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Of the 250 babies born every minute globally, approximately 1 in 5 of their mothers will develop some form of perinatal mental illness. That is 72,000 women every day.  ‘These illnesses frequently go unnoticed and untreated, often with tragic and long-term consequences to both mother and child.’ http://wmmhday.postpartum.net/  “Suicide due to psychiatric illness is now considered as a Direct cause of Maternal death. Moreover, stress and mental health conditions during pregnancy when untreated, can lead to many obstetric complications, such as pre-eclampsia, pre-term labour, and intra-uterine growth restriction of the fetus. Therefore, mental health care is vital during every pregnancy and should be an integral part of Antenatal care (and postpartum care). This is important regardless of previous mental health history as this can occur for the first time (sometimes in a serious form and deteriorate rapidly) during pregnancy and perinatal period. Moreover, partners should be supported too. But sadly, perinatal mental health care has remained neglected in the Maternity Units in many parts of the UK and globally. There is also an urgent need for training for all the obstetricians and midwives in this field.” Dr. R Gangopadhyay

If you are involved in the physical aspects of the care of these women, doesn’t it make complete sense that there should be some awareness, responsibility and involvement in their mental care too?

This was the main point that I focused on as I spoke last week. I was privileged to be invited to speak at the Royal College of Obstetricians and Gynecologists World Congress at ExCel in London. There were over 4,000 delegates from 100 countries at the event. I aimed to highlight the need for all healthcare professionals to work as part of a holistic team to recognise that our minds and bodies are connected and that how they treat our physical condition can impact upon our mental condition. I have to say that I have left the Congress feeling shocked that this seems to be a ‘new’ approach.

I met some obstetricians who are passionate about this and do consider this a lot. Dr Raja Gangopadhyay  (pictured with me above)is a leading voice in this in the UK and he has been encouraging his peers in this area very much. He campaigns for better Perinatal Mental Health Care within the Maternity Units across the world and runs events (including House of Commons, UK Parliament) to raise awareness of the importance of addressing mental health and well-being during pregnancy. He is the Founder of International Forum for Wellbeing In Pregnancy (IFWIP),  This is for anyone who is interested in health and well-being during pregnancy, regardless of their professional role.

I only discovered at the Congress that this was the first time that perinatal mental health has been an item on their programme. That shocked me! I was also “amazed” at the surprised attitudes of some that I chatted to – as to why it was part of the programme!

I hadn’t realised this before I attended and therefore want to encourage more obstetricians and gynecologists to get involved in the whole-team approach around the women. I am not suggesting that they should be psychiatrists too – I am suggesting that they are aware of the risks and signs to look for in their patients and also that their personal actions and words can have a dramatic affect on the mental health of those in their care. I also want to highlight the need for greater sensitivity and awareness of this at the menopause stage of a woman’s life.

The RCOG did publish a report in 2017 on ‘Maternal Mental Health – Women’s Voices.’  in which recommendations were made. Perhaps this is why the college are beginning to appreciate that this area must be covered.

We are generally led to believe that new parenthood is idyllic. The glossy magazines, the images all over social media, even the young royal families all portray this. For many, this is the case. I was one that had those expectations. In reality, infections during pregnancy, a traumatic delivery, a seriously ill baby, sleep deprivation and my personality of wanting things to be perfect culminated in me developing puerperal psychosis when my son was 8 months old. My full story is written in my first book, ‘Eyes without sparkle – a journey through postnatal illness’.

