Clinical Practice Guidelines Antenatal care - Module I

4.4 Women with serious mental health disorders

Page last updated: 02 April 2013

“Women with a serious mental illness are just as likely to be mothers and their fertility rates are no different from the general population of women.” (Nicholson & Biebel 2002)

Mental health disorders have been identified as a leading cause of maternal morbidity and mortality in the UK (Lewis 2007) and as one of the top three causes of indirect maternal mortality in Australia (Austin et al 2007).

While specific data on the prevalence of serious mental health disorders (eg schizophrenia, bipolar disorder, severe personality disorders) in pregnant women in Australia are not available, recent studies suggest that schizophrenia is present in 1% of the population world wide, lifetime prevalence of bipolar disorder in Australia is estimated as 1.2% (University NSW 2002) and personality disorders are present in 6.5% of the Australian population (Jackson & Burgess 2000). Australian research indicates that up to one in ten (9%) women experience depression during pregnancy (Buist & Bilszta 2006) and anxiety disorders are likely to be as, or more, common (see Section 7.6).

Women with serious mental health disorders are at higher risk for pregnancy and birth complications (eg preterm birth, still birth and low birth weight [Nilsson et al 2002]) and there are increased neurological developmental risks for their children (Jablensky et al 2005). Lifestyle factors such as smoking, use of illicit drugs, poor compliance with folate supplementation, poor nutrition as well as failure to access antenatal care have been implicated in this increased risk (Hauck et al 2008; King-Hele et al 2009; Matevosyan 2011). Pregnancy can evoke many issues for women who have experienced complex traumas (eg in borderline personality disorder) and may lead to difficulties in attendance or follow-up (SA Perinatal Practice Guidelines Working Group 2011). Postnatally, many issues will present that challenge families and professionals (Mares et al 2005; Newman & Stevenson 2005).

Women with serious mental health disorders are also more likely to have had a negative early sexual experience or to have been a victim of sexual assault and therefore are more at risk of unplanned or unwanted pregnancy (Miller & Finnerty 1996). Not only are these women less likely to receive antenatal care, but they have more chance of being without partner support, separated or divorced (Rudolph et al 1990), at risk of suicide and using illicit drugs (Miller 1990).

Women who are taking psychotropic medicines may experience side effects such as nausea, breast tenderness and menstrual cycle disruption, which mask the signs of early pregnancy (Fitzgerald & Seeman 2000) and may delay diagnosis of pregnancy.

Improving outcomes for women with serious mental health disorders

While there is clear evidence of the detrimental effects of serious mental disorders on both mother and infant, there are few evaluated interventions to improve outcomes. Objectives include enabling cessation or reduction of smoking (see Section 10.1), and optimising mental health care while providing collaborative antenatal care (Hauck et al 2008).

Given the prevalence of mental health problems, the Australian Government has provided funding for screening during pregnancy for psychosocial factors that affect mental health (see Section 7.5) and for symptoms of the more common mental health problems, depression and anxiety (see Section 7.6), and for the training of health professionals to undertake this screening and understand pathways to care (see Section 7.6.4). Assessing women for psychosocial risk factors and symptoms of distress during regular pregnancy checks gives the opportunity to link women with appropriate services (Austin et al 2008). Antenatal screening also seeks to identify whether a woman has experienced, or received treatment for, more severe mental health disorders. If this is affirmed, further understanding of current and future significance is indicated along with collaboration with relevant mental health professionals.

It is also appropriate to ensure knowledge of current psychotropic medicine use. While no recent Australian statistics are available, figures from comparable populations suggest that at least 2% of women take antidepressants in the first trimester of pregnancy (Ververs et al 2008). It is important that the risks/ benefits of treatment are discussed (Lorenzo et al 2011). Women will seek information about the safety of psychotropic medicines and will also need information regarding risks of relapse if they stop taking their medicines because of pregnancy. Medicine use in pregnancy is discussed in Section 10.3. As information in this field can change rapidly, current information about specific medicines should be sought (see Section 10.3.6).

For more severe mental health issues, such as schizophrenia and drug-related psychoses, working collaboratively with trained mental health professionals is appropriate. When risk of suicide is identified (eg through question 10 of the Edinburgh Postnatal Depression Scale; see Section 7.6) referral to a psychiatrist or other mental health professional is required. Sources of information about serious mental health disorders in perinatal practice and mental health referral and advice are included in Section 4.5.