechanisms are implicated in the transmission of risk and resilience within the perinatal period; and how to leverage these into treatment approaches.

AIMS AND METHODS

In this paper, we explore the potential for mentalization as a candidate psychological approach to intergenerational mental health.

RESULTS

We contextualize this issue in terms of the points of contact between mentalization and broader theoretical models such as the social determinants of health and the Developmental Origins of Health and Disease (DoHaD) model. Further, we provide an overview of the existing evidence base for the relevance of mentalization to perinatal mental health.

DISCUSSION

Finally, we sketch out an outline model for integrating mentalization into perinatal and intergenerational mental health, highlighting several areas of opportunity to develop research and practice from diverse geographies and demographics. Here, we suggest that integration of mentalization with other conceptual frameworks such as DoHaD can mutually enrich the understanding of each model, pointing the way towards more effective early and preventative interventions.

Circulating JKAP levels may correlate with postpartum anxiety and depression through its interaction with T helper 17 cells

Jun N-terminal kinase pathway-associated phosphatase (JKAP) regulates CD4+ T-cell differentiation and immunity, which are linked to mental disorders. This study aimed to explore the relationships between JKAP and T helper 17 (Th17)/regulatory T (Treg) ratio, as well as their associations with anxiety and depression in postpartum women. Serum JKAP were measured by enzyme-linked immunosorbent assay and blood Th17 and Treg cells were measured by flow cytometry in 250 postpartum women. Anxiety and depression were evaluated by the 6-item State-Trait Anxiety Inventory (STAI6) and Edinburgh Postnatal Depression Scale (EPDS). Anxiety and depression rates were 22.0 and 28.4%, respectively, among postpartum women. Notably, JKAP was negatively associated with the STAI6 (P=0.002) and EPDS scores (P<0.001) in postpartum women and was lower in postpartum women with anxiety (P=0.023) or depression (P=0.002) than in those without. Moreover, JKAP was inversely related to Th17 cells and Th17/Treg ratio but positively correlated with Treg cells in postpartum women (all P<0.001). Interestingly, Th17 cells and Th17/Treg ratio were both positively associated with STAI6 and EPDS scores in postpartum women (all P<0.001). Furthermore, Th17 cells and Th17/Treg ratio were lower in postpartum women with anxiety or depression than in those without (all P<0.01). Nevertheless, Treg cells were not linked to anxiety or depression in postpartum women. JKAP was negatively associated with Th17 cells and Th17/Treg ratio; moreover, they all related to anxiety and depression in postpartum women, indicating that JKAP may be involved in postpartum anxiety and depression via interactions with Th17 cells.

The role of sleep protection in preventing and treating postpartum depression

Postpartum sleep disruption is a risk factor for postpartum depression (PPD) as well as a potential treatment target. In the first 6 months after delivery, when the risk of PPD is greatest, fragmented maternal sleep is most often related to necessary infant night feedings. Clinicians' conversations about planning for and navigating postpartum sleep should include questions about patient expectations, cultural traditions, and available support. For women at high risk of PPD, or with moderate to severe PPD or other symptoms of mental illness, protecting one 4-5 hour period of consolidated nighttime sleep may be necessary and effective. This can be achieved by having another adult step in for 1-2 infant night feedings or by employing other strategies. OBs can encourage high-risk patients to develop a postpartum plan for sleep protection by initiating this conversation during pregnancy.

Guideline No. 454: Identification and Treatment of Perinatal Mood and Anxiety Disorders

OBJECTIVE

To help perinatal health care providers identify and assist pregnant and postpartum patients with perinatal mental illness, specifically perinatal mood and anxiety disorders. Areas of focus include risk factors and identification, screening, treatment, and referral.

TARGET POPULATION

All individuals who are pregnant or in the first year postpartum.

OUTCOMES

Open dialogue and evidence-informed care for perinatal mood and anxiety disorders, including competency for identification, screening, treatment, and referral, which will lead to improvements in patient care.

BENEFITS, HARMS, AND COSTS

Pregnant and postpartum individuals with untreated perinatal mental illness, including mood and anxiety disorders, may suffer devastating effects and their family may experience short- and long-term adverse outcomes.

EVIDENCE

A literature search was conducted using Medline (Ovid), PubMed, Embase and the Cochrane library from inception to June 2024. Additional articles were identified from article bibliographies and grey literature published by reputable societies and organizations (see online Appendix A).

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All heath care providers who provide preconception counselling and/or care during pregnancy and the postpartum period. The term "perinatal" will be used throughout this guideline to refer to these health care providers.

SOCIAL MEDIA ABSTRACT

New SOGC Guideline! Identify, support, and treat perinatal mood and anxiety disorders. Focused on risk factors, screening, treatment and referrals during pregnancy and the postpartum period. Let's open dialogue and provide evidence-informed care for improved patient outcomes.

SUMMARY STATEMENTS

RECOMMENDATIONS: IDENTIFICATION AND RISKSCREENINGTREATMENT.

Global contribution of suicide to maternal mortality: a systematic review protocol

INTRODUCTION

Maternal suicide is a significant contributor to maternal mortality with devastating consequences for women, families and society. Maternal mortality reporting systems differ across countries and there is no up-to-date overview of maternal suicide deaths globally. This systematic review aims to synthesise the evidence on maternal suicide. The primary objective is to determine the contribution of suicide towards maternal mortality globally and explore differences between geographical regions. The secondary objectives are to summarise the availability and quality of data globally and to describe how suicide deaths are classified across different countries.

