Longer wait time after identification of peripartum depression symptoms is associated with increased symptom burden at psychiatric assessment.

Untreated peripartum depression (PD) affects one in seven women and is associated with negative maternal outcomes. This retrospective observational study used health record data from an integrated health system in Texas to assess the extent to which time to access reproductive psychiatry influences the mental health of peripartum women. Women with at least one screening for depression symptoms conducted in obstetric or pediatric settings between May 2014 and October 2019 and subsequently seen by the reproductive psychiatry clinic (n=490) were included. Descriptive and inferential statistics were used to assess timing and factors related to psychiatry follow-up. Findings from this study demonstrated that the average time between a positive screen and a psychiatry assessment was 5 weeks. At psychiatry referral appointments, 85% of women continued to screen positive for PD symptoms. Depression symptom scores at the psychiatry appointment were significantly higher than scores precipitating the referral (p = 0.002). Wait time between initial positive screen and referral appointment was positively correlated with clinically meaningful increases in depression symptom scores (p < 0.001). Each week spent waiting for an appointment produced a 13% increase in odds of clinically meaningful worsening of PD scores and 9% increase in odds of developing new self-harm ideation. Given the findings that a longer period between primary care referral and subspecialty appointment has a negative impact on the mental health of women, this study supports the need for earlier psychiatric assessment to minimize decompensation. Expansion of reproductive psychiatry services are needed to support peripartum women and improve maternal outcomes.

Engagement in perinatal depression treatment: a qualitative study of barriers across and within racial/ethnic groups.

BACKGROUND: To better understand previously observed racial/ethnic disparities in perinatal depression treatment rates we examined care engagement factors across and within race/ethnicity. METHODS: Obstetric patients and women's health clinician experts from a large healthcare system participated in this qualitative study. We conducted focus groups with 30 pregnant or postpartum women of Asian, Black, Latina, and White race/ethnicity with positive depression screens. Nine clinician experts in perinatal depression (obstetric, mental health, and primary care providers) were interviewed. A semi-structured format elicited treatment barriers, cultural factors, and helpful strategies. Discussion transcripts were coded using a general inductive approach with themes mapped to the Capability-Opportunity-Motivation-Behavior (COM-B) theoretical framework. RESULTS: Treatment barriers included social stigma, difficulties recognizing one's own depression, low understanding of treatment options, and lack of time for treatment. Distinct factors emerged for non-White women including culturally specific messages discouraging treatment, low social support, trauma history, and difficulty taking time off from work for treatment. Clinician factors included knowledge and skill handling perinatal depression, cultural competencies, and language barriers. Participants recommended better integration of mental health treatment with obstetric care, greater treatment convenience (e.g., telemedicine), and programmatic attention to cultural factors and social determinants of health. CONCLUSIONS: Women from diverse backgrounds with perinatal depression encounter individual-level, social, and clinician-related barriers to treatment engagement, necessitating care strategies that reduce stigma, offer convenience, and attend to cultural and economic factors. Our findings suggest the importance of intervention and policy approaches effecting change at multiple levels to increase perinatal depression treatment engagement.

Abuse and disrespectful care on women during access to antenatal care services and its implications in Ndola and Kitwe health facilities.

BACKGROUND: Antenatal care utilization is fundamental in preventing adverse pregnancy and birth outcomes. This paper assessed abuse and disrespectful care on women during access to antenatal care services and its implications in Ndola and Kitwe districts of Zambia. METHODS: The assessment used a cross-sectional study design with a sample size of 505 women of child bearing age (15-49). Eighteen (18) high volume health facilities were identified as benchmarks for catchment areas (study sites) and using cluster sampling, households within catchment areas of health facilities were sampled. Chi-square and poison regression analysis was performed to ascertain associations between abuse and disrespect and antenatal care utilization. RESULTS: One third (33%) of the participants attended less than half of the recommended antenatal visits. Results reveal a statistical significant association between; physical abuse (p value = 0.039); not being allowed to assume position of choice during examination (p value = 0.021); not having privacy during examination (p value = 0.006) and antenatal care service utilization. The difference in the logs of expected count on the number of antenatal care visits is expected to be; 0.066 (CI: -0.115,-0.018) unit lower for women who experienced lack of privacy during examinations; 0.067 (CI: -0.131,-0.004) unit lower for women who were discriminated based on specific attributes and 0.067 (CI: -0.120,-0.014) unit lower for women who were left unattended. CONCLUSION: Abuse and disrespect during antenatal care service impedes demand for health care and service utilization thereby barricading the element of the package of services aimed at improving maternal and newborn health.

