Introduction
The perinatal frame of mind is a concept that aims to capture the unique mental state, context and experiences of individuals planning a pregnancy and during the perinatal period, which spans from conception to one year postpartum. The term was coined by a group of clinicians tasked by Health Education England and The Tavistock and Portman NHS Trust in 2018 to develop a competency framework for professionals working with women who have perinatal mental health problems [1]. We hope that this chapter and textbook epitomise what they meant by the perinatal frame of mind: the concept that every aspect of the physical, social, psychological and psychiatric care of women in the perinatal period requires a deep understanding of them as individuals.
Such understanding needs to encompass many aspects of a woman’s life, from childhood to her current context, including traumatic and positive experiences, cultural factors, both good and bad relationships, experiences of mental and physical illness and their risks and relevance to the perinatal context, her journey to becoming pregnant, and her personal strengths and challenges. The term asks that we think not only about the woman, her well-being and needs, but also those of the fetus or infant, the intimate partner and/or co-parent, and other family members. It means that we consider the relationships between the parents and the infant, as well as within the couple and among other family members. In essence, we don’t just think about the individual woman, we hold in mind the community and cultural context surrounding them, which will include the partner, family, friends and, very often, and importantly, healthcare professionals, who can provide the right kind of support to help navigate any mental health challenges.
The focus of the perinatal frame of mind is on relating and relationships and how these affect and are affected by the woman’s mental health condition and the perinatal context. Hence, working with the woman and her family means that we pay particular attention to who she is and where she has come from within her life. Vikram Patel has written about the universal right to mental health and how this must always be embedded in the right to be protected from known harms to mental health and the right to agency, freedom, inclusion, and dignity in mental health care [Reference Patel2]. His statement neatly pulls into our thinking the need to not only care for women with mental health problems but also to ensure that there is as little harm as possible to the woman and others, particularly the infant, caused by the disorders. It also implies that treatment should be provided with great care, respect and dignity within our services. The perinatal frame of mind, in addition, asks that we as clinicians develop the skills to reflect on and to be aware of our own emotional responses to the complex work of maternal mental health and perinatal psychiatry. We need to reflect on and understand our own attitudes, values and cultural influences in terms of how we view motherhood, and what our own expectations are of the families we meet. This will lead naturally to us thinking about our own experience of being parented and for many, being parents. Many clinicians training in perinatal psychiatry are at an age when they themselves are becoming, or considering becoming, parents with all that this entails for them. This may affect how they experience the clinical role and the often-unsettling themes and scenarios that they must deal with. Therefore, reflective practice, good and regular supervision and, when required, access to personal therapy, all play important roles in supporting the development of clinicians and ensuring best outcomes for services and the individuals and families they offer care to.
William Osler’s (1849–1919) words, ‘it is much more important to know what sort of a patient has a disease than what sort of a disease a patient has’, serve as a reminder that there is an obligation to understand the individual woman, her relationships and her life experience so that we can best make sense of why she is presenting to clinical services now and what approaches can best help her at this critical time in both her and her family’s lives. We want to know ‘who is she?’.
The Experience of Pregnancy and New Motherhood
The term matrescence was coined by the anthropologist Dana Raphael as ‘the process of becoming a mother – a developmental passage where a woman transitions, through pre-conception, pregnancy and birth, surrogacy, or adoption to the postnatal period and beyond’ [Reference Raphael3]. It alludes to the profound environmental, hormonal and neurobiological changes that mark the transition to motherhood as an extremely significant biopsychosocial life event and an important developmental stage in the lives of those who give birth. Orchards et al.’s paper [Reference Orchard, Rutherford, Holmes and Jamadar4] compared matrescence to adolescence where there are not only major hormonal and social changes but also morphological changes to the maternal brain occurring across pregnancy. The functional and structural neuroplasticity of matrescence primes the brain to prepare for developing and acquiring the skills and knowledge for parenthood.
Pregnancies may be planned or unplanned, wanted or unwanted, happen with ease or following years of lack of success, investigations and interventions, be a source of joy or fear and anxiety, be accompanied by optimism about the future or profound personal, political, economic and ecological pessimism. Each woman comes to her pregnancy with different circumstances and thinking, worries, preoccupations and hopes. The changes in her physical state and physiology may make her feel well and positive or may expose a vulnerability that makes her feel physically quite undone. Society, particularly through the media, often portrays an idealised picture of pregnancy and early motherhood. This may include unrealistic expectations of her appearance, her emotional state, the time needed for physical recovery and her ability to balance multiple aspects of her life. These ideas and images can be alienating and lead to feelings of inadequacy if the woman’s experiences don’t match these expectations.
