Rapid repeat pregnancy in women with schizophrenia

Experiences of Sexual and Reproductive Health Care Access for Women and Nonbinary People With Early Psychosis: Towards an Integrated Perspective of Service Users and Clinicians

OBJECTIVE

Individuals with psychosis are at elevated risk of adverse sexual and reproductive health (SRH) outcomes, and not receiving adequate SRH care. SRH is important for youth, yet little is known about SRH care access and experiences among those with early psychosis. This study explored SRH care experiences among women and nonbinary individuals with early psychosis.

METHOD

We conducted semistructured qualitative interviews with 19 service users (cisgender and transgender women, nonbinary individuals) receiving care in 2 early psychosis programs in Ontario, Canada. We also conducted semistructured interviews and focus groups with 36 clinicians providing SRH or mental health care to this population. Participants were asked about SRH care access/provision experiences and the interplay with psychosis. Using a social interactionist orientation, a thematic analysis described and explained service user and clinician perspectives regarding SRH care.

RESULTS

Amongst both service users and clinician groups, common themes developed: (a) diversity of settings: SRH services are accessed in a large range of spaces across the health care system, (b) barriers in nonpsychiatric SRH care settings: psychosis impacts the ability to engage with existing SRH services, (c) invisibility of SRH in psychiatric settings: SRH is rarely addressed in psychiatric care, (d) variability of informal SRH-related conversations and supports, and cutting across all of the above themes, (e) intersecting social and cultural factors impacted SRH services access.

CONCLUSIONS

SRH is important for health and wellbeing; improvements are urgently needed across the healthcare system and within early psychosis programs to meet this population's multifaceted SRH needs.

Reproductive Health Among Those with Schizophrenia Spectrum Disorders: An Overview of Considerations Related to the Premenopausal Period, Pregnancy and Postpartum, and the Menopausal Transition, with a Focus on Recent Findings

PURPOSE OF REVIEW

Schizophrenia spectrum disorders (SSD) impact many aspects of reproductive health for women and non-binary and transgender individuals assigned female at birth. In this narrative review, we highlight considerations and recent research related to (1) the premenopausal period, (2) pregnancy and postpartum, and (3) the menopausal transition.

RECENT FINDINGS

Most recent research has focused on pregnancy and the postpartum period, and specifically on elucidating perinatal risk factors, adverse obstetrical and neonatal outcomes (and modifiable contributors such as smoking), long-term child health, and psychotropic medications (with reassuring results related antipsychotic-associated gestational diabetes mellitus and neurodevelopmental outcomes). Much less recent focus has been on menstruation and menopause, although some research has highlighted the relative worsening of illness peri-menstrually and peri-menopausally. Despite the many important reproductive considerations for those with SSD, many aspects including menstruation and menopause have received very little attention. Further research is needed on how to best support women, non-binary, and transgender people assigned female at birth with SSD throughout the lifespan.

Adverse perinatal pregnancy outcomes in women with schizophrenia: A systematic review and meta-analysis

INTRODUCTION

Schizophrenia is a severe mental illness that affects a significant proportion of the global population, particularly those of childbearing age. Several studies have attempted to find an association between schizophrenia and obstetric complications, with varying results.

OBJECTIVE

The primary objective of this systematic review and meta-analyses was to summarize the relationship between maternal schizophrenia and perinatal pregnancy outcomes.

DATA SOURCES

PubMed, Web of Science and Ovid EMBASE were searched from January 2001 to September 2022 using keywords related to pregnancy, women, schizophrenia.

STUDY SELECTION

A total of 23 independent studies across 21,253 individuals with schizophrenia were identified and included in the analysis.

DATA EXTRACTION

The following data were extracted: author, year of publication, country/continent of data collection, study design, demographic characteristics, diagnoses criteria, related complications. Data were analyzed using random-effects pairwise meta-analysis and were reported as prevalence and odd ratios (OR). Statistical heterogeneity was quantified with the I2 statistic.

