11/2/2021 0 Comments Pre-existing Mental IllnessMay has presented to her first antenatal hospital visit at 20 weeks gestation with a self-acknowledged mental illness. In this essay I will discuss mental illness and its impact on attachment and maternal and child outcomes. Midwifery care provided during the perinatal period will be discussed with reference to contemporary literature. Risk and protective factors will be considered, as well as screening, medication use, and consultation and referral in care. The ongoing care of May will be addressed including planning to promote positive maternal bonding and infant attachment in this potentially at-risk situation. Globally, the rates for perinatal mental illness range from 10 to 41 per cent dependent on both definition and measurement1. In Australia, suicide is a leading cause of maternal death, categorised as ‘aggravated by the physiologic effects of pregnancy’ 2. These effects can occur in the perinatal period as an ongoing, aggravation or relapse of an existing condition, or as a new response to the changes in the perinatal period 1 and show worse outcomes for women, children and families living with these conditions 3. Outcomes include higher rates of pre-eclampsia 4 and other poor obstetric consequences 5, low weight and preterm birth for the neonate 6, and are further compounded by the biophysical changes, social upheavals and adjustments in the postnatal period 7,8. Mental illness may impair the woman’s ability to bond and care for her infant during pregnancy and in the early postpartum period 5, impacting the ability of the infant to form a secure attachment 9,10. Without this security, the infant’s ongoing development is compromised 11. The deficits in the rapidly developing neurology of the child impair physical, psychological, language, emotional and behavioural growth and impact the immune function with effects continuing into adulthood 5,12. Later in life we find this childhood stress has been associated with a broad range of health problems such as increased reactivity to trauma, cognitive deficits, and psychiatric and behavioural disorders 13. This highlights the importance of woman-centred, mental health education, assessment, support and treatment for the perinatal period, especially when more women are beginning their pregnancies or developing these issues during their pre and post-natal periods 3. In the present case study, May has disclosed an existing mental health illness. The midwife is in a privileged position to care for and respond to May’s emotional state and to offer support and referrals 14. This is within the midwife’s scope of practice, respecting their professional relationship and in a culturally safe, trauma-informed manner 15. The first step is to understand May’s situation and personal, risk and protective factors that can make her and her baby more vulnerable or resilient 11. These factors can be identified through routine ‘booking visit’ checks that include psychosocial, medical, and physical assessment, history-taking, through empathetic and non-judgemental listening 16,4, and a mental state examination 17. Risk factors to look for include May’s personal and family history 11, low socioeconomic status, membership of minority groups, substance misuse, low support resources, poor self-esteem 11, current and past trauma 1, and intimate partner and family violence 18. As May’s number of risk factors increase, so too does the likelihood of her poorer psychosocial health 11. Of particular note for May, the major risk factor for developing a perinatal mental health condition is a pre-existing mental health history 11,19,4. Her illness could range from managing a normal life through to feeling disabled, chronically symptomatic and on medication, and should therefore be addressed in relation to her particular case 16. The midwife should enquire if May is currently in contact with psychiatric services or if they need to be engaged. Fear of judgment by health professionals can lead women suffering mental illness to delay their first consultation 11. This is another risk factor for May. It is also important to notice any resilience factors where May is able to adapt well to adversity, facilitating better psychological strength, and coping behaviours 1. These strengths can include knowledge, skills, attitude, self-efficacy 11 and partner, family, and social support 20. The Edinburgh Postnatal Depression Scale (EPDS) is used as a screening tool and would be offered to May as a screening instrument 21. The midwife should repeat this screening at least once later in pregnancy or if clinically indicated 11. An appropriately translated version should be used if applicable, such as if May identifies as an Aboriginal and/or Torres Strait Islander 21. If assessing for psychosocial risk, administer the Antenatal (Psychosocial) Risk Questionnaire as well 4. Before screening and assessment, the midwife should