Assisted reproductive technologies could be associated with higher risk of parenting difficulties in women with postpartum major depression.

No increased risk of postpartum major depression (PPMD) was reported in women conceiving through assisted reproductive technologies (ART). However, ART may be associated with a higher risk of parenting difficulties in women with PPMD. In 359 women with a PPMD admitted to a Mother-Baby Unit (MBU), ART-women (4.2%) showed a 5-fold higher rate of parenting difficulties than those with spontaneous pregnancy (73.33% vs. 35.17%, multivariate ORa = 5.09 [1.48-17.48] p = 0.01). Specific support for mother-child relationship should be implemented in ART-women with PPMD.

Impact of paternal psychiatric disorders on parents-baby separation after mother-baby unit care.

BACKGROUND: Paternal mental health may have an impact on parenthood especially in case of maternal postpartum severe psychiatric illness. OBJECTIVE: The aim of this study was to search for an association between paternal psychiatric disorder and parents-baby separation after a maternal joint hospitalization for a severe postpartum psychiatric episode. PARTICIPANTS AND SETTINGS: In an observational, naturalist and multicentric study, 787 fathers whose partner was hospitalized in a mother-baby unit were included. METHODS: Fathers were assessed for psychiatric diagnoses associated with parents-baby separation. RESULTS: 25 % of the fathers had a psychiatric disorder. 69 babies (8.77 %) were separated from their parents at the end of the joint hospitalization. In multivariate analysis, parents-baby separation was associated with a paternal diagnosis of addictive disorder (OR = 8.35, 95 % CI [3.45-30.30]) and psychotic disorder (OR = 5.76, 95 % CI [1.97-16.78]), independently from potential confounding variables including maternal psychiatric diagnosis. CONCLUSIONS: This study shows the major impact of a paternal psychiatric disorder in the outcome of a joint hospitalization. A paternal mental illness should be systematically looked for in case of a severe maternal postpartum psychiatric episode, considering it is predictive of parenthood difficulties.

Pathways between Risk/Protective Factors and Maternal Postnatal Depressive Symptoms: The ELFE Cohort.

OBJECTIVE: The risk factors for postnatal depressive symptoms (PNDS) are numerous, but little is known about the protective factors or the interactions between different exposures. The present study explored the pathways between maternal, infant and parenthood vulnerabilities or risk/protective factors and PNDS at 2 months postpartum (PP) in a large sample of women from the general population. METHODS: We used data from the French ELFE cohort, a nationally representative cohort of children followed-up from birth. The available information about vulnerabilities or risk/protective factors for PNDS was collected during the maternity ward stay (mother or medical records) and at 2 months PP (mother by phone). PNDS were evaluated with the Edinburgh Postnatal Depression Scale (EPDS) at 2 months. A measurement model was built based on the psychosocial model for PNDS of Milgrom and colleagues using exploratory factor analysis. The Structural Equation Model was used to investigate the pathways between vulnerability, risk/protective factors and PNDS at 2 months PP. RESULTS: In the study sample (n = 11,583), a lack of a partner's perceived antenatal emotional support, consultation with a mental health specialist before pregnancy, family financial difficulties, prenatal psychological distress and a difficult pregnancy experience were directly associated with the severity of maternal PNDS at 2 months PP, as well as lack of perceived postnatal support. Family financial difficulties and consultation with a mental health specialist before pregnancy were also indirectly associated with the intensity of PNDS through a lack of perceived antenatal emotional support, a difficult pregnancy experience, prenatal psychological distress and a lack of perceived postnatal support. Regarding infant and parenthood characteristics, infant self-regulation difficulties, maternal difficulty in understanding infant crying and infant hospitalisation were directly associated with PNDS severity at 2 months PP, while maternal difficulty in understanding an infant's cries was also indirectly associated with infant self-regulation difficulties. CONCLUSIONS: Perinatal professional support should begin antenatally and target the couple's prenatal functioning, with particular attention to women presenting a history of psychiatric disorders, especially those of low socioeconomic status. After delivery, addressing infant and parenthood characteristics is also recommended.