METHODS AND ANALYSIS

This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Medline, Embase, PsycINFO, Global Health and CINAHL databases and the grey literature were searched with no date or language restrictions. Observational studies, national surveys and reports that present data on maternal deaths due to suicide occurring during pregnancy, intrapartum and in the postpartum period will be included. Screening, data extraction and quality assessment will be conducted independently by two reviewers. Results will be summarised narratively. If sufficient outcome data are available, random-effects meta-analyses will be conducted to determine global pooled estimates of suicide-related maternal mortality rates and the proportion of maternal deaths attributable to suicide.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. Results will be written up for publication in a peer-reviewed journal and findings will be shared at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42023429072.

Perioperative esketamine administration for prevention of postpartum depression after the cesarean section: A systematic review and meta-analysis

BACKGROUND

Postpartum Depression (PPD) exerts a substantial negative effect on maternal well-being post-delivery, particularly among Cesarean Section (C/S) recipients. In this study, we aimed to review the efficacy of perioperative esketamine, the S-enantiomer of ketamine, in preventing PPD incidence and depressive symptoms as measured with the Edinburgh Postnatal Depression Scale (EPDS) after C/S.

METHODS

A systematic search for relevant articles was conducted in Scopus, PubMed, Web of Sciences, and PsycINFO until April 6, 2024. Meta-analyses were conducted using random-effect models to compare the PPD incidence and EPDS scores via log odds ratio and Hedge's g, respectively, during the first week post-C/S and at 42 days post-C/S in the esketamine and control group.

RESULTS

Fourteen studies, including 12 randomized controlled trials and 2 retrospective cohorts, were reviewed. Our meta-analyses found lower PPD incidence during the first week (log odds ratio: -0.956 [95 % confidence interval: -1.420, -0.491]) and at day 42 post-C/S (log odds ratio: -0.989 [95 % confidence interval: -1.707, -0.272]) among patients administered esketamine compared to controls. Additionally, EPDS scores for the esketamine group were significantly lower than controls during the first week (Hedge's g: -0.682 [95 % confidence interval: -1.088, -0.276]) and at day 42 post-C/S (Hedge's g: -0.614 [95 % confidence interval: -1.098, -0.129]).

LIMITATIONS

Presence of various concomitant medications and heterogeneous study designs.

CONCLUSION

Our review highlights the potential impact of esketamine in PPD prevention, as well as in alleviating depressive symptoms post-C/S, regardless of PPD occurrence, therefore suggesting the benefits of adding esketamine to peri-C/S analgesic regimen.

Can Obstetrics and Gynecology Hospitalists Reduce Severe Maternal Morbidity?

Maternal mortality in the United States has risen steadily over the past 20 years. Several interventions including maternal mortality committees and safety bundles have been introduced to decrease the trend. Severe maternal morbidity is a more frequent occurrence related to maternal mortality and can be used to track interventions. Within safety bundles, the presence of well-trained on-site staff such as obstetrics and gynecology (OB/GYN) hospitalists is key to correct implementation. In this article, the authors review the role of OB/GYN hospitalists in specific diagnoses and the evidence present to date on OB/GYN hospitalists' role in decreasing severe maternal morbidity.

A Concept Analysis of Maternal Resilience against Pregnancy-Related Mental Health Challenges in Low- and Middle-Income Countries

Suicide accounts for 33% of deaths of women during the postnatal period in many low- and middle-income countries (LMICs). Resilience refers to an ability to adapt and recover from adversity or misfortune. Resilience building against mental health challenges during pregnancy and the postnatal period is critical for women to raise their child efficiently and maintain a healthy life. The exploration of maternal resilience against mental health challenges including its developmental processes and the determinants of its successful or unsuccessful cultivation among mothers during pregnancy and childbirth is of paramount importance. Understanding why a subset of mothers effectively develops resilience while others significantly struggle is critical for devising targeted interventions and support mechanisms aimed at improving maternal well-being. This inquiry not only seeks to delineate the factors that contribute to or hinder the development of resilience but also aims to inform the creation of comprehensive support systems that can bolster maternal health outcomes. This paper endeavors to present a comprehensive analysis of maternal resilience, aiming to cultivate a nuanced and profound understanding of the concept within the framework of previous traumatic events and adverse pregnancy outcomes in LMICs. The eight-step method approach proposed by Walker and Avant was utilized for this concept analysis. Several defining attributes were identified in the analysis including social adaptation, support system, optimistic approach, and mindfulness. This analysis contributes to knowledge advancement regarding maternal resilience and provides nurses and other healthcare professionals with a clear understanding of the concept of maternal resilience to help promote resilience among mothers.

"She Was Feeling Overwhelmed at Home Caring for Her Children": Expectations of "Intensive Motherhood" as a Risk Factor for Young Women's Suicide

Suicide is a leading cause of death among young women and perinatal mothers. This paper explores how expectations of motherhood played a role in young women's deaths by suicide. I question the notion that motherhood is a "protective" factor against suicide. Using the concept of "intensive motherhood," I interrogate how expectations of mothers became fatal. Through analysis of 31 young Australian mothers who died by suicide, three key themes are explored, centered upon the theme of "failing motherhood": mothering without a father, mothering with mental illness, and the loss of care of children.