On reflection, there were aspects of my obstetric care that could have been better:

1. When I was admitted on two occasions to hospital during pregnancy for urinary tract infections, I did not see the obstetrician I was assigned to because he was on holiday. Instead, I was seen by a variety of ward doctors who seemed to be puzzled what to do with me. At the time I was very worried about my baby. I was given rest and medication, with some emotional support mainly by the midwives on the ward.
2. When I finally was admitted to have my baby, I saw a different obstetrician who looked at my notes and commented that someone should have told her about my UTIs as it was her specialty. I had seen her visiting other pregnant mothers whilst I had been in nearby beds. She saw me in the water birth suite whilst I was in labour and was happy that all was going well.
3. My body did not respond well to the birth. My son was born with the cord around his neck; I had a retained placenta and postpartum hemorrhage. I remember slipping into blackness even before I got to the emergency theatre. When I came around, a doctor simply told me that I was lucky – had it been a home birth or 20 years earlier, I would be dead!
4. At my 6-week checkup, I saw the lady obstetrician who had seen me in the birthing pool. She was shocked and angry that no-one had told her what had subsequently happened to me. On examination, she discovered that the neck of my womb was wide open, and she was amazed that I had not developed a serious infection! I was back in theatre within 24 hours.

In the months that followed, as I have described, my mental health unraveled worsened dramatically. I became one of the statistics – the ‘1 in 5’.  I learned that perinatal mental illness affects more than the mother. It is now well-documented that a woman who is mentally unwell during pregnancy can have adverse effects on the unborn child. The new infant can suffer in mental, social and emotional development. The partner may be affected by a traumatic delivery and subsequent changes in their lives. Existing children can suffer. The wider family and friends can be impacted. Workplace and society are affected financially. Suicide is still a leading cause of death during the postnatal period. We all must play our role in minimizing the risks to everyone.

Please let me say with emphasis that I am eternally grateful for the care I did receive. Without it, both my son and I would probably not have survived. It is impossible to say for sure, that had my physical health been better before, during and after the birth of my son, that my physical health would also have improved. I do know that if I had gone on to have another child, my anxiety and concerns for a subsequent baby, would have been very significant. I do feel that from my personal experience and that of others, there are some aspects that we would love to strongly point out to those in the obstetric and gynecologic world.

What we need from our obstetric team

1. Signposting and services within your area for you to refer us to. If you haven’t a perinatal mental health team, then create one. In the UK, the areas of the country who had simply taken the initiative to connect interested professionals together, are the ones that ultimately got funding when it became available.
2. Care co-ordination. With women who have greater needs, who is linking the services together?
3. The acknowledgment that her mental health is being assessed and checked on as well as her physical monitoring.
4. Excellent communication within the team. Are you being informed? Are you informing those who need to know?
5. Information to make women feel empowered to help themselves at each stage of the perinatal journey

• Preconception counselling for those at high risk of mental and physical conditions. This could involve the partner as well. (Consider the work of Elly Taylor in ‘Becoming Us‘.)
• Pregnancy well-being for mind and body. Look at International Forum of Wellbeing in Pregnancy.
• The birth – consider using the term ‘library’ as opposed to ‘plan’ to reduce the perception of failure if alternative approaches are used.
• Postnatally, show us ways that we can help ourselves in the fourth trimester. For example, The Mommy Plan by Valerie Lynn, and Life after birth by Diane Speier.

What we need from our obstetrician

1. Take my concerns seriously. Please do not dismiss them.
2. Listen to me. This may be my first and only pregnancy and birth. It matters deeply to me.
3. Be sensitive to my high-risk first or subsequent anxious pregnancy. I may need more reassurance than a passing sentence.
4. Use positive and realistic language.
5. Be my advocate for the care I need.
6. Be proactive in building a perinatal team.

Suffering from a pre-existing mental health condition or developing one in the perinatal period robs women and their families of what can be a very precious time. Please support us.

The other area that I am increasingly concerned about, is the mental health of women as they approach menopause. When I compiled my second book, ‘Another Twinkle in the Eye’, the many women who contributed also commented on the impact later in their lives. I would love to see more research that looks at the link between the mental health of these two significant times.  If you had mental health challenges in the perinatal period, are you more vulnerable at menopause?