Comorbid borderline personality disorders in women with post-partum depression admitted to mother-baby units.

Borderline personality disorder (BPD) is associated with perinatal depression and parenting difficulties. However, little is known about the characteristics and specific effects of BPD in women with postpartum depression. This study aimed to explore 1) the sociodemographic, mental health characteristics, and motherhood difficulties in women with a major depressive postpartum episode (MDPE) and a comorbid diagnosis of BPD, compared to those with other personality disorders (other PD) or no PD and 2) whether BPD itself may be an independent risk factor for infant neglect in women with a MDPE. 412 women admitted to a Mother and Baby Unit (2001-2010) with a MDPE were involved in this study. Our study showed that women with MDPE-BPD (n = 64) more frequently reported a history of childhood maltreatment, single status, low social support, a history of depression, smoking during pregnancy and suicide attempt during the perinatal period compared to women with other PDs (n = 88) or no PD (n = 260). Women with comorbid BPD had a greater length of stay. Regarding infant care, neglect, abuse, and separation at discharge were more frequent in women with comorbid BPD. Logistic regression was performed to specifically examine whether BPD in women with a MDPE was an independent risk factor for infant neglect during the postpartum period. Comorbid BPD was independently associated with infant neglect (OR = 2.21; CI95% [1.02-4.81]). Our results underline the importance of screening for BPD in women with perinatal depression. Further studies are needed to explore the links between MDPE, BPD, and infant development.

Bipolar disorder in the postpartum period: the impact of a prenatal mood episode on maternal improvement at postpartum discharge after joint inpatient hospitalization.

Bipolar disorder (BD) is linked to a high risk of relapse in the year postpartum. The aim of this study was to search for an association of a mood episode during pregnancy with a lack of maternal improvement after a post-partum episode requiring joint hospitalization. In an observational, naturalist, and multicentric study, 261 women suffering from a BD and jointly hospitalized with their child in a Mother-Baby Unit (MBU) were assessed for risk factors associated with a lack of maternal improvement at discharge. A directed acyclic graph (DAG)-based approach was used to identify confounders to be included in a multiple regression model. In bivariate analyses, a lack of improvement (16.9%) was associated with pregnancy specificities (decompensation, psychotropic treatment, antipsychotics, and benzodiazepines intake), as well as maternal smoking during pregnancy and baby's neonatal hospitalization. In a multivariate analysis based on DAG, a lack of improvement was linked to psychiatric decompensation during pregnancy (OR = 3.31, 95%CI [1.55-7.35], p = 0.002), independently from maternal age, mother's maltreatment during childhood, low level of education, single status, low familial social support, and diagnosis of personality disorder. This study shows the critical importance of mental health during pregnancy in women with BD. Clinical screening and evaluation of the benefit/risk balance of psychotropics during pregnancy are essential.

Perinatal mental health around the world: priorities for research and service development in France.

France has a long tradition of concern for maternal and perinatal mental health. However, the national organisation of psychiatric care does not yet provide structured guidelines on the organisation of perinatal psychiatric care. This paper provides an update on existing resources and their linkage to primary care and obstetric and paediatric services, as well as a review of current and future national priorities that are under development.

Impact of a prenatal episode and diagnosis in women with serious mental illnesses on neonatal complications (prematurity, low birth weight, and hospitalization in neonatal intensive care units).