Non-specialist delivered psycho-social interventions for women with perinatal depression living in rural communities: A systematic review

Evidence from low- and middle-income countries suggests that non-specialist-delivered interventions effectively improve access to perinatal mental health care. However, there have been no systematic attempts to synthesize the evidence on effectiveness, relevance, and application of this strategy to resource-limited settings such as rural areas. The aim of this review is to synthesize the evidence about the effectiveness of non-specialist delivered interventions in improving depression and related outcomes in women with perinatal depression living in rural communities. Seven electronic databases were searched using the following search concepts: perinatal depression (e.g., puerperal depression, antenatal depression), rural areas (e.g., remote, nonmetropolitan, underserved), and non-specialist workers (e.g., lay worker, volunteer aide, informal caretaker. The risk of bias was assessed using RoB-2 and ROBINS-I tools. A narrative synthesis was performed as the high degree of study heterogeneity precluded a meta-analysis. Nine unique studies were eligible for inclusion. Psychoeducation and problem-solving techniques were the most used intervention elements. Two interventions significantly reduced the prevalence of perinatal depression compared to usual care, and three interventions reported effectiveness in reducing depression symptom severity. There was little to no consistent evidence for other outcomes, including but not limited to maternal health care utilization, breastfeeding behaviors, and child health. This review provides limited evidence to suggest that non-specialist delivered interventions effectively improved outcomes among women with perinatal depression living in rural communities. The paucity of high-quality studies included in this review demonstrates that this rural demographic is frequently neglected in the context of maternal mental health research.

Investigating the association between metabolic syndrome conditions and perinatal mental illness: a national administrative claims study

BACKGROUND

Although the association between mental disorder and metabolic syndrome as a bidirectional relationship has been demonstrated, there is little knowledge of the cumulative and individual effect of these conditions on peripartum mental health. This study aims to investigate the association between metabolic syndrome conditions (MetS-C) and maternal mental illness in the perinatal period, while exploring time to incident mental disorder diagnosis in postpartum women.

METHODS

This observational study identified perinatal women continuously enrolled 1 year prior to and 1 year post-delivery using Optum's de-identified Clinformatics® Data Mart Database (CDM) from 2014 to 2019 with MetS-C i.e. obesity, diabetes, high blood pressure, high triglycerides, or low HDL (1-year prior to delivery); perinatal comorbidities (9-months prior to and 4-month postpartum); and mental disorder (1-year prior to and 1-year post-delivery). Additionally, demographics and the number of days until mental disorder diagnosis were evaluated in this cohort. The analysis included descriptive statistics and multivariable logistic regression. MetS-C, perinatal comorbidities, and mental disorder were assessed using the International Classification of Diseases, Ninth, and Tenth Revision diagnosis codes.

RESULTS

372,895 deliveries met inclusion/exclusion criteria. The prevalence of MetS-C was 13.43%. Multivariable logistic regression revealed prenatal prevalence (1.64, CI = 1.59-1.70) and postpartum incident (1.30, CI = 1.25-1.34) diagnosis of mental health disorder were significantly higher in those with at least one MetS-C. Further, the adjusted odds of having postpartum incident mental illness were 1.51 times higher (CI = 1.39-1.66) in those with 2 MetS-C and 2.12 times higher (CI = 1.21-4.01) in those with 3 or more MetS-C. Young women (under the age of 18 years) were more likely to have an incident mental health diagnosis as opposed to other age groups. Lastly, time from hospital discharge to incident mental disorder diagnosis revealed an average of 157 days (SD = 103 days).

CONCLUSION

The risk of mental disorder (both prenatal and incident) has a significant association with MetS-C. An incremental relationship between incident mental illness diagnosis and the number of MetS-C, a significant association with younger mothers along with a relatively long period of diagnosis mental illness highlights the need for more screening and treatment during pregnancy and postpartum.

Suicide Mortality During the Perinatal Period

Importance

The US has the highest maternal mortality rate among developed countries. The Centers for Disease Control and Prevention deems nearly all of these deaths preventable, especially those attributable to mental health conditions. Coordination between US health care and social service systems could help further characterize circumstances and risks associated with perinatal suicide mortality.

Objective

To examine contextual and individual precipitating circumstances and risks associated with perinatal suicide.

Design, Setting, and Participants

This cross-sectional observational study used a convergent mixed methods design to explore factors contributing to maternal suicides and deaths of undetermined intent (hereinafter, undetermined deaths) identified in National Violent Death Reporting System (NVDRS) data for January 1, 2003, to December 31, 2021. Analyses included decedents who were aged 10 to 50 years and pregnant or post partum at death (collectively, the perinatal group) and demographically matched female decedents who were not pregnant or recently pregnant (nonperinatal group) at death. Analyses were performed between December 2022 and December 2023.

Exposures

Pregnancy status at death (perinatal or nonperinatal).

Main Outcomes and Measures

The main outcomes included contributing circumstances associated with suicides and undetermined deaths cited in coroner, medical examiner, or law enforcement case narratives. The study examined quantitative differences between groups using a matched analysis and characterized key themes of salient suicide circumstances using qualitative content analysis.

