Perinatal self-harm: an overlooked public health issue

[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.

Self-harm thoughts among postpartum women - associated factors

BACKGROUND

Even though in many countries suicide is the leading cause of maternal deaths during the postpartum period, the prevalence of thoughts of self-harm (SHTs), an important risk factor for suicide attempts, is still not well documented.

AIM

We aimed to investigate the prevalence of SHTs in a Polish cohort of postpartum women and identify socio-demographic and maternal mental health factors associated with experiencing SHTs.

METHOD

1545 women took part in a midwife-led postpartum depression (PPD) screening. 337 of them reported SHTs. The Edinburgh Postpartum Depression Scale (EPDS) was administered. Specifically, we used an abbreviated 5-item version to assess depression symptoms, item 10 to assess SHTs, a composite score of items 1 and 2 - anhedonia, and a composite score of items 3, 4, and 5 - anxiety. Logistic regression analyses were performed to examine associations between variables.

RESULTS

Approximately 2% (n = 337) of women self-reported experiencingSHTs. Within the group of postpartum mothers who self-reported SHTs, 65.60% (n = 221) manifested the symptoms of PPD, and 56.40% (n = 190) - of anxiety. The symptoms of PPD, a mood disorder diagnosed in the past, and younger age were predictors of SHTs.

CONCLUSION

The results of this study can contribute to the development of prevention strategies: analysing separately items from PPD screening questionnaires focusing on SHTs can be an important part of prevention. The lack of the symptoms of PPD and anxiety risk does notexclude experiencing SHTs.

Barriers to perinatal mental health care experiences by midwives and obstetricians and their patients: A rapid review

INTRODUCTION

While perinatal mental health concerns are common, little attention is paid to noticing or addressing these concerns. Midwives and obstetricians are uniquely positioned to universally screen their patients for mental health conditions during the perinatal period, and provide referrals for additional mental health supports if relevant. Previous studies on perinatal mental health care have focused primarily on midwifery care, excluding perinatal healthcare providers such as obstetricians. This rapid review aims to examine the barriers to accessing mental health care during the perinatal period as experienced by obstetricians, midwives, and their patients.

METHODS

A rapid review of literature was conducted on barriers to perinatal mental health care as experienced by patients, midwives, and obstetricians. The search strategy included published literature from PubMed, CINAHL, PsycINFO, and Web of Science published between 2000 and 2020. All documents were screened by two researchers and disagreements were resolved through consensus with a third reviewer. After data from all included articles were extracted, thematic analysis was conducted, and findings were compared with related reviews that focused on mental health access for individuals who accessed midwifery care.

RESULTS

Of the 539 references and documents that were screened, 31 articles met the inclusion criteria. In the extraction phase, country, study objective(s), study design, perspective(s), barriers, and the dimension(s) impacted along the pathway to accessing care were retrieved from the 31 included articles. After all barriers were classified using the Supply-Side Dimensions of Access, we developed a classification framework to further examine stigma at the societal, institutional, and individual levels.

DISCUSSION

While midwives utilize a more holistic approach to care as compared with obstetricians, the barriers identified through this rapid review indicate that obstetricians and their patients face similar struggles to accessing and providing mental health care. Moreover, stigma plays a large role in the barriers experienced by patients, midwives, and obstetricians - at individual and institutional levels.

CONCLUSION

Obstetricians encounter similar stigma-related barriers as midwives in detecting mental health concerns, as well as connecting clients to available mental health resources and supports. Therefore, to effectively eliminate barriers to accessing perinatal mental health care, a systemic change must be enacted throughout all three layers to address the deep-rooted stigma associated with accessing mental health care during the perinatal period.

Suicidal behaviours in the peripartum period: a systematic scoping review of data linkage studies

The purpose of this scoping review was to summarize research that uses linked data to examine peripartum suicidal behaviours and critically appraise studies to identify evidence gaps and future research priorities. A systematic search of PubMed, Scopus, and grey literature was undertaken to identify data linkage studies that examined suicidal behaviours among women in the peripartum period. All articles available through PubMed and Scopus up until the search date of 26 September 2019 were deemed eligible for inclusion. A grey literature search was also undertaken, through the Google search engine, on 11 November 2019. Studies were analysed descriptively and synthesized qualitatively. Eighteen studies were identified that met inclusion criteria. All studies examined the incidence of suicidal behaviours. Twelve studies examined sociodemographic correlates, associations, or risk factors, and nine studies examined mental health. There was a high degree of variability regarding how both peripartum status and suicidal behaviours were defined. Few studies used data linkage to examine suicidal behaviours from a health services or social services perspective. The evidence base could benefit from conceptual clarity and standardization of constructs regarding suicidal behaviours in the peripartum period, to enable meaningful synthesis of results across studies. Data linkage can be used to improve understandings of risk factors and pathways. It can also be harnessed to examine both health and social services utilization, to inform coordinated multi-sectoral interventions and care pathways for women and their children.