Pregnancy in women with mental disorders is increasingly common. The aim of this study was to determine, in women with severe mental illnesses, whether a prenatal episode was related to neonatal complications and if a specific disorder was associated with a higher risk. A population of infants and their mothers (n = 1439) jointly admitted to psychiatric Mother-Baby Units in France and Belgium (2001-2010) was assessed respectively for prematurity, low birth weight (LBW), hospitalization in neonatal intensive care units (NICUs), and maternal mental health during pregnancy. Logistic regression was used to explore the association between neonatal complications and a prenatal episode of mental illness and if the presence of a specific disorder was related to a higher risk, taking into account maternal socio-demographic characteristics, pregnancy data, and antenatal exposure to psychotropic drugs. Among the children, 145 (10.2%) were premature, 226 (15.8%) had a LBW, and 348 (24.3%) have been hospitalized in neonatology. The presence of an episode of mental illness during pregnancy was linked to LBW (OR = 2.21 [1.44-3.38]; p = 0.003) and NICU hospitalizations (OR = 1.53 [1.06-2.19], p = 0.002). Among diagnoses, the presence of a severe substance use disorder in these women was related to LBW (OR = 2.96 [1.49-5.85]; p = 0.002) and NICU (OR = 2.88 [1.56-5.29]; p = 0.04). Our results underline the importance of systematic and early detection of psychiatric symptoms and substance use disorders during pregnancy in preventing neonatal complications in women with serious mental illness.

Pregnancy in women with psychotic disorders: risk factors associated with mother-baby separation.

Pregnancy in women suffering from psychotic disorders is becoming more common. However, this psychiatric disorder is linked to the highest risk of early mother and child separation. The aim of this study was to evaluate risk factors associated with these separations. In an observational, naturalist, and multicentric study, 320 women suffering from a psychotic disorder and jointly hospitalized with their child in one of the sixteen mother-baby units (MBUs) in France and Belgium between 2001 and 2010 were assessed for risk factors associated with mother-child separation. Eighty-seven (27.2%) mothers were separated from their infant at discharge from MBUs. Early separation was linked to the placement of the mother herself in an institution in childhood (OR 4.44; CI 95% 1.12-18.69), to the mother being single (OR 3.84; CI 95% 1.38-11.44), to early hospitalization of the baby in neonatology (OR 2.88; CI 95% 1.27-6.59), and to maternal psychiatric decompensation during pregnancy (OR 2.60; CI 95% 1.15-6.20), independently from maternal neglectful behaviors. Low family/social support showed a trend towards association with separation (OR 2.17; CI 95% 0.91-5.42). This study shows that separation is mostly linked to mothers' environmental and interactive past and current history, to the child's health, and to maternal mental health decompensation. The identification of these factors is essential to implement antenatal prevention and social programs for these women. Further studies should focus on the long-term development of children of schizophrenic mothers, whether or not they have been placed, in order to help clarifying the impact of the risk factors.

Risk factors for suicide attempt in pregnancy and the post-partum period in women with serious mental illnesses.

Suicide is a major public health concern worldwide, and mental disorders have been identified as a main risk factor. Suicide is also one of the leading causes of perinatal maternal mortality, but very few studies have focused on suicide attempts (SA) in the perinatal period. This work aims to assess risk factors associated with SA in pregnancy and in the post-partum period in women with mental health disorders. Women (n = 1439) with psychiatric disorders jointly admitted with their infant to 16 psychiatric Mother-Baby Units over 10 years (2001-2010) were assessed retrospectively for the occurrence of SA in pregnancy or the postpartum period. Multinomial logistic regression was used to explore the independent impact of maternal sociodemographic characteristics, history of childhood maltreatment and abuse, current mental illness and pregnancy data on SA in pregnancy and/or postpartum. One hundred and fifty-four women (11.68%) attempted suicide: 49 in pregnancy (3.71%) and 105 (7.97%) in the post-partum period. SA in pregnancy was related to alcohol use (OR = 2.37[1.02-5.53]; p = 0.04) and smoking during pregnancy (OR = 1.87[1.01-3.49]; p = 0.04) and also to a history of miscarriage (OR = 2.29[1.18-4.41]; p = 0.01). SA in the post-partum period was associated with major depressive episode (OR = 2.72[1.40-5.26]; p = 0.003) or recurrent depression (OR = 4.12[2.25-7.51], p < 0.001) and younger age (OR = 0.96[0.93-0.99], p = 0.03). SAs in the course of pregnancy and the postpartum period have different risk factors. Special attention to risk of suicide is needed during pregnancy for women with severe mental illness and a history of miscarriage, alcohol or cigarette use, young age and depression in the perinatal period.