Each woman will likely experience a profound shift in perspective accompanied by emotional, physical, social and intellectual upheaval during pregnancy. There will be much anticipation and preparation for the arrival of a new life, an increased focus on her health and well-being and that of the baby, heightened awareness of bodily changes, increased concern about potential risks, and a desire to create as safe and nurturing an environment for the child and family as possible. As new mothers they have additional responsibilities and increased cognitive demands, whilst attending to their own needs and existing responsibilities, and recovering physically and emotionally from childbirth. Her experience of childbirth is critical in how she adjusts to the early postpartum period. The birth is highly likely to be intense and transformative, often involving a mix of excitement, fear, joy, physical discomfort and pain. Traumatic births may lead to significant distress and morbidity (see Chapter 11, ‘Anxiety Disorders’) and may influence her adjustment and transition to parenthood. This transition often involves a significant shift in identity and role and with it the realisation that she now carries an immense responsibility for the new life of her infant, through their childhood and into early adulthood. She may begin to think about her own early relationships and how she will be as a parent, which can be particularly challenging for women who have experienced childhood adversity. There will be psychological and practical adjustments with changes in how she perceives herself, her relationships, daily routines, personal goals, values and priorities. As author Lucy Jones commented, ‘the pregnant woman hovers between internal and external worlds, at a crossroads of past, present and future; self and other’ and that motherhood took her ‘to the edge of what it means to be human’ [Reference Jones5].
There is likely to be a developing awareness by the mother of societal and cultural expectations of motherhood. This may come from social media, mainstream cultural influences, healthcare and other allied professionals, work colleagues, as well as from her partner, extended family and friends. Her perception of and response to these expectations may make her feel happy and accomplished or place her under strain, make her feel inadequate, frustrated, scrutinised and judged. Societal expectations of mothers vary by culture, and may shape the woman’s experience in profound ways. Some cultures may place a high value on extended family support, while others expect mothers to be largely independent or return to work quickly after childbirth. Parenting practices vary considerably across cultures and within societies and include the role of the extended family, and approaches to feeding, sleeping and comforting the infant. These cultural expectations may complicate how an individual mother experiences the transition to parenthood with or without any mental health problems, as they may feel torn between their own needs, the style of caregiving they wish to deliver and the expectations placed on them by their families or communities. This can be additionally complex for intercultural couples if there are conflicting expectations from their different cultures.
In 1953, Donald Winnicott, a renowned British paediatrician and psychoanalyst, developed the concept of the ‘good enough mother’ as part of his work on early childhood development, psychoanalytic theory of attachment and the psychological formation of the child [Reference Winnicott6]. He introduced this idea to emphasise the importance of a mother’s responsiveness to her child’s needs, but also her ability to allow her child to experience some frustration and discomfort, which ultimately contributes to the child’s emotional and psychological development. His idea of the ‘good enough mother’ challenged the idealised image of a mother who is attuned to her child’s every need or want in a self-sacrificing way and suggested that it is more important for a mother to be ‘good enough’. She must be sufficiently present and responsive in the early years but not perfect. He believed that the child develops resilience from not always having their needs met instantly. The ‘good enough mother’, while providing a secure environment for the infant to feel safe, loved and nurtured, would also allow the infant to experience the ordinary frustrations of life, enabling the child to gradually become more independent and develop a sense of self. Her imperfections – such as moments of frustration or fatigue – are seen as essential for the child’s emotional growth because they help the child to understand that not all needs can be instantly fulfilled and that the world is not always perfectly responsive. By this, he attempted to reframe societal expectations of motherhood so that instead of striving for unattainable perfection, the more compassionate and realistic image of the ‘good enough mother’ allowed space for the child to grow, learn and adapt, whilst also enabling a secure and loving attachment to develop:
A mother is neither good nor bad nor the product of illusion, but is a separate and independent entity: The good-enough mother … starts off with an almost complete adaptation to her infant’s needs, and as time proceeds she adapts less and less completely, gradually, according to the infant’s growing ability to deal with her failure. Her failure to adapt to every need of the child helps them adapt to external realities. [Reference Winnicott7]
Writers have tried to explore societal expectations and women’s responses to them over many decades. Adrienne Rich, an American poet, essayist and feminist, wrote extensively about the complexities of motherhood, often exploring its psychological, political and social dimensions. One of her most significant works on the subject is her book Of Woman Born: Motherhood as Experience and Institution, written in 1976, where she delved into the duality of motherhood as both a deeply personal experience and an institution shaped by cultural expectations and power dynamics [Reference Rich8]. Her writings on motherhood presented a critical exploration of how motherhood is shaped by both personal feelings and societal structures, examining how motherhood is often idealised and romanticised in society as a pure, selfless role for women. She noted the way society has historically used motherhood to control and limit women’s autonomy, contributing to women’s oppression, and confining them to traditional roles that restrict their freedom and potential. She also, however, recognised that motherhood can be a profound, transformative experience and acknowledged the deep emotional connection that many mothers feel towards their children and the complexities and challenges of mother–child relationships, highlighting the tension between the personal experience of motherhood and the societal expectations that contain it. She said, ‘but before we were mothers, we have been, first of all, women, with actual bodies and minds’, highlighting the profound changes in self that motherhood can bring for many women.