The Association between Delivery during the COVID-19 Pandemic and Immediate Postpartum Maternal Cognitive Function

Survivors of the 2003 SARS epidemic were found to have higher rates of adverse mental conditions. This study aimed to assess cognitive function in women delivering during the COVID-19 pandemic, as compared to women who delivered before the COVID-19 pandemic. A cohort study was performed during the immediate postpartum period of women delivering singletons at term. Cognitive function was assessed using an objective neurocognitive test (Symbol Digit Modalities Test SDMT90, SDMT4) and a subjective self-estimation questionnaire (Attention Function Index AFI). The exposed group was recruited during the COVID-19 outbreak in Israel (May 2020), whereas the comparison group consisted of women delivering at the same medical center before the COVID-19 pandemic (2016–2017). Multivariable regression models were constructed to control potential confounders. There were 79 parturients recruited during the COVID-19 pandemic and compared with 123 women who delivered before the COVID-19 pandemic. Women delivering during the COVID-19 pandemic scored lower in the subjective AFI test compared to the unexposed group (70.0 ± 15.4 vs. 75.1 ± 14.7, p = 0.018). However, no significant difference was found in the objective SDMT tests scores. These results remained similar in the multivariable regression models when controlling for maternal age, ethnicity and time from admission to assessment, for AFI, SDMT90 and SDMT4 scores (p = 0.014; p = 0.734; p = 0.786; respectively). While no significant difference was found in objective tests, our findings propose that the exposure to the COVID-19 pandemic is independently associated with a significant decrease in subjective maternal cognitive function during the immediate postpartum period.

Perinatal mental health: a review of progress and challenges

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high-income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.

Thoughts of self-harm and associated risk factors among postpartum women in Canada

BACKGROUND

The prevalence of thoughts of self-harm during the postpartum period is not well documented in Canada. To estimate the prevalence of thoughts of self-harm among postpartum women in Canada, this study explored prevalence by socio-demographic characteristics and examined the associations between thoughts of self-harm and aspects of maternal mental health.

METHODS

This study used data from the 2018/2019 Survey on Maternal Health which surveyed women living in the 10 provinces anywhere between 6-13 months postpartum. Participants were asked to report experiencing thoughts of self-harm, rate their mental health, and participate in the abbreviated Edinburgh Postpartum Depression Scale and Generalized Anxiety Disorder (GAD) scale. Adjusted logistic regression analyses were performed to examine associations.

RESULTS

Of the 6,558 respondents who agreed to share their data, 10.4% reported thoughts of self-harm since the birth of their child. Of these women, 37.0% reported low mental health, 54.2% had moderate levels of symptoms of postpartum depression (PPD) and 37.1% had symptoms of GAD. Women who experienced low mental health, moderate levels of symptoms of PPD and/or GAD were more likely to report thoughts of self-harm.

LIMITATIONS

As thoughts of self-harm and aspects of mental health are self-reported, there is the potential for social desirability bias and underreporting. The cross-sectional survey design did not allow the reporting of thoughts of self-harm at different time points.

DISCUSSION

The high proportion of postpartum women in Canada reporting thoughts of self-harm and strong associations with aspects of maternal mental health highlight the need for effective supports during postpartum.

Incidence and general hospital costs of self-harm across England: estimates based on the multicentre study of self-harm

AIMS

The aim of this study was to estimate incidence of self-harm presentations to hospitals and their associated hospital costs across England.

METHODS

We used individual patient data from the Multicentre Study of Self-harm in England of all self-harm presentations to the emergency departments of five general hospitals in Oxford, Manchester and Derby in 2013. We also obtained cost data for each self-harm presentation from the hospitals in Oxford and Derby, as well as population and geographical estimates from the Office for National Statistics. First, we estimated the rate of self-harm presentations by age and gender in the Multicentre Study and multiplied this with the respective populations to estimate the number of self-harm presentations by age and gender for each local Clinical Commissioning Group (CCG) area in England. Second, we performed a regression analysis on the cost data from Oxford and Derby to predict the hospital costs of self-harm in Manchester by age, gender, receipt of psychosocial assessment, hospital admission and type of self-harm. Third, the mean hospital cost per age year and gender were combined with the respective number of self-harm presentations to estimate the total hospital costs for each CCG in England. Sensitivity analysis was performed to address uncertainty in the results due to the extrapolation of self-harm incidence and cost from the Multicentre Study to England.

RESULTS

There were 228 075 estimated self-harm presentations (61% were female) by 159 857 patients in 2013 in England. The largest proportions of self-harm presentations were in the age group 40-49 years (30%) for men and 19-29 years (28%) for women. Associated hospital costs were approximately £128.6 (95% CI 117.8-140.9) million in 2013. The estimated incidence of self-harm and associated hospital costs were lower in the majority of English coastal areas compared to inland regions but the highest costs were in Greater London. Costs were also higher in more socio-economically deprived areas of the country compared with areas that are more affluent. The sensitivity analyses provided similar results.

CONCLUSIONS

The results of this study highlight the extent, hospital costs and distribution of self-harm presentations to hospitals in England and identify potential sub-populations that might benefit from targeted actions to help prevent self-harm and assist those who have self-harmed. They can support national as well as local health stakeholders in allocating funds and prioritising interventions in areas with the greatest need for preventing and managing self-harm.