An international position paper on mother-infant (perinatal) mental health, with guidelines for clinical practice.

The purpose of this paper is to set out informal, provisional and comprehensive but concise guidelines for mother-infant (perinatal) mental health (psychiatry), as an area of specialisation. It is informal in the sense that the authors are clinicians and researchers from many different nations, who share a common goal and vision, speaking on their own behalf and not with the backing of any authority or society. It is provisional in the expectation that it can be improved by criticism and new research findings. It is a comprehensive summary of the development of the specialty, its core knowledge and recommended investigations and interventions. It is concise (under 6,000 words, taking less than an hour to read) in order to increase readership and facilitate translation. No attempt has been made to parade the evidence for these suggestions, because the document would have been too long to translate, and for many to read. Instead, drafts were circulated for criticism by those included in the authorship, resulting in a consensus (finalised by the three principal authors), providing a framework to guide service provision, clinical practice and research. The full list of authors, from 33 nations, is given in the postscript. They include mother-infant (or parent-infant) and perinatal adult or child psychiatrists and those with a special interest; mother-infant, perinatal and forensic psychologists; psychiatric nurses; the founders of Postpartum Support International and the Association for Postnatal Illness; representatives of social work and obstetrics and the management of these services, and research scientists working in the field.

Tobacco and alcohol use in pregnancy in France: the role of migrant status: the nationally representative ELFE study.

INTRODUCTION: Tobacco and alcohol use in pregnancy are modifiable yet frequent risk factors of poor perinatal outcomes. We examined whether characteristics associated with substance use in pregnancy vary between native and migrant women, who often differ in terms of socio-demographic characteristics. METHODS: Data come from a nationally representative sample of children born in France in 2011 (ELFE study, n=18,014). Maternal substance use in pregnancy (tobacco: ≥1 cigarette/day, alcohol: ≥1 time, binge drinking: ≥3 units of alcohol on one occasion) was assessed using survey methodology by a) trained interviewers and b) self-reports. Migration status was determined based on country of birth (native-born vs. migrant). The sample included 2330 migrant women, predominantly from North Africa (35.4% - primarily Algeria and Morocco), Sub-Saharan Africa (27.3% - primarily Senegal, Ivory Coast, the Congo and Cameroun), Europe (20.2% - primarily Portugal and Germany) and Asia (10.2% - primarily Turkey). Characteristics potentially associated with substance use included socio-demographics (maternal age, number of children, relationship status, educational attainment, employment status), health (psychological difficulties, incomplete prenatal care) and partner's characteristics (migration status, employment). RESULTS: Compared to the native-born, migrant women had lower levels of tobacco smoking (8.8 vs. 21.9%) and alcohol use (23.4 vs. 40.7%), but not binge drinking (2.9 vs. 3.3%). Unfavorable socioeconomic circumstances were associated with tobacco smoking in native-born women only. Single parenthood was associated with alcohol use only in migrant women. In migrant women, co-occurring use of another substance and psychological difficulties were more strongly associated with use of tobacco, alcohol or binge drinking than in native-born women. CONCLUSIONS: Migrant women have less favorable socioeconomic characteristics than native women but are generally less likely to use tobacco and alcohol in pregnancy. However those who experience single-parenthood need special attention, as they are disproportionately likely to use psychoactive substances which put them and their children at risk of poor health outcomes.

Impact of prenatal exposure to psychotropic drugs on neonatal outcome in infants of mothers with serious psychiatric illnesses.