RESULTS

The prevalence of adverse perinatal pregnancy outcomes was represented in descending order: cesarean section (26.0 %); labor induction (24.0 %); small for gestational age (10.5 %); gestational diabetes mellitus (9.2 %); preterm birth (9.1 %); low birth weight (7.8 %); preterm rupture of membranes (6.1 %); 1-Minute Apgar Score < 7 (5.6 %); large for gestational age (5.5 %); birth defect (5.4 %); antepartum hemorrhage (4.4 %);preeclampsia/eclampsia (4.8 %); postpartum hemorrhage (3.9 %); 5-Minute Apgar Score < 7 (3.6 %); gestational hypertension (3.3 %); placental abruption (1.0 %); placenta previa (0.6 %); thromboembolic disease (0.4 %); neonatal mortality (0.3 %) (P ≤ 0.05). There was a higher risk of adverse outcomes including gestational diabetes mellitus, preeclampsia/eclampsia, placental abruption, thromboembolic disease, preterm birth, birth defect, 1-Minute Apgar score < 7, small for gestational age, low birth weight and neonatal mortality compared with non-schizophrenia population (P ≤ 0.05).

CONCLUSIONS

Women with schizophrenia are at higher risk of adverse perinatal pregnancy outcomes. It is imperative that research efforts continue to focus on the reproductive safety of women with schizophrenia during their childbearing years.

Long-acting injectable antipsychotic treatment during pregnancy: Outcomes for women at a tertiary maternity hospital

Our study aimed to examine pregnancy, neonatal and psychosocial outcomes for women treated with LAIs at tertiary maternity hospital. A retrospective review of all women who were treated with LAIs between 1999 and 2017. Cases were identified via the hospital dispensary system and outcome data were extracted case notes as well as the midwifery notification system. Measures included sociodemographic data, smoking, alcohol and illicit substance use, pregnancy complications such as gestational diabetes, and neonatal outcomes. Psychosocial profiles such as psychiatric admission during pregnancy and statutory child protection involvement were also assessed. Where available, outcomes were compared with state population data. The study found 38 pregnancies to 36 women, who had LAI treatment. Two congenital malformations (5.7%) were recorded. Compared to general population data, pregnant women treated with LAIs were more likely to have obstetric complications including gestational diabetes and pregnancy hypertension and special care nursery admission for their babies. They also had elevated rates of psychiatric admissions during pregnancy and statutory child protection involvement. Outcomes were similar first and second generation LAIs exposure. As women on LAI have limited options for treatment of their psychotic disorders, the findings point towards a need for enhanced multidisciplinary pregnancy care for this vulnerable cohort.

Serious mental illness in women

PURPOSE OF REVIEW

Psychiatric illnesses are very prevalent in the United States and impact women and men differently. In this review, we will explore some gender differences in the expression of psychopathology, discuss the most common serious mental illnesses (SMI) affecting women, and review treatment options according to specific life stages. We hope to raise awareness of these issues and consequently improve outcomes for women with serious mental illness.

RECENT FINDINGS

SMI have different rates and are manifested differently in women and men because of biological, psychological, social, and cultural factors. Some SMI are more prevalent in women whereas others uniquely affect them during particular life stages. Even in disorders that have a similar prevalence in men and women or are more prevalent in men, the presentation, course, management, and repercussions can vary significantly between the two genders. Medical and psychiatric comorbidities, which directly influence treatment, prognosis, and disability, are more common in women.

SUMMARY

Several differences in the gender expression of SMI have not yet been fully described. It is important to become familiar with important characteristics of SMI in women, including biological determinants, treatment differences, and psychosocial aspects. Recognizing gender biases, cultural considerations, and adaptive responses can help identify women at risk, promote early recognition of symptoms, and prompt interventions that may lead to improved outcomes.

Towards better care for women with schizophrenia-spectrum disorders

Women with a schizophrenia-spectrum disorder (SSD) have a better clinical profile than do men at the start of their illness but progress to the same state within the first few years of living with SSD. There are benefits to be gained across different areas in the care currently offered to women with psychosis. An important point for improvement is the early detection of female-specific signs of a first episode of psychosis, to shorten the duration of untreated psychosis, with prompt access to early intervention services. Special attention should be paid to sexual health, and to any history of childhood trauma. Antipsychotics require dosing and prescription tailored to the female physiology that consider hormonal life phases such as menopause. Switching to prolactin-sparing medications can benefit both mental and somatic health. Finally, hormone replacement therapy should be considered for postmenopausal women. By providing female-specific care, women with schizophrenia-spectrum disorders will have optimal chances to fare well.