Results

This study included 1150 perinatal decedents identified in the NVDRS: 456 (39.6%) were pregnant at death, 203 (17.7%) were pregnant within 42 days of death, and 491 (42.7%) were pregnant within 43 to 365 days before death, yielding 694 postpartum decedents. The nonperinatal comparison group included 17 655 female decedents aged 10 to 50 years. The mean (SD) age was 29.1 (7.4) years for perinatal decedents and 35.8 (10.8) years for nonperinatal decedents. Compared with matched nonperinatal decedents, perinatal decedents had higher odds of the following identified contributing circumstances: intimate partner problems (IPPs) (odds ratio [OR], 1.45 [95% CI, 1.23-1.72]), recent argument (OR, 1.33 [95% CI, 1.09-1.61]), depressed mood (OR, 1.39 [95% CI, 1.19-1.63]), substance abuse or other abuse (OR, 1.21 [95% CI, 1.03-1.42]), physical health problems (OR, 1.37 [95% CI, 1.09-1.72]), and death of a family member or friend (OR, 1.47 [95% CI, 1.06-2.02]). The findings of the qualitative analysis emphasized the importance of mental health and identified 128 decedents (12.4%) with postpartum depression.

Conclusions and Relevance

This study provides insights into complex factors surrounding maternal suicide, and it highlights opportunities for further research to understand long-term consequences of perinatal mental health. These findings also underscore the need for targeted evidence-based interventions and effective policies targeting mental health, substance use, and IPPs to prevent maternal suicide and enhance maternal health outcomes.

Evaluating cognitive behavioral therapy as a solution for postnatal depression in economically disadvantaged regions

PURPOSE

Postnatal depression (PND) impacts numerous women after childbirth, leading to various impairments in their lives. Mental health interventions, such as cognitive behavioral therapy (CBT), need further evaluation in low- and middle-income countries (LMICs) where resources may be scarce. This study aimed to assess the effectiveness of CBT in treating PND in women from LMICs, comparing it to standard care.

METHODS

A systematic review and meta-analysis were conducted following the PRISMA Statement 2020 guidelines. Databases such as PubMed, CINAHL Plus, Cochrane Library, and PsycINFO were searched until September 2022. A modified Delphi process was employed to identify relevant studies. The primary outcome was mean depression scores, measured by the Edinburgh postnatal depression scale at baseline and post-intervention.

RESULTS

Out of 487 studies identified, five trials were included, totaling 1056 participants (520 in the intervention group and 536 in the comparator group). At baseline, a minor, insignificant positive effect size was found (Cohen's d = 0.1, 95% CI =  - 0.15, 0.35). Post-CBT, the intervention group showed significant improvements in depression scores (Cohen's d =  - 1.9, 95% CI =  - 3.8, 0). When accounting for the influence of one study, (Ngai et al., Psychother Psychosom 84:294-303, 2015), which held substantial weight in the initial analysis, the effect size was adjusted to d = 0.5, highlighting a lesser but still significant difference.

CONCLUSIONS

CBT appears to be effective in improving PND symptoms among women in LMICs and may be considered a first-line treatment for at-risk mothers, including those who are displaced. However, the significant impact of one study on the results emphasizes the need for more rigorous research. The study also highlights the challenges and limitations of providing psychotherapies across LMICs, emphasizing the need for culturally adapted and contextually appropriate interventions to ensure successful implementation and sustainability of mental health care for postnatal women in these settings.

Mindfulness in Pregnancy and Postpartum: Protocol of a Pilot Randomized Trial of Virtually Delivered Mindfulness-Based Cognitive Therapy to Promote Well-Being during the Perinatal Period

BACKGROUND

During the period from pregnancy through the first year postpartum, vulnerable individuals are at elevated risk for the onset or worsening of psychological distress, and accessible (e.g., virtually delivered) mental health interventions are needed. Research suggests that Mindfulness-Based Cognitive Therapy (MBCT) can effectively mitigate psychological distress, although few studies have evaluated MBCT in the perinatal period, and samples have been clinically homogenous. Thus, we have designed and are conducting a pilot trial of virtually delivered MBCT with pregnant individuals experiencing a range of psychological symptoms to assess its feasibility and preliminarily explore its effectiveness. Here, we present the study protocol.

METHODS

Eligible participants (target N = 70) are ≥18 years with pregnancies between 12 and 30 weeks of gestation. Participants complete a diagnostic interview, self-report symptom ratings, and a computerized cognitive battery assessing self-regulation at the baseline. Participants are then randomized to either MBCT or care as usual. The MBCT intervention involves eight weekly group sessions delivered virtually, with each session focusing on a mindfulness practice followed by group discussion and skill development. Participants in the intervention group are also encouraged to practice mindfulness skills between sessions. Participants in the control condition are provided with information about mindfulness and treatment resources. Baseline measures are repeated following the eight-week intervention period and at three months postpartum.

CONCLUSIONS

This pilot study is designed to evaluate the feasibility of virtually delivered MBCT and explore group differences in psychological symptoms during the perinatal period, and will lay the foundation for a larger clinical trial focused on optimizing this intervention to improve psychological functioning among diverse pregnant individuals.