OBJECTIVE: To assess whether prenatal exposure to 4 major classes of psychotropic drugs compared with no exposure differed with respect to neonatal outcome. METHOD: We used the database collected from 13 mother-baby units (MBUs) by the French Network of MBUs. The Marcé Clinical Checklist was used to collect data from maternal interview and clinical record with respect to maternal demographic and clinical characteristics, prenatal exposure to psychotropic drugs, and neonatal outcome (birth weight, preterm birth, neonatal hospitalization). Multivariate logistic regression was used to explore the independent impact of each therapeutic class of psychotropic drug (antipsychotics, antidepressants, mood stabilizers, and anxiolytics/hypnotics) on infant outcomes. All the models were adjusted for maternal confounding factors. RESULTS: The sample included 1,071 women and their infants. Nearly half (40.2%) used at least 1 psychotropic drug during pregnancy. The risk of low birth weight was increased by antenatal exposure to mood stabilizers (adjusted odds ratio [aOR] = 2.04, 95% confidence interval [CI] = 1.03-4.04, P = .04). The risk of neonatal hospitalization was increased by prenatal exposure to antipsychotics (aOR = 1.74, 95% CI = 1.19-2.54, P = .004), antidepressants (aOR = 1.59, 95% CI = 1.05-2.41, P = .03) or anxiolytics/hypnotics (aOR = 1.89, 95% CI = 1.30-2.75, P = .001), independent of birth weight and term delivery status. CONCLUSIONS: Infants exposed to psychotropic drugs during pregnancy have less optimal neonatal outcome than unexposed infants and should be considered as a high-risk population.

Treatment - mother-infant inpatient units.

Infants of parents with psychiatric disorders may be particularly vulnerable and have a higher risk of developing psychiatric disorders in adulthood. Until the second half of the 20th century, women and infants were cared for separately. Today, hospitalisation of women with their babies in psychiatric mother-baby units enables psychiatric care of women and promotion of parent-infant interactions and child development. The distribution of psychiatric mother-baby units around the world, as well as within countries, varies strongly. Reasons for this may be related to the absence of national perinatal mental health policies related to psychiatric mother-baby unit location, differences in sources of referral for admission, and criteria for psychiatric mother-baby unit admission. Two principal national epidemiologic studies, in England and in France and Belgium, have described issues related to discharge from such care, as have smaller local studies, but no epidemiologic studies have yet demonstrated that joint inpatient psychiatric mother-baby unit care is cost-effective compared with separate care.

Predictors of infant foster care in cases of maternal psychiatric disorders.

PURPOSE: Our aim was to investigate the factors associated with mother-child separation at discharge, after joint hospitalization in psychiatric mother-baby units (MBUs) in France and Belgium. Because parents with postpartum psychiatric disorders are at risk of disturbed parent-infant interactions, their infants have an increased risk of an unstable early foundation. They may be particularly vulnerable to environmental stress and have a higher risk of developing some psychiatric disorders in adulthood. METHODS: This prospective longitudinal study of 1,018 women with postpartum psychiatric disorders, jointly admitted with their infant to 16 French and Belgian psychiatric mother-baby units (MBUs), used multifactorial logistic regression models to assess the risk factors for mother-child separation at discharge from MBUs. Those factors include some infant characteristics associated with personal vulnerability, parents' pathology and psychosocial context. RESULTS: Most children were discharged with their mothers, but 151 (15 %) were separated from their mothers at discharge. Risk factors independently associated with separation were: (1) neonatal or infant medical problems or complications; (2) maternal psychiatric disorder; (3) paternal psychiatric disorder; (4) maternal lack of good relationship with others; (5) mother receipt of disability benefits; (6) low social class. CONCLUSIONS: This study highlights the existence of factors other than maternal pathology that lead to decisions to separate mother and child for the child's protection in a population of mentally ill mothers jointly hospitalized with the baby in the postpartum period.