Issue 140, July/August 2006
Interest in postnatal depression has proliferated recently, fuelled by new research, media coverage and celebrity stories. In 2005 the Bluebell Day Campaign was launched to promote wider awareness and understanding of postnatal depression. All of this has begun to help reduce stigma and increase awareness that further support services are needed for new mothers.
Among this new research, the Confidential Enquiry into Maternal Deaths (CEMD) report Why Mothers Die 1997-1999 reinforced existing knowledge about postnatal depression - for example, the importance of past history in relation to the risk of reoccurrence - but has also brought to the forefront the shocking fact that suicide is now the leading cause of death in new mothers.
Between 1997 and 1999, 11 per cent of maternal deaths reported to the CEMD were due to psychiatric causes. The majority of coincidental psychiatric deaths were a result of an accidental overdose of heroin, and 12 per cent of indirect deaths (those not directly caused by childbirth) were due to suicide. This meant that suicide was the lead cause of indirect death and the second lead cause of death overall in the cases reported to the CEMD.(1)
This in itself was a disturbing finding. However, at the Royal College of Psychiatrists' Annual Meeting in 2002, Dr Oates (2) presented evidence that the findings were also misleading. The report had not taken into account an additional 59 deaths caused by psychiatric disorders released by the Office of National Statistics the day after the report was printed and the original data was destroyed. Originally, the findings had stated that there had been 28 suicides. However, Dr Oates has confirmed that the figure was actually 68. Moreover, the total number of psychiatric deaths (including accidental deaths from overdose) reported to be 42 by the enquiry was actually 101. (2) This now meant that 28 per cent of maternal deaths were due to suicide, which makes it the leading cause of maternal death.(1)
In keeping with earlier CEMD findings, 86 per cent of the women died violently, mainly by hanging or jumping.This is in contrast to previous suicide research, which consistently found that women are less likely to die violently and more likely to die from an overdose. In addition, compared to maternal deaths from physical causes and from substance misuse, maternal suicides were linked to being relatively socially advantaged and supported, and having higher education. This confirms recent suicide research which indicates that female suicide is less associated with unemployment, adversity, single status and divorce than is male suicide.
The CEMD findings have highlighted a number of directions within health care. There were very few instances where either the psychiatric or maternity services had been aware of the women's past history and risk of reoccurrence following delivery, and even fewer where plans had been put in place to support the women. This points to the need for enquiry into the past psychiatric history of patients at antenatal bookings. Oates suggests that almost half of the women who died from suicide might still be alive if this had happened and plans for support had been put in place.
Since the publication of the CEMD findings, such concerns and recommendations are beginning to be met. In 2002, the SIGN Guideline (60) for Postnatal Depression and Puerperal Psychosis was published, providing guidelines for the diagnosis, intervention and prevention of perinatal illness. This has led to an increased awareness of perinatal illness and greater provision of services and support for women in the perinatal period.
In addition, Integrated Care Pathways (ICP) for Perinatal Mental Illness are now being rolled out around the country. These are multidisciplinary outlines of anticipated care, placed in an appropriate timeframe, to help a patient with a perinatal mental illness move progressively through a clinical experience to positive outcomes. Although there are teething problems, the ICP for Perinatal Mental Illness is helping guide health professionals who work with this client group to identify and treat postnatal depression more effectively. Clearly, the recognition of postnatal depression as an important area of mental health services has been gaining pace. However, there is still a long way to go in raising awareness and implementing services.
1. Oates M. (2003) 'Suicide: the leading cause of maternal death',British Journal of Psychiatry 183: 279-81.
2. 'Suicide leading cause of deaths among new mothers'. Press release from The Royal College of Psychiatrists: Annual Meeting:Psychiatry Today, 2002.