ensure May’s privacy and that only appropriate persons are present 21. Health professionals should be available to provide advice, supervision, support and follow-up to deal with potential responses and issues raised 4. May should be provided with a clear explanation of the purpose of the screening and the limits to confidentiality before offering her informed consent 4. Screening is supported by collaboration, consultation and referral pathways that involve working with mental health and other obstetrics services 1. Collaboration with members of May’s health care team needs to be coordinated between all professionals ensuring continuity of care 22. This involves effective sharing of information and documentation between all involved, including May 14. Building on collaboration, consultation includes other professionals with specialised knowledge 22. This could be indicated by concerns for a current or historical psychological or perinatal mental health issue, an EPDS score greater than 12, a positive response to the EPDS self-harm question (Q10), antenatal depression and/or anxiety, significant social isolation and lack of social support 22. If the level of responsibility required for May falls outside the midwife’s scope of practice, a referral is needed and the primary responsibility transferred to another qualified health service professional or provider, while the midwife still remains a key member of May’s team and maintains continuity of care 22. This should be planned early enough in the pregnancy that May can build trusting relationships as a safety net for her and her baby 4. Referral includes for an acute and unstable mental health concern 16. If May is using medication for her mental illness, the midwife should have knowledge and understanding of the use of common psychiatric drugs in pregnancy and lactation 16. Most antidepressants are not associated with major congenital abnormalities, with preferred drugs being Sertraline and Citalopram 23. Mental health medications to avoid include Clomipramine, Paroxetine and Sodium Valproate 24. Modifying the use of psychotropic medications during pregnancy, like ceasing Lithium with bipolar disorder, can be detrimental to both maternal and infant outcomes 24. Consultation with a specialist pharmacist is important to provide access to their expertise in medication management 24. The midwife should discuss all possible support and treatment options and their potential problems and advantages 23, facilitating choice so that May maintains control 16. This information should be based on evidence and promote emotional health 14. Ongoing care with May should involve opportunities for her to discuss her expectations and experiences including any issues and concerns that may have arisen 4. The midwife should monitor for signs of relapse, especially if medication is modified before or during pregnancy 4. Providing realistic expectations of motherhood and the post-natal period, including the normal hormonal, psychological, emotional and physical changes, will promote greater wellbeing for May, maximising her coping skills, self-regulation and bonding with her infant 25. Exploring strategies May has previously used and reinforcing these strengths to help develop parental confidence could avoid or minimise factors that contribute to a traumatic birth 26. Working with May to increase her capacity to manage her own problems in the future 27 could reduce stress by promoting autonomy 16. If the midwife is reliable, accessible and provides a secure base for May, this could create a safe space for May to be a secure base for her child and will enhance her reflective capacity, emotional regulation and empathy 28. This will promote positive attachment in the next generation 29. I have provided evidence of the significance of the midwife in offering woman-centred, continuity of care planning for May who is at risk of adverse perinatal mental health outcomes. I have looked at the importance of maternal bonding and infant attachment for the future healthy development of the child and provided risk and resilience factors of relevance and the pathway of screening, consulting and referring for May to build a collaborative multidisciplinary team to support and promote the current and future wellbeing for her and her baby. By non-judgementally and empathetically working within their scope of practice, the midwife has the capacity to change transgenerational mental health patterning for May. References(1) Jomeen, J.; Fleming, S. E.; Martin, C. R. Women with a Diagnosed Mental Health Problem. In Psychosocial Resilience and Risk in the Perinatal Period; Thomson, G., Schmied, V., Eds.; Routledge: Abingdon, Oxon ; New York, NY : Routledge, 2017., 2017; pp 9–26. https://doi.org/10.4324/9781315656854-2.
