Wilkinson reported that the Royal College of Psychiatrists is concerned by the failure of one in six NHS trusts to still not report whether they do the antenatal booking appointment mental health check(1) as recommended by NICE 9 years ago.(2)
However, highlighting perinatal mental illness as the leading cause of maternal death in the first year after birth using the MBRRACE-UK programme that runs the Confidential Enquiry(3) is wrong for four reasons:
i) the majority of maternal suicides occur between six weeks and a year after pregnancy while thrombosis and thromboembolism remain the leading cause of direct deaths occurring within 42 days of birth.(3) Similarly, in France, cardiovascular death and suicides rank first (14% each) for maternal death, the latter occurring after 42 postnatal days in 77% of cases (mean, 4 months);(4)
ii) suicide has complex roots including precariousness, isolation, psychiatric history(s), painful life events or complications during pregnancy/childbirth.(5) Focusing on a single, usually first trimester, mental health check can hardly be the solution for preventing suicide well over a year later;
iii) the UK’s Maternal Mental Health Alliance is a genuine beacon;
iv) the increase in (very small number) suicides from 0.46 to 1.48 per 100,000 pregnant women between 2017-19 and 2020 suggest a social crisis, and potential pandemic effects, rather than poor early pregnancy care for one sixth of the population.
Certainly, screening for mental health must be better implemented and NHS England’s failure to comment when requested is disappointing.(1) Standards must be raised: e.g. identifying women with a very high probability of elevated anxiety and/or depressive symptoms using relatively modifiable factors such as challenges in roles and poor partner relationship.(6) A medicalized and silo strategy cannot be the solution in an unfriendly society impacting the general health of the most vulnerable citizens, and citizens-to-be.
1. Wilkinson E. Psychiatrists urge NHS England to improve data on antenatal mental health screening. BMJ. 2023;381:1015. doi:10.1136/bmj.p1015
2. National Institute of Health and Social Care Excellence Antenatal and postnatal mental health: clinical management and service guidance 2014 (updates 2020) https://www.nice.org.uk/guidance/cg192
3. MBRRACE-UK Saving Lives Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. 10 November 2022. https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-a…
4. Doncarli A, Gorza M, Gomes E, Cardoso T et al. Suicide en période périnatale: données épidémiologiques récentes et stratégies de prévention [Perinatal suicide: recent epidemiological data and prevention strategies.] BEH 2003;3-4 :68-79. https://www.santepubliquefrance.fr/content/download/517864/3816766?versi…
5. Orri M, Russell AE, Mars B, Turecki G, Gunnell D, Heron J, Tremblay RE, Boivin M, Nuyt AM, Côté SM, Geoffroy MC. Perinatal adversity profiles and suicide attempt in adolescence and young adulthood: longitudinal analyses from two 20-year birth cohort studies. Psychol Med. 2022;52(7):1255-1267. doi: 10.1017/S0033291720002974
6. Adhikari K, Racine N, Hetherington E, et al. Women’s Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada. Can J Psychiatry. 2023 Apr;68(4):269-282. doi: 10.1177/07067437221140387.
Psychiatry, maternal death and silo interpretation