An “urgent” need to improve training in perinatal mental illness for healthcare professionals is needed, according to an inquiry into maternal deaths, which found “major” gaps in care.
An in-depth five-year investigation into deaths of mothers after giving birth in the UK and Ireland found that, in half of the 93 cases of suicide it was able to analyse, improvements to care would have made a difference to the outcome.
The inquiry’s report, called Saving Lives, Improving Mothers’ Care, found maternal deaths from direct causes – related to complications of the pregnancy – had continued to decrease over the years.
“[There was]a lack of an individual taking overall responsibility for each woman, which is symptomatic of the increasing division of care into sub-specialties”
Saving Lives report
But maternal death rates from indirect causes – existing diseases or those that had developed and were made worse by pregnancy, such as mental health – were still high.
The investigation looked at evidence from 2009 to 2013. In this period around 160 women died from psychiatric causes – 101 by suicide and 58 as a consequence of substance misuse.
The majority of these – 129 – occurred between six weeks and one year after pregnancy, being classed as “late” maternal deaths.
Late maternal deaths were of “particular relevance to high resource countries, where women may be kept alive by supportive therapies for many weeks or months after their pregnancy-related or pregnancy exacerbated illness” noted the report.
“Junior medical or nursing staff may not have the breadth of experience to recognise herald symptoms, such as mounting anxiety”
Saving Lives report
Those behind the investigation said clinicians needed to be better trained in perinatal mental health, particularly around the speed at which the illness can deteriorate.
Other problems identified by the investigation included insufficient communication between primary care, maternity and mental health services.
It found that in at least 30% of women with a prior history of mental health who then died by suicide, “significant” information about their past psychiatric history had not been passed between services.
Other issues included a lack of senior assessment of some women, and a possible failure to recognise symptoms of mental health by more junior workers.
“Junior medical or nursing staff may not have the breadth of experience to recognise herald symptoms, such as mounting anxiety,” said the report.
“They may misattribute symptoms to normal emotional changes associated with childbirth, under-diagnose psychotic disorder, or fail to take into account the natural history of rapid deterioration in postpartum psychosis, which requires early and frequent reassessment,” it said.
The report also noted seven women who died by suicide voiced strong beliefs that they had no relationship with their baby or had arranged for the baby to be cared for by others.
It said this was a new finding and should be considered a “red flag behaviour” – an instance that prompts urgent senior psychiatric assessment.
“Employers should now ensure [nurses and midwives] have the training, and the time, to support better mental health of mothers”
The inquiry looked at the range of causes of maternal deaths, which also included conditions such as thrombosis, cardiac disease, sepsis and cancer.
In its conclusion, it found that throughout the review there was evidence of “fragmented” care.
“[There was] a lack of an individual taking overall responsibility for each woman, which is symptomatic of the increasing division of care into sub-specialties. This was particularly evident postnatally,” said the report.
“Every member of healthcare staff has a responsibility to ensure that women have appropriate care, even if it is outside their specialty area, and should take personal responsibility for ensuring she has proper follow-up arranged; a letter to the GP will not suffice,” it added.
In response to the report, the president of the Royal College of Paediatrics and Child Health, Neena Modi, noted health visitors were ideally placed to identify early signs of maternal mental health.
“To support women, and subsequently their children, we must ensure every family has access to health visiting services,” she said.
However, she noted the planned £200m in-year cuts to public health budgets would place health visitors under “immense strain” and called upon the government to reverse its decision.
Carmel Bagness, professional lead for midwifery and women’s health at the Royal College of Nursing said: “Midwives and nurses know how important openness and understanding is when it comes to mental health.
“Their employers should now ensure they have the training, and the time, to support better mental health of mothers,” she said.
“The huge cuts in the public health budget are going to once again lead to under resourcing of the service”
Dr Cheryll Adams, director of the Institute of Health Visiting, said: “Once again perinatal illness is found to be a key contributor to maternal death in the first year of a child’s life – with about a quarter of women who died between six weeks and one year after pregnancy dying from mental health related causes.
“Despite recent government investment in the health visiting service, which has reduced health visitor caseloads and enabled better support to families, the huge cuts in the public health budget are going to once again lead to under resourcing of the service,” she said. ”Already student commissions have been reduced.”
Dr Adams added: “We know from the last time the service was cut, just 10 years ago, that this is likely to have a very significant impact on outcomes for children and families, including maternal mental health.
“We call on the government to reconsider their public health cuts, or to find a way to ring fence health visiting services from those cuts, thereby protecting the results of its impressive policy from the last parliament,” she said.