Effect of intraoperative and/or postoperative esketamine administration on preventing postpartum depression: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the impact of intraoperative and/or postoperative esketamine application on the prevention of postpartum depression (PPD). PubMed, Embase, and Web of Science were thoroughly searched for eligible randomized controlled trials (RCTs) regarding the application of esketamine for postnatal depression prevention. Nine RCTs including 1277 participants were involved in the final analysis. It was found that intraoperative and/or postoperative administration of esketamine significantly reduced the PPD incidence and the Edinburgh Postnatal Depression Scores in the early postoperative period. Meanwhile, esketamine lowered the occurrence of postoperative nausea and vomiting with no influence on other psychiatric symptoms.

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.

Integrating Mental Health In Perinatal Care: Perspectives Of Interprofessional Clinicians

Despite the prevalence of perinatal mental health issues in the United States, gaps in care persist. To address this, perinatal health care settings are asked to focus on patients' mental health by administering standardized screening and, increasingly, by integrating mental health teams in their clinics. Using in-depth interviews and ethnographic observations, I investigated these emerging practices, exploring the experiences of certified nurse-midwives, obstetricians, and mental health clinicians. I found that certified nurse-midwives and obstetricians lack time, resources, and expertise, restricting their ability to address patients' mental health. Integrated mental health clinicians are constrained by the stratified organization of health care and structural deprioritization of mental health. Redesigning perinatal health care and de-siloing mental health training are necessary to increase clinicians' effectiveness and to improve perinatal health outcomes.

Diagnosis of peripartum depression disorder: A state-of-the-art approach from the COST Action Riseup-PPD

BACKGROUND

Peripartum depression (PPD) is a major depression disorder (MDD) episode with onset during pregnancy or within four weeks after childbirth, as defined in DSM-5. However, research suggests that PPD may be a distinct diagnosis. The goal of this study was to summarize the similarities and differences between PPD and MDD by synthesizing the current research on PPD diagnosis concerning different clinical features and give directions for improving diagnosis of PPD in clinical practice.

METHODS

To lay the groundwork for this narrative review, several databases were searched using general search phrases on PPD and its components of clinical diagnosis.

RESULTS

When compared to MDD, peripartum depression exhibits several distinct characteristics. PPD manifests with a variety of symptoms, i.e., more anxiety, psychomotor symptoms, obsessive thoughts, impaired concentration, fatigue and loss of energy, but less sad mood and suicidal ideation, compared to MDD. Although PPD and MDD prevalence rates are comparable, there are greater cross-cultural variances for PPD. Additionally, PPD has some distinct risk factors and mechanisms such as distinct ovarian tissue expression, premenstrual syndrome, unintended pregnancy, and obstetric complications.

CONCLUSION

There is a need for more in-depth research comparing MDD with depression during pregnancy and the entire postpartum year. The diagnostic criteria should be modified, particularly with (i) addition of specific symptoms (i.e., anxiety), (ii) onset specifier extending to the first year following childbirth, (iii) and change the peripartum onset specifier to either "pregnancy onset" or "postpartum onset". Diagnostic criteria for PPD are further discussed.

Extended Postpartum Medicaid In Colorado Associated With Increased Treatment For Perinatal Mood And Anxiety Disorders

Perinatal mood and anxiety disorders (PMAD), a leading cause of perinatal morbidity and mortality, affect approximately one in seven births in the US. To understand whether extending pregnancy-related Medicaid eligibility from sixty days to twelve months may increase the use of mental health care among low-income postpartum people, we measured the effect of retaining Medicaid as a low-income adult on mental health treatment in the postpartum year, using a "fuzzy" regression discontinuity design and linked all-payer claims data, birth records, and income data from Colorado from the period 2014-19. Relative to enrolling in commercial insurance, retaining postpartum Medicaid enrollment was associated with a 20.5-percentage-point increase in any use of prescription medication or outpatient mental health treatment, a 16.0-percentage-point increase in any use of prescription medication only, and a 7.3-percentage-point increase in any use of outpatient mental health treatment only. Retaining postpartum Medicaid enrollment was also associated with $40.84 lower out-of-pocket spending per outpatient mental health care visit and $3.24 lower spending per prescription medication for anxiety or depression compared with switching to commercial insurance. Findings suggest that extending postpartum Medicaid eligibility may be associated with higher levels of PMAD treatment among the low-income postpartum population.

[Maternal mortality due to suicide and other psychiatric causes in France 2016-2018]

This report, covering the period 2016-2018, confirms that psychiatric causes (largely dominated by suicides) are the leading cause of maternal mortality up to 1year after childbirth, a finding already made in the previous 2013-2015 report. There were 47 deaths from psychiatric causes in 3years, including 45 maternal suicides, giving a maternal mortality ratio (MMR) of 2.1 per 100,000 live births (NV) (95% CI: 1.4-2.6). The median time to suicide was 138days postpartum. This group represents 17.3% (16.5% for suicides) of all maternal deaths for the period. Maternal suicide is linked to an interaction of several risk factors, including a history of personal and family psychiatric disorders not always known to the obstetric team (53% of women), socioeconomic disparities (29% present social vulnerability, and 14% domestic violence), stressful events, and inadequate access to healthcare services. Psychiatric causes are among those in which the proportion of sub-optimal care and preventable deaths, i.e. 79% of cases, are the highest. An analysis of all the women who died in France of psychiatric causes during pregnancy reveals a number of recurring elements that point to the need for improvement, both in terms of the quality and organization of care, and in terms of women's interaction with the healthcare system. Screening for a history of psychiatric disorders and ongoing psychiatric pathologies must be carried out systematically at all stages of pregnancy and postpartum by all those involved, with communication with future parents on the not inconsiderable risk of perinatal depression. Finally, it is important to develop an adapted and graduated response across the country, according to resources, and to strengthen city-hospital collaboration and training for all those involved.