Current Reports on Perinatal Intimate Partner Violence.

PURPOSE OF REVIEW: The purpose of this study was to review the literature on perinatal intimate partner violence, focusing on recent knowledge to guide mental health professionals on the best approaches to identify and treat women exposed to perinatal intimate partner violence. RECENT FINDINGS: Risk factors have been broadened from individual victim and perpetrator factors to include relationship, community, and societal factors which interact together. Better information is now available on how to identify, document, and treat women exposed to violence around the time of conception, pregnancy, and the postpartum period. Recent information helps psychiatrists and other mental health professionals assist women exposed to violence related to the perinatal period; however, further research is needed to provide improved evidence for optimal interventions for better patient outcomes.

Assessment and Care of Childbearing Women With Severe and Persistent Mental Illness.

Severe and persistent mental illness (SPMI) refers to complex mood disorders that include major depressive disorder with or without psychosis; severe anxiety disorders resistant to treatment; affective psychotic disorders including bipolar affective disorder, schizophrenia, and schizoaffective disorder; and other nonaffective subtypes of schizophrenia. SPMIs affect 1 in 17 people and are among the leading causes of disability and impaired health-related quality of life in the United States. Caring for childbearing women with preexisting SPMI can be challenging for maternal-child health clinicians. This article provides an overview of SPMI during pregnancy and challenges for clinicians, including early identification, accuracy of diagnoses, and appropriate management through care coordination among an interdisciplinary team that includes obstetric providers, psychiatrists, nurses, and others.

The prevalence of disrespect and abuse during facility-based childbirth in urban Tanzania.

BACKGROUND: In many countries, rates of facility-based childbirth have increased substantially in recent years. However, insufficient attention has been paid to the acceptability and quality of maternal health services provided at facilities and, consequently, maternal health outcomes have not improved as expected. Disrespect and abuse during childbirth is increasingly being recognized as an indicator of overall poor quality of care and as a key barrier to achieving improved maternal health outcomes, but little evidence exists to describe the scope and magnitude of this problem, particularly in urban areas in low-income countries. METHODS: This paper presents findings from an assessment of the prevalence of disrespectful and abusive behaviors during facility-based childbirth in one large referral hospital in Dar es Salaam, Tanzania. Client reports of disrespect and abuse (D&A) were obtained through postpartum interviews immediately before discharge from the facility with 1914 systematically sampled women and from community follow-up interviews with 64 women four to six weeks post-delivery. Additionally, 197 direct observations of the labor, delivery, and postpartum period were conducted to document specific incidences of disrespect and abuse during labor and delivery, which we compared with women's reports. RESULTS: During postpartum interviews, 15 % of women reported experiencing at least one instance of D&A. This number was dramatically higher during community follow-up interviews, in which 70 % of women reported any experience of D&A. During postpartum interviews, the most common forms of D&A reported were abandonment (8 %), non-dignified care (6 %), and physical abuse (5 %), while reporting for all categories of D&A, excluding detention and non consented care, was above 50 % during community follow-up interviews. Evidence from direct observations of client-provider interactions during labor and delivery confirmed high rates of some disrespectful and abusive behaviors. CONCLUSIONS: This study is one of the first to quantify the prevalence of disrespect and abuse during facility-based childbirth in a large public hospital in an urban setting. The difference in respondent reports between the two time periods is striking, and more research is needed to determine the most appropriate methodologies for measuring this phenomenon. The levels and types of disrespect and abuse reported here represent fundamental violations of women's human rights and are symptomatic of failing health systems. Action is urgently needed to ensure acceptable, quality, and dignified care for all women.

Suicide risk among perinatal women who report thoughts of self-harm on depression screens.