(2) Australian Institute of Health and Welfare. Maternal Deaths in Australia. 2019. https://doi.org/10.25816/7Q4E-G697. (3) CCOPMM; Safer Care Victoria. Victoria’s Mother, Babies and Children - 2019; 58; Victorian Government: Melbourne, Victoria, Austraia, 2021; p 57. (4) Department of Health. Clinical Practice Guidelines: Pregnancy Care; Australian Government Department of Health: Canberra, 2018. (5) McNamara, J.; Townsend, M. L.; Herbert, J. S. A Systemic Review of Maternal Wellbeing and Its Relationship with Maternal Fetal Attachment and Early Postpartum Bonding. PLOS ONE 2019, 14 (7), e0220032. https://doi.org/10.1371/journal.pone.0220032. (6) Eastwood, J.; Ogbo, F. A.; Hendry, A.; Noble, J.; Page, A.; Group, E. Y. R. The Impact of Antenatal Depression on Perinatal Outcomes in Australian Women. PLOS ONE 2017, 16. (7) Osman, N. N.; Bahri, A. I. Impact of Altered Hormonal and Neurochemical Levels on Depression Symptoms in Women During Pregnancy and Postpartum Period. 2019, 9. (8) Rihua, X.; Haiyan, X.; Krewski, D.; Guoping, H. Plasma Concentrations of Neurotransmitters and Postpartum Depression. 2017, 8. (9) 1st 1001 Days APPG. Building Great Britons. Conception to Age 2; First 1001 Days All Parties Parliamentary Group: London, 2015. (10) Bowlby, J. Attachment Theory and Its Therapeutic Implications. Ann. Am. Soc. Adolesc. Psychiatry 1978, No. 6, 5–33. (11) Schmied, V.; Dixon, L. Women’s Psychosocial Health and Wellbeing. In Midwifery : preparation for practice; Elsevier Australia: Chatswood, NSW, 2019; p 23. (12) Biaggi, A.; Conroy, S.; Pawlby, S.; Pariante, C. M. Identifying the Women at Risk of Antenatal Anxiety and Depression: A Systematic Review. J. Affect. Disord. 2016, 191, 62–77. https://doi.org/10.1016/j.jad.2015.11.014. (13) Provençal, N.; Binder, E. B. The Effects of Early Life Stress on the Epigenome: From the Womb to Adulthood and Even Before. Exp. Neurol. 2015, 268, 10–20. https://doi.org/10.1016/j.expneurol.2014.09.001. (14) COAG Health Council. Woman-Centred Care: Strategic Directions for Australian Maternity Services. Department of Health August 2019. (15) NMBA. Code of Conduct for Midwives. Nursing and Midwifery Board of Australia. 2018. (16) Raynor, M. D.; Mason, A.; Williams, M.; Wallroth, P.; Skene, G.; Whibley, S. Perinatal Mental Health. In Myles Textbook for Midwives (Seventeenth Edition); 2020; pp 756–784. (17) Hercelinskyj, G.; Alexander, L. Asseessment and Diagnosis. In Mental health nursing; ProQuest Ebook Central, 2019. (18) Zhang, S.; Wang, L.; Yang, T.; Chen, L.; Qiu, X.; Wang, T.; Chen, L.; Zhao, L.; Ye, Z.; Zheng, Z.; Qin, J. Maternal Violence Experiences and Risk of Postpartum Depression: A Meta-Analysis of Cohort Studies. Eur. Psychiatry 2019, 55, 90–101. https://doi.org/10.1016/j.eurpsy.2018.10.005. (19) Cao, H.; Zhou, N.; Leerkes, E. M.; Qu, J. Multiple Domains of New Mothers’ Adaptation: Interrelations and Roots in Childhood Maternal Nonsupportive Emotion Socialization. J. Fam. Psychol. 2018, 32 (5), 575–587. https://doi.org/10.1037/fam0000416. (20) Abdollahpour, S.; Keramat, A. The Relationship between Perceived Social Support from Family and Postpartum Empowerment with Maternal Wellbeing in the Postpartum Period. J. Midwifery Reprod. Health 2016, 4 (4). https://doi.org/10.22038/jmrh.2016.7612. (21) Austin, M.-P.; Highet, N.; Expert Working Group. Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline; Centre of Perinatal Excellence.: Melbourne, 2017; p 121. (22) Australian College of Midwives. National Midwifery Guidelines for Consultation and Referral, 4th ed.; ACM: Canberra, 2021. (23) Molenaar, N. M.; Kamperman, A. M.; Boyce, P.; Bergink, V. Guidelines on Treatment of Perinatal Depression with Antidepressants: An International Review. Aust. N. Z. J. Psychiatry 2018, 52 (4), 320–327. https://doi.org/10.1177/0004867418762057. (24) Niethe, M.; Whitfield, K. Psychotropic Medication Use during Pregnancy. J. Pharm. Pract. Res. 2018, 48 (4), 384–391. https://doi.org/10.1002/jppr.1483. (25) Rizzo, I.; Watsford, C. The Relationship between Disconfirmed Expectations of Motherhood, Depression, and Mother–Infant Attachment in the Postnatal Period. Aust. Psychol. 2020, 55 (6), 686–699. https://doi.org/10.1111/ap.12472. (26) Hollander, M. H.; van Hastenberg, E.; van Dillen, J.; van Pampus, M. G.; de Miranda, E.; Stramrood, C. A. I. Preventing Traumatic Childbirth Experiences: 2192 Women’s Perceptions and Views. Arch. Womens Ment. Health 2017, 20 (4), 515–523. https://doi.org/10.1007/s00737-017-0729-6. (27) NMBA. Midwife Standards for Practice. Nursing and Midwifery Board of Australia. October 1, 2018. (28) Berry, K.; Danquah, A. Attachment-Informed Therapy for Adults: Towards a Unifying Perspective on Practice. Psychol. Psychother. Theory Res. Pract. 2016, 89 (1), 15–32. https://doi.org/10.1111/papt.12063. (29) Newman, L.; Sivaratnam, C.; Komiti, A. Attachment and Early Brain Development – Neuroprotective Interventions in Infant–Caregiver Therapy. Transl. Dev. Psychiatry 2015, 3 (1), 28647. https://doi.org/10.3402/tdp.v3.28647.
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