Maternal Deaths Using Coroner's Data: A Latent Class Analysis

OBJECTIVE

Knowledge regarding the antecedent clinical and social factors associated with maternal death around the time of pregnancy is limited. This study identified distinct subgroups of maternal deaths using population-based coroner's data, and that may inform ongoing preventative initiatives.

METHODS

A detailed review of coroner's death files was performed for all of Ontario, Canada, where there is a single reporting mechanism for maternal deaths. Deaths in pregnancy, or within 365 days thereafter, were identified within the Office of the Chief Coroner for Ontario database, 2004-2020. Variables related to the social and clinical circumstances surrounding the deaths were abstracted in a standardized manner from each death file, including demographics, forensic information, nature and cause of death, and antecedent health and health care factors. These variables were then entered into a latent class analysis (LCA) to identify distinct types of deaths.

RESULTS

Among 273 deaths identified in the study period, LCA optimally identified three distinct subgroups, namely, (1) in-hospital deaths arising during birth or soon thereafter (52.7% of the sample); (2) accidents and unforeseen obstetric complications also resulting in infant demise (26.3%); and (3) out-of-hospital suicides occurring postpartum (21.0%). Physical injury (22.0%) was the leading cause of death, followed by hemorrhage (16.8%) and overdose (13.3%).

CONCLUSION

Peri-pregnancy maternal deaths can be classified into three distinct sub-types, with somewhat differing causes. These findings may enhance clinical and policy development aimed at reducing pregnancy mortality.

Insomnia, poor sleep quality and perinatal suicidal risk: A systematic review and meta-analysis

Suicidal risk in mothers is a public health priority. Risk factors include biological, psychological and psychosocial factors. Among the biological factors, the role of sleep disturbances as potential contributors to increased suicidal risk during the peripartum period is becoming apparent. To explore this further, we conducted a systematic review following the PRISMA criteria. Currently, 10 studies have examined the role of insomnia and poor sleep quality in suicidal risk during the peripartum period and have involved 807,760 women. The data showed that disturbed sleep and poor sleep quality increase the risk of suicidal ideation in both pregnant women with and without perinatal depression. The results of the meta-analysis indicated that insomnia and poor sleep quality increase the odds of suicidal risk in pregnant women by more than threefold (OR = 3.47; 95% CI: 2.63-4.57). Specifically, the odds ratio (OR) for poor sleep quality was 3.72 (95% CI: 2.58-5.34; p < 0.001), and for insomnia symptoms, after taking into account perinatal depression, was 4.76 (95% CI: 1.83-12.34; p < 0.001). These findings emphasise the importance of assessing and addressing sleep disturbances during the peripartum period to mitigate their adverse effects on peripartum psychopathology and suicidal risk.

Does preterm birth increase the initiation of antidepressant use during the postpartum? A population-based investigation

Background

Preterm birth may affect maternal mental health. We explored the relationship between preterm birth and the risk of initiating antidepressant use during the year after birth.

Methods

We conducted a population-based investigation using regional healthcare utilization databases. The exposure considered was preterm birth. The outcome was having at least one prescription for antidepressant medications during the year after birth. We used a log-binomial regression model including terms for maternal age at birth, nationality, educational level, parity, modality of conception, modality of delivery, use of other psychotropic drugs, and diabetes to estimate relative risk (RR) and 95% confidence intervals (CI) for the association between preterm birth and the initiation of antidepressant use. In addition, the absolute risk differences (ARD) were also computed according to the timing of birth.

Results

The cohort included 727,701 deliveries between 2010 and 2020 in Lombardy, Northern Italy. Out of these, 6,522 (0.9%) women had at least one prescription for antidepressant drugs during the year after birth. Preterm births were related to a 38% increased risk of initiation of antidepressant use during the year after birth (adjusted RR = 1.38; 95% CI: 1.25-1.52) for moderate to late preterm and to 83% (adjusted RR = 1.83; 95% CI: 1.46-2.28) for extremely and very preterm. Excluding women with only one antidepressant prescription, the association was consistent (adjusted RR = 1.41, 95%CI: 1.23-1.61 for moderate to late preterm and adjusted RR = 1.81, 95% CI: 1.31-2.49 for extremely and very preterm). Also, excluding women who used other psychotropics, the association remained consistent (adjusted RR = 1.39, 95%CI: 1.26-1.54 and adjusted RR = 1.91, 95% CI: 1.53-2.38, respectively for moderate to late and extremely and very preterm).

Conclusion

Women who delivered preterm may have an excess risk of initiation of antidepressant consumption during the first year after birth.