OBJECTIVE: To estimate the incidence and clinical significance of suicidal ideation revealed during perinatal depression screening and estimate the associated suicide risk. METHODS: Retrospective cohort study of women completing the Edinburgh Postnatal Depression Scale at 24-28 weeks of gestation and 6 weeks postpartum through a suburban integrated health system with approximately 5,000 annual deliveries on two hospital campuses. Suicidal ideation on the Edinburgh Postnatal Depression Scale and prediction of suicide risk were examined through multivariable modeling and qualitative analysis of clinical assessments. RESULTS: Among 22,118 Edinburgh Postnatal Depression Scale questionnaires studied, suicidal ideation was reported on 842 (3.8%, 95% confidence interval [CI] 3.5-4.1%) and was positively associated with younger maternal age (antepartum mean age 30.9 compared with 31.9 years, P=.001), unpartnered relationship status (antepartum 29.5% compared with 16.5%, P<.001 and postpartum 25.0% compared with 17.5%, P<.01), non-Caucasian race (antepartum 62.1% compared with 43.8%, P<.001 and postpartum 62.4% compared with 45.2%, P<.001), non-English language (antepartum 11.0% compared with 6.6%, P<.001 and postpartum 12.4% compared with 7.7%, P<.01), public insurance (antepartum 19.9% compared with 12.5%, P<.001 and postpartum 18.2% compared with 14.2%, P<.001), and preexisting psychiatric diagnosis (antepartum 8.4% compared with 4.2%, P<.001 and postpartum 12.0% compared with 5.8%, P<.001). Multivariable antepartum and postpartum models retained relationship status, language, relationship status by language interaction, and race; the postpartum model also found planned cesarean delivery negatively associated with suicidal ideation risk (odds ratio [OR] 0.56, 95% CI 0.36-0.87) and severe vaginal laceration positively associated with suicidal ideation risk (OR 2.1, 95% CI 1.00-4.40). A qualitative study of 574 women reporting suicidal ideation indicated that 330 (57.5%, 95% CI 53.5-61.5%) experienced some degree of suicidal thought. Six patients (1.1%, 95% CI 0.2-1.9%) demonstrated active suicidal ideation with plan, intent, and access to means. Within this highest risk group, three patients reported a suicide attempt within the perinatal period. CONCLUSION: Among perinatal women screened for depression, 3.8% reported suicidal ideation, but only 1.1% of this subgroup was at high risk for suicide. These findings support the need for systematic evaluation of those who report suicidal ideation to identify the small subset requiring urgent evaluation and care.

[Multidisciplinary care during peripartum: mother-baby dyad in the center of the relational constellations]. / Prise en charge multidisciplinaire du péripartum: le lien mère-bébé au centre des constellations relationnelles.

Pregnancy and new motherhood may be crisis and vulnerability periods and therefore increase the risk of psychiatric disorders. Liaison psychiatry plays a major role in the first psychiatric evaluation of mothers in order to specify a diagnosis and to initiate a treatment when necessary. This article describes the care of mothers suffering from peripartum psychiatric disorders by the liaison psychiatry in the maternity ward, an outpatient practice, as well as an in-patient care unit where mother and baby can stay together. The multidisciplinary approach and its constellation around the mother-baby dyad are detailed and two clinical cases are reported.

Women's experience of discrimination in Australian perinatal care: the double disadvantage of social adversity and unequal care.

BACKGROUND: Discrimination in women's health care, particularly perinatal care, has received minimal attention. The aim of this study is to describe women's experience of discrimination in different models of maternity care and to examine the relationship between maternal social characteristics and perceived discrimination in perinatal care. METHODS: A population-based postal survey was mailed 6 months postpartum to all women who gave birth in two Australian states in September and October 2007. Perceived discrimination was assessed using a five-item measure designed to elicit information about experiences of unequal treatment by health professionals. RESULTS: A total of 4,366 eligible women completed the survey. Women attending public models of maternity care were significantly more likely to report perceived discrimination compared with women attending a private obstetrician (30.7% vs 19.7%, OR 1.79, 95% CI 1.5-2.1). Compared with women reporting no stressful life events or social health issues in pregnancy, those reporting three or more stressful life events or social health issues had a twofold increase in adjusted odds of perceived discrimination (41.1% vs 20.4%, adj OR 2.27, 95% CI 1.8-2.8). Young women (< 25 yr) and women who were smoking in pregnancy were also at increased risk of experiencing perceived discrimination. CONCLUSIONS: Discrimination is an unexplored factor in how women experience perinatal care. Developing approaches to perinatal care that incorporate the capacity to respond to the needs of vulnerable women and families requires far-reaching changes to the organization and provision of care.