On a personal level, when I had to have a hysterectomy a few years ago, the gynecologist did ask if I had wanted more children.  Although practically at the time it was not feasible, I had always wanted a second baby. Her quick reply was that regardless of my desire, this was nature’s way of saying it was not possible. End of…! I know that some women struggle emotionally with the ‘change’ that means the end of fertility. If you did not complete your family due to fears of being mentally unwell, it can make this reality very hard to process. My suggestion is that women and their partners need the opportunity for preconception counselling in the years where another baby may be a possibility. To consider the risks, possible care plan, etc. in order to reach a decision one way or the other, could save relationships as well as personal peace of mind.

I also appeal to gynecologists to ask about the perinatal history of the women in their care. It may be significant. We might need more than a sentence or two to tell us that we can no longer bear a child.

I truly respect and admire the excellent work that the obstetricians and gynecologists across the world do. I am simply appealing for a greater awareness and sensitivity around the mental health of the women and families in their care.

As additional information and call to action, I invite you to listen to ‘How to influence policy and get more help for perinatal mental health, in the UK and around the world’, by Dr Alain Gregoire at the Begin Before Birth conference in London on 27th June. Here are the key points:

• 02:02  It is pitiful the care that women across the world receive – we need to come together to make a change.
• 05:05  80% of the women suffering are in the lowest income countries. We have clear evidence for individual, social and economic needs; clear evidence for financial investment; successful models of care.
• 09:02  Huge impact on so many in a small community if a woman develops puerperal psychosis, e.g. in Malawi.
• 10:10   Attitude that mental health treatment a luxury, globally?
• 11:50   We do not have an infra-structure for perinatal mental health, even though depressive illness is a major health complication for maternity.
• 14:00  Global Burden of Disease (WHO 2008) shows clearly that depressive disorders are the highest for life years lost through death or illness for women aged 15 – 44.
• 15:20  People ignore the most burdensome condition – there are no specialist services for it! Even in UK, there are still women and families who cannot get the support and care they need.
• 18:00  It is discrimination. We need to work harder – need more training, skills, knowledge all over the world.
• 20:40  We CAN change by sharing what we know. Use the knowledge and power to make a difference.
• 22:14   Maternal deaths across the world are now being collected to show how many are due to mental illness. Many died because of the despair their illness took them into with no-one to treat and support them.
• 25:00  Politicians ‘don’t care’ about anything other than statistics – the Economic review in the UK showed the impact of maternal mental illness.
• 29:00   We spend more on NHS for compensation for being sued for poor care (communication) than it would cost per birth to offer all that is needed.
• 33:00  Evidence now being collected to show what we are doing works as regards services they need – women’s health; relationship with their babies; specialist unit vs community;
• 34:00  Impact of many people pulling together to form Maternal Mental Health Alliance to call for better maternal mental health care. You can achieve more by joining together. Talk to those around you who are also interested.
• 36:00  Involve those who have suffered with live experience. Take one with you to speak to those with influence & decision makers, as they cannot then ignore that this suffering is real.
• 38:30  Use both science and visuals to convince the decision makers too – in the UK the map showing the traffic light system of levels of care made a big difference, created by the Economic review.
• 40:00  Use media and reports to get the awareness and funds.
• 42:00  Globally groups are now coming together to be involved in the Global Maternal Mental Health Alliance. 196 countries; 131 million live births each year. 131,000 women each year with puerperal psychosis. 13 million with postnatal depression NOW. This does not include the counted millions with PTSD (or those with still-birth or miscarriage).
• 45:00  – 48:00 Powerful summary from Alain.

There are some other excellent presentations from this event too, by Vivette Glover and Lord Robert Winston, for example. Please register here to get access to the programme and the full web stream of the day.

As regards perinatal mental health and the need for us all to work together to get more and better services to reduce so much unnecessary suffering,

• What are you going to do?
• Who will you share this information with?
• The next World Congresses for the RCOG are in Oman in 2020 and Hong Kong in 2021. How can we ensure that perinatal mental health is on the programme? How do we get it on the main stage this time?

Let’s all come together to make a REAL difference for women and their families.

I will also post more about the Congress!

Elaine 🙂