Evaluation of a pilot online education program to develop midwives' knowledge, skill and confidence in perinatal mental health in rural South Australia

One in five women will experience perinatal anxiety and/or depression. In South Australia, a rural health service identified a high proportion of women with risk of perinatal mental health challenges and sought additional education for midwives. In response, a six-week facilitated, online perinatal mental health education program (e-PMHEP) was piloted.

AIM

The aim of this study was to evaluate the effectiveness of the (e-PMHEP) for rural midwives, nurses and Aboriginal maternal infant care practitioners.

METHOD

Program evaluation incorporated a validated online pre/post survey to assess self-reported knowledge, skill and confidence regarding perinatal mental healthcare. Additional questions sought feedback on satisfaction and feasibility.

FINDINGS

Sixteen participants from rural South Australia engaged in the project from June to August 2022. Twelve participants completed the online pre/post survey. The overall pre/post knowledge scores were statistically significant (t = 2.73, 8df, p = 0.025) with improvement from the pre to post-test. Pre/post data also showed a measurable increase in confidence and skills. All respondents agreed that the content addressed their learning needs and would recommend this program to other practitioners.

DISCUSSION

The e-PMHEP appeared beneficial in developing knowledge, skills and confidence regarding perinatal mental healthcare in rural midwives and practitioners. Only a third of practitioners routinely developed a mental health care plan with women. Key strengths of the program included the accessible content, and the combination of an experienced mental health clinician and a facilitator with lived experience.

CONCLUSION

Providing an accessible, facilitated online perinatal mental health education program could be beneficial for rural midwives.

The lived experiences of individuals with postpartum psychosis: A qualitative analysis

Postpartum psychosis (PP) is a severe psychiatric illness that occurs in about 1 to 2 per 1000 people in the perinatal period. To date, qualitative research investigating PP has focused on specific topics, such as treatment experiences or the impact of the illness on patients' lives and families. These studies have included small samples of women with histories of PP, often limited to certain geographical areas or treatment centers. Given the heterogeneity in presentations of PP and access to care, larger and geographically diverse samples are needed to broadly understand this complex illness. Initiated in 2018, the Massachusetts General Hospital Postpartum Psychosis Project (MGHP3) consists of a large, international sample of those who have experienced PP. In addition to the specific aims of MGHP3, which include to better understand the phenomenology and potential genetic underpinnings of PP, this investigation invites participants to qualitatively describe their narratives of postpartum psychosis. This analysis included 130 participants who reported on 133 episodes of PP. Participants' responses to the PP narrative prompt fell under several overarching categories: 1) broad psychosocial experiences surrounding postpartum psychosis, 2) impact on the mother-baby dyad, 3) treatment experiences, and 4) recovery experiences. Our findings shed light on a range of ways in which individuals' lives are impacted by this illness, and point to areas for future research and clinical directions to improve the support and care for individuals with PP and their families.

Perinatal depression and risk of mortality: nationwide, register based study in Sweden

OBJECTIVE

To determine whether women with perinatal depression are at an increased risk of death compared with women who did not develop the disorder, and compared with full sisters.

DESIGN

Nationwide, register based study.

SETTING

Swedish national registers, 1 January 2001 to 31 December 2018.

PARTICIPANTS

86 551 women with a first ever diagnosis of perinatal depression ascertained through specialised care and use of antidepressants, and 865 510 women who did not have perinatal depression were identified and matched based on age and calendar year at delivery. To address familial confounding factors, comparisons were made between 270 586 full sisters (women with perinatal depression (n=24 473) and full sisters who did not have this disorder (n=246 113)), who gave at least one singleton birth during the study period.

MAIN OUTCOME MEASURES

Primary outcome was death due to any cause. Secondary outcome was cause specific deaths (ie, unnatural and natural causes). Multivariable Cox regression was used to estimate hazard ratios of mortality comparing women with perinatal depression to unaffected women and sisters, taking into account several confounders. The temporal patterns of perinatal depression and differences between antepartum and postpartum onset of perinatal depression were also studied.

RESULTS

522 deaths (0.82 per 1000 person years) were reported among women with perinatal depression diagnosed at a median age of 31.0 years (interquartile range 27.0 to 35.0) over up to 18 years of follow-up. Compared with women who did not have perinatal depression, women with perinatal depression were associated with an increased risk of death (adjusted hazard ratio 2.11 (95% confidence interval 1.86 to 2.40)); similar associations were reported among women who had and did not have pre-existing psychiatric disorder. Risk of death seemed to be increased for postpartum than for antepartum depression (hazard ratio 2.71 (95% confidence interval 2.26 to 3.26) v 1.62 (1.34 to 1.94)). A similar association was noted for perinatal depression in the sibling comparison (2.12 (1.16 to 3.88)). The association was most pronounced within the first year after perinatal depression but remained up to 18 years after start of follow up. An increased risk was associated with both unnatural and natural causes of death among women with perinatal depression (4.28 (3.44 to 5.32) v (1.38 (1.16 to 1.64)), with the strongest association noted for suicide (6.34 (4.62 to 8.71)), although suicide was rare (0.23 per 1000 person years).

CONCLUSIONS

Even when accounting for familial factors, women with clinically diagnosed perinatal depression were associated with an increased risk of death, particularly during the first year after diagnosis and because of suicide. Women who are affected, their families, and health professionals should be aware of these severe health hazards after perinatal depression.

