Maternal Mental Health Workshop
“Keeping Mothers Healthy”
A National Maternal Mental Health Workshop was held at Waipuna Conference Centre on 29th October 2008. This was organised by the Perinatal and Maternal Mortality Review Committee with considerable support from the Ministry of Health. The workshop was well attended by over 250 delegates, the majority of whom were midwives.
Following a welcome from Professor Cindy Farquhar, Chairperson of the PMMRC, the workshop was formally opened by the Hon. Steve Chadwick, Associate Minister of Health, (who has previously been both a midwife and a health manager), who recognised the issues raised by mental illness during pregnancy and post partum, and outlined initiatives to respond to these issues.
Professor Margaret Oates was the keynote speaker and she gave both the opening and closing addresses. Professor Oates is currently Clinical Director of the East Midlands Perinatal Mental Health Managed Care Network in the U.K. She developed and led the Nottinghamshire Perinatal Psychiatry Service until 1998, which included a Regional Mother and Baby Unit and Community and Maternity Liaison Service. She was the first psychiatrist to be appointed to the UK Confidential Enquiry into Maternal and Child Health (CEMACH) and has been a member since 1994. Her talk, entitled ‘Why Mothers Die and Saving Mothers Lives: Changing Policy and Practice’ addressed the process of enquiring into perinatal maternal deaths in the UK, which has been undertaken since the 19th Century but has been in its current form for fifty years. CEMACH uses a confidential and anonymous process and reports every three years. Professor Oates gave an overview of CEMACH’s findings in this area, which include:
· Deaths from psychiatric causes, including suicide, are a leading cause of maternal death in the perinatal period.
· There is increased incidence of serious affective disorder and an increased risk of recurrence of serious psychiatric disorder in the peripartum period.
· Mental illness is modified in its presentation, cause and consequences by pregnancy. There is a more abrupt onset and rapid deterioration than at other times. The risk factors for maternal suicide are different.
· Importantly physical illness can present as, coexist with, or result from psychiatric disorder.
Professor Oates emphasised the need for good communication between services at this time.
Other speakers included:
· Dr Cathy Hapgood, perinatal psychiatrist at Waitemata Health, who used a clinical vignette to illustrate the importance of obtaining a history of serious psychiatric illness at booking, or at the beginning of pregnancy, so that the associated risk can be appropriately managed.
· Professor Tony Dowell, who chaired the National Guidelines Group which developed ‘Management of Depression in Primary Care’, emphasised the importance of obtaining a past psychiatric history early in pregnancy and the need for good communication between professionals. He discussed the issues associated with identifying clinical depression in primary care.
· Dr Debbie Wilson and Dr Liz McDonald, both perinatal psychiatrists from the Christchurch Mother and Baby Unit, gave a history of Mother-Baby Units worldwide, described their unit in Christchurch, and summarised what such a unit provides to mothers with severe mental illness and their babies. Essentially such units provide treatment of the mother’s illness, whilst maintaining the mother–infant relationship. The relationship itself can also be assessed and treated by a specialist team in a safe environment. In addition such a unit can provide improved understanding of the illness and relief for the family.
· Dr Trecia Wouldes PhD outlined the difficulties posed by co-morbid mental illness and substance abuse in pregnancy. Substance abuse together with maternal psychopathology is associated with poor outcomes for children. She highlighted the need for improved recognition of such problems.
· Dr Hinemoa Elder spoke about Keeping Maori Mothers Healthy Tupu Kotahi: We all come from one womb. She challenged us all to think about what might keep Maori mothers healthy, and what might undermine their health. There is currently a lack of access to services that reinforce positive Maori cultural identity. She emphasised Navigating Beyond the Horizon: Matiro Whakamua, the importance of future planning, given the current disparity in health statistics for Maori. There is a need to build a culturally and clinically competent workforce to work with Maori mothers.
· Dr Sara Weeks Lotofale PIMHS explained some of the cultural beliefs and practices of the Pacific people around childbirth, family and mental illness. There is considerable stigma around mental illness and consequently they seek treatment at a very low rate. There are many challenges in the delivery and take up of services to women with perinatal mental illness.
· Ms Emma Farmer, Associate Director of Midwifery at Waitemata DHB, illustrated how improved liaison between the midwifery service and the maternal mental health service has occurred at Waitemata DHB. There is now a formally established maternity liaison service, where women who are at risk of serious mental illness in the perinatal period can be directly referred to the specialised MMH team.
Cathy Hapgood outlined the need for a national strategy for the provision of specialised psychiatric services throughout New Zealand. Margaret Oates then followed this by describing how services are delivered in the East Midlands, which has a population comparable to that of New Zealand. The key points of both strategies were the need for availability of specialised perinatal community psychiatric teams to manage women with serious mental illness in pregnancy and the first post natal year. In addition, women at risk of serious post natal illness should be assessed by a specialised perinatal service during pregnancy. Women with serious mental illness during pregnancy and the first post natal year who require admission should be admitted to a specialist Mother-Baby Unit. These services should be equitable, appropriate, complete comprehensive and integrated.
So how can we improve maternal mental health care in New Zealand? The workshop was a good start. We have several high quality MMH services in New Zealand including an excellent long established Mother-Baby Unit in Christchurch. Perhaps the biggest problem is that services are inequitable in delivery, and depend largely on where the woman resides. If a woman develops a serious mental illness in pregnancy or post partum, her access to specialised services will be very different depending upon where she lives. If she lives in the North Island she will have no chance of admission to a Mother-Baby Unit. There are specialised perinatal community psychiatric teams in certain areas but not throughout New Zealand. Access to these teams varies considerably, as does the quality and availability of psychiatric liaison with maternity services. The Hub and Spoke model outlined by Margaret Oates with centres of specialisation providing outreach services, consultation and advice, would seem workable here and is implemented in some areas now. A national strategy is required that recognises the need for specialisation of perinatal mental health services which are fully integrated into New Zealand’s current maternity and psychiatric services. It is essential that experienced clinicians be involved in the development of these guidelines.