Psychiatric vulnerability and the risk for unintended pregnancies, a systematic review and meta-analysis

Background

Unintended pregnancies (UPs) are a global health problem as they contribute to adverse maternal and offspring outcomes, which underscores the need for prevention. As psychiatric vulnerability has previously been linked to sexual risk behavior, planning capacities and compliance with contraception methods, we aim to explore whether it is a risk factor for UPs.

Methods

Electronic databases were searched in November 2020. All articles in English language with data on women with age ≥ 18 with a psychiatric diagnosis at time of conception and reported pregnancy intention were included, irrespective of obstetric outcome (fetal loss, livebirth, or abortion). Studies on women with intellectual disabilities were excluded. We used the National Institutes of Health tool for assessment of bias in individual studies and the Grading of Recommendations Assessment, Development and Evaluation method for assessment of quality of the primary outcome.

Findings

Eleven studies reporting on psychiatric vulnerability and UPs were included. The participants of these studies were diagnosed with mood, anxiety, psychotic, substance use, conduct and eating disorders. The studies that have been conducted show that women with a psychiatric vulnerability (n = 2650) have an overall higher risk of UPs compared to women without a psychiatric vulnerability (n = 16,031) (OR 1.34, CI 1.08–1.67) and an overall weighed prevalence of UPs of 65% (CI 0.43–0.82) (n = 3881).

Interpretation

Studies conducted on psychiatric vulnerability and UPs are sparse and many (common) psychiatric vulnerabilities have not yet been studied in relation to UPs. The quality of the included studies was rated fair to poor due to difficulties with measuring the outcome pregnancy intention (use of various methods of assessment and use of retrospective study designs with risk of bias) and absence of a control group in most of the studies. The findings suggest an increased risk of UPs in women with psychiatric vulnerability. As UPs have important consequences for mother and child, discussing family planning in women with psychiatric vulnerabilities is of utmost importance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04452-1.

Pregnancy, delivery and neonatal complications in women with schizophrenia: a national population-based cohort study

Background

Existing studies evaluating the association between schizophrenia and complications associated with pregnancy, delivery and neonatal outcomes are based on data prior to 2014 and have reported heterogeneous results. The objective of our study was to determine whether pregnant women with schizophrenia were at increased risk of pregnancy, delivery and neonatal complications compared with women without severe mental disorders.

Methods

We performed a population-based cohort study of all singleton deliveries in France between Jan. 1, 2015, and Dec. 31, 2019. We divided this population into cases (i.e., women with schizophrenia) and controls (i.e., women without a diagnosis of severe mental disorder). Cases and controls were matched (1:4) inside the same hospital and the same year by age, social deprivation, parity, smoking, alcohol and substance addictions, malnutrition, obesity, and comorbidities. Univariate and multivariate models with odds ratios and 95% confidence intervals (ORs [95% CIs]) were used to estimate the association between schizophrenia and 24 pregnancy, delivery and neonatal outcomes.

Findings

Over 5 years, 3,667,461 singleton deliveries were identified, of which 3,108 occurred in women with schizophrenia. Compared to controls, women with schizophrenia were found to be older; have more frequent smoking, alcohol and substance addictions; suffer from obesity, diabetes and chronic obstructive pulmonary disease; and often be hospitalized in tertiary maternity hospitals. Compared to matched controls, women with schizophrenia had more pregnancy complications (adjusted OR=1.41[95%CI 1.31-1.51]) (i.e., gestational diabetes, gestational hypertension, genito-urinary infection, intrauterine growth retardation and threatened preterm labour). They had more delivery complications (aOR=1.18[95%CI 1.09 1.29]) with more still births/medical abortions (aOR=2.17[95%CI 1.62-2.90]) and caesarean sections (aOR=1.15[95%CI 1.05-1.25]). Newborns of women with schizophrenia had more neonatal complications (aOR=1.38[95%CI 1.27-1.50]) with more born preterm (aOR=1.64[95%CI1.42 -1.90]), small for gestational age (aOR=1.34[95%CI 1.19-1.50]) and low birth weight (aOR=1.75[95%CI 1.53-2.00]).

Interpretation

Our results highlight the importance of health disparities between pregnant women with and without schizophrenia, as well as in their newborns. Our study calls for health policy interventions during and before pregnancy, including proportionate intensified care to the level of needs, effective case management and preventive and social determinant approaches.

Funding

No funding.