A hybrid effectiveness-implementation trial of application-based tiered care (Mom's Good Mood) in treating perinatal anxiety within a primary health care system in China

INTRODUCTION

Perinatal anxiety (PNA) is a major public health concern.

METHODS

A hybrid effectiveness-implementation trial was conducted in two antenatal clinics in Hefei, China, to assess the effectiveness and cost-effectiveness of application-based tiered care (Mom's Good Mood, MGM) in treating PNA and to understand how well it fits into routine practices. Pregnant women who scored at least 5 points on the 7-Item Generalised Anxiety Disorder Scale (GAD-7) scale were successively assigned to the control group or the intervention group, which were given the usual care and MGM on usual care, respectively. At 6 months post partum, anxiety, depression and life satisfaction were assessed. Intention-to-treat analysis and the Reach, Effectiveness, Adoption, Implementation and Maintenance framework were adopted.

RESULTS

A total of 214 women were assigned to the control group and 341 to the intervention group. The mean changes in GAD-7 scores (Least-squares means, LSM, -1.42, 95% CI -2.18 to -0.66) and the risk of anxiety (adjusted odds ratio, aOR 0.30, 95% CI 0.18 to 0.51) were decreased, and the anxiety remission rate (aOR 2.72, 95% CI 1.69 to 4.40) were improved in the intervention group. Similar findings were observed regarding the change in Edinburgh Postnatal Depression Scale scores (LS -1.92, 95% CI -2.85 to -0.99), depression remission rate (aOR 2.24, 95% CI 1.39 to 3.63) and the risk of depression (aOR 0.57, 95% CI 0.33 to 0.98). MGM only costs ¥1.88 (US$0.27) per pregnant woman to boost the postpartum anxiety remission rate by 1% and was revealed to have a high reach rate of 78.3%, an adoption rate of 51.3%-80.8%.

CONCLUSION

MGM is a cost-effective and accessible tool in coping with PNA.

TRIAL REGISTRATION NUMBER

ChiCTR2100053419.

The efficacy of zuranolone in postpartum depression and major depressive disorder: a review & number needed to treat (NNT) analysis

INTRODUCTION

Major depressive disorder (MDD) is a common and debilitating mental illness. Postpartum depression (PPD) impacts women globally and is one of the most common complications of childbirth that is underdiagnosed and undertreated, adversely impacting the mental health of women, children, and partners.Available antidepressant medications require weeks to months before showing effect. In this setting, zuranolone, an oral neuroactive steroid and a positive allosteric modulator of GABAA receptors, is an attractive alternative as a rapid-acting antidepressant treatment.

AREAS COVERED

This article reviews zuranolone (SAGE217), focusing on available clinical studies in individuals with PPD and MDD. This paper adds to the extant literature by presenting the efficacy data as Number Needed to Treat (NNT) to facilitate indirect comparisons with other antidepressants.

EXPERT OPINION

Zuranolone is a novel rapid-acting (i.e. two week course) oral antidepressant for the treatment of adults with PPD with ongoing clinical trials evaluating its efficacy in adults with MDD. Zuranolone is well tolerated with no significant safety concerns in any clinical trials completed to date. Zuranolone will be scheduled by the Drug Enforcement Agency (DEA).

Improving maternal mental health: assessing the extent of screening and training about peripartum depression

OBJECTIVE

Peripartum depression (PPD) is a common mental health complication of pregnancy and increases risk for maternal mortality and poorer outcomes for children. Despite its importance, screening rates vary across organizations and care team members. The goal of the current study was to explore the perspectives from care team members in both behavioral health and acute care settings about how they screen and refer pregnant and post pregnant women for PPD, what training around PPD is currently offered by their organization, and if they could benefit from additional PPD training.

METHODS

Data were collected from an online self-report survey of care team members from behavioral health and acute care settings in the US. Questions focused on (1) when/if the care teams had a screening protocol for PPD, (2) beliefs about the efficacy of their organization's PPD screening, identification, and referral process, and (3) if their organization currently offered or needed training around the topic of PPD.

RESULTS

A total of 794 care team members in behavioral health and acute care responded to the survey between December 2021 and May 2022. Nearly, all (96.7%) reported having a specific protocol for screening for PPD when they know a patient is pregnant; however, only 69.6% of respondents routinely screen regardless of symptoms being reported by the patient. While 93.3% of the sample believed their organization does a good job screening for and identifying PPD, gaps in the referral processes were described, especially in acute settings. 95.3% of the sample reported their organization currently gives training in screening, identifying, or treating PPD or in the process for establishing outpatient referrals for PPD care for care team members who have direct contact with pregnant patients; however, 96.5% also reported their organization would benefit from additional training in one or more of these areas.

CONCLUSION

High rates of self-reported PPD screening and training indicate that care team members in both behavioral health and acute care are aware of the importance of maternal mental health issues. However, other research indicates that high rates of screening may not lead to improved outcomes, and there are still high rates of maternal suicide and suicidal ideation in the US. It is possible that high self-reported screening rates may indicate a false sense of security such that care team members feel the issue is addressed while problems remain. Alternatively, many respondents felt their organizations would benefit from further training, perhaps indicating an awareness of this gap. Care team members in behavioral health and acute care settings should increase collaboration to ensure high rates of screening lead to improved maternal mental health care.