Schizophrenia during pregnancy

PURPOSE OF REVIEW

A diagnosis of schizophrenia has significant implications for women of childbearing age, pregnant or considering a pregnancy, ranging from sexual health, psychopharmacological treatment, to the occurrence of negative pregnancy and foetal outcomes. We provide a short narrative review of recent papers focusing on these issues.

RECENT FINDINGS

Although pregnancy rates have been increasing in women with a diagnosis of schizophrenia, they also tend to have altogether fewer pregnancies and fewer live births than women without this diagnosis, and also higher rates of induced abortions.Use of antipsychotics in pregnancy has also increased, and evidence suggests lack of significant contraindications for their use in this period. However, drug levels monitoring may be recommended across the three trimesters, as levels may change in relation to pregnancy-related physiology.Monitoring of physical health is an increasingly crucial issue, given higher risk of gestational diabetes, negative obstetric and infant outcomes in these women.

SUMMARY

There is an urgent need to generate valid and reproducible research that could help implement appropriate treatment protocols and relapse-prevention approaches, and interventions based on strong pharmaceutical targets for the benefit of pregnant women with a diagnosis of schizophrenia, their families and their children.

Schizophrenia around the time of pregnancy: leveraging population-based health data and electronic health record data to fill knowledge gaps

BACKGROUND

Research in schizophrenia and pregnancy has traditionally been conducted in small samples. More recently, secondary analysis of routine healthcare data has facilitated access to data on large numbers of women with schizophrenia.

AIMS

To discuss four scientific advances using data from Canada, Denmark and the UK from population-level health registers and clinical data sources.

METHOD

Narrative review of research from these three countries to illustrate key advances in the area of schizophrenia and pregnancy.

RESULTS

Health administrative and clinical data from electronic medical records have been used to identify population-level and clinical cohorts of women with schizophrenia, and follow them longitudinally along with their children. These data have demonstrated that fertility rates in women with schizophrenia have increased over time and have enabled documentation of the course of illness in relation with pregnancy, showing the early postpartum as the time of highest risk. As a result of large sample sizes, we have been able to understand the prevalence of and risk factors for rare outcomes that would be difficult to study in clinical research. Advanced pharmaco-epidemiological methods have been used to address confounding in studies of antipsychotic medications in pregnancy, to provide data about the benefits and risks of treatment for women and their care providers.

CONCLUSIONS

Use of these data has advanced the field of research in schizophrenia and pregnancy. Future developments in use of electronic health records include access to richer data sources and use of modern technical advances such as machine learning and supporting team science.

Women with Schizophrenia over the Life Span: Health Promotion, Treatment and Outcomes

Women with schizophrenia show sex-specific health needs that differ according to stage of life. The aim of this narrative review is to resolve important questions concerning the treatment of women with schizophrenia at different periods of their life—paying special attention to reproductive and post-reproductive stages. Review results suggest that menstrual cycle-dependent treatments may be a useful option for many women and that recommendations re contraceptive options need always to be part of care provision. The pregnancy and the postpartum periods—while constituting vulnerable time periods for the mother—require special attention to antipsychotic effects on the fetus and neonate. Menopause and aging are further vulnerable times, with extra challenges posed by associated health risks. Pregnancy complications, neurodevelopmental difficulties of offspring, cancer risk and cognitive defects are indirect results of the interplay of hormones and antipsychotic treatment of women over the course of the lifespan. The literature recommends that health promotion strategies need to be directed at lifestyle modifications, prevention of medical comorbidities and increased psychosocial support. Careful monitoring of pharmacological treatment has been shown to be critical during periods of hormonal transition. Not only does treatment of women with schizophrenia often need to be different than that of their male peers, but it also needs to vary over the course of life.

Sexual health of women with schizophrenia: A review

Women with schizophrenia experience low rates of sexual satisfaction and high rates of sexual dysfunction. They are at high risk for adverse sexual health outcomes including unplanned pregnancies, induced abortions, and human immunodeficiency virus (HIV), and face higher rates of sexual violence and various forms of intimate partner violence. This review explores the complex and intersecting biopsychosocial risk factors that explain these outcomes among women with schizophrenia, including factors related to the illness itself, antipsychotic medications, medical and psychiatric comorbidities, stigma, childhood trauma, and social determinants of health including poverty and housing instability. Sexual health interventions designed to help women with schizophrenia achieve pleasurable and safe sexual experiences, free of coercion, discrimination and violence are few and far between, suggesting opportunities for future development in this area.