Rachel Cusk, a British novelist and essayist, also addressed the complexities of motherhood in her memoir A Life’s Work: On Becoming a Mother, with a frank perspective based on her own experience of becoming a mother [Reference Cusk9]. She reflected on her struggle with the expectations placed on women, particularly in terms of how they are supposed to embody selflessness and nurturing qualities and grappled with the ambivalence and emotional difficulties that can accompany the transition into motherhood. She examined how culture can pressurise women to feel that they must be naturally fulfilled by motherhood or that they should feel entirely devoted to their children, without room for personal doubt or self-interest. She addressed her disorientation on becoming a mother and the way it affected her sense of identity, whilst noting the feelings of isolation, the overwhelming nature of caring for a child, and the way it reshaped both her inner life and her external relationships. She said: ‘As it stands, motherhood is a sort of wilderness through which each woman hacks her way, part martyr, part pioneer; a turn of events from which some women derive feelings of heroism, while others experience a sense of exile from the world they knew.’
There can be an unspoken assumption that when a woman gives birth, she immediately experiences an instinctive, all-encompassing love for and connection with her baby. This of course does happen for many women, but it is not universal and often not immediate. The birth may leave the woman exhausted, frightened, traumatised and in pain so that she is unable to access a positive emotional response to the baby. Women can feel alienated, distressed, guilty and perplexed if they don’t meet the expectation of an intense emotional connection to the infant. Following childbirth, the woman begins to adjust to her new role and the profound responsibilities of parenthood whilst recovering physically and emotionally. There is often a complex mix of joy, hope, love, anxiety, fear, profound fatigue and relief. Some women feel overwhelmed by their new responsibilities, the making of many small but important decisions and choices on an hour-by-hour basis, the worry about making mistakes and not being good enough, while coping with their physical recovery, the art of breastfeeding and sleep deprivation. The love that develops comes to be experienced as a new kind of love, not always joyful, as described here by Harold in A Little Life by Hanya Yangihara [Reference Yanagihara10].
I didn’t feel that before Jacob, and I didn’t feel that after. But it is a singular love, because it is a love whose foundation is not physical attraction, or pleasure, or intellect, but fear. You have never known fear until you have a child, and maybe that is what tricks us into thinking that it is more magnificent, because the fear itself is more magnificent. Every day, your first thought is not ‘I love him’ but ‘How is he?’ The world, overnight, rearranges itself into an obstacle course of terrors.
However, some women find that an intense, protective love for and attachment to their child does not present itself and they have a protracted ambivalence towards the infant. There may be a complex mix of conflicting emotions. It can be unsettling, frightening, shame- and guilt-inducing, and difficult for the woman to bear. The infant will not understand and may withdraw, making few demands or make increasingly desperate attempts to engage their mother. Ambivalence can develop from a variety of often overlapping factors including depression, anxiety, motherhood not meeting her expectations or conflicts with her own needs, frustration with the relentless tasks of caring for the infant, resentment if the birth was traumatic, unresolved issues with her partner, having poor emotional support, past trauma, and anger if the pregnancy was conceived through sexual violence.
The effects on the mother–infant relationship can vary and the ambivalence may resolve over time, as the mother adjusts to her new role and receives appropriate support for the underlying causative factors. It is therefore important to understand what the woman’s expectations of early parenthood were and explore what factors are contributing to her difficulties.
And so, the discourse on how and what a mother is, or is expected to be, reveals a potential disconnect between the actual experience of the mother and what society at large expects from the role and relationship. What is clear is that there are a wide range of experiences, attitudes, pressures, challenges and opinions and that these change continually across generations, societies and cultures. As clinicians we must be aware of the societal and cultural narrative that a particular woman is operating within and how this affects her view of herself as a mother, whether she feels she fits in or is at odds with it, and how this affects her emotional well-being and mental health. Within perinatal mental health services and particularly within the Mother and Baby Unit context, mental health professionals need to be aware of how constant scrutiny and expectations that women will parent in a ‘perfect way’ may adversely affect her recovery and developing confidence as a mother. It is very important for perinatal mental health practitioners to understand that there is a range of parenting styles and cultural practices around child-rearing. As clinicians we need to be aware of the attitudes to and expectations of mothers we bring to our work and be able to reflect on whether these are helpful within the clinical context. We must strive to develop a compassionate, flexible and understanding approach that acknowledges the diverse experiences of mothers and to support them in confronting unrealistic ideals, of their own or society’s making.
Individual Factors and Context for the Woman
There are many factors influencing the woman’s experience of pregnancy and parenthood. Her life experience, coping strategies, resilience, expectations, social and emotional support, environmental factors, mental and physical health all play a part. Some of these will be explored below and many others are dealt with in detail in the relevant sections of this textbook.
Timing of Pregnancy
Teenage pregnancies occur for multifaceted reasons, have health and social consequences and are likely to be unplanned and unwanted. Young women are likely to be physiologically, psychologically and socially unprepared for what becomes an abrupt and often traumatic transition to adulthood and parenthood. Adolescence is a time during which major developments take place, at physiological and psychological levels, and in terms of the development of the personality. Early or teenage pregnancy is a worldwide phenomenon that occurs most frequently – but not only – in middle- and low-income countries. There are however some common risk factors and consequences particularly in terms of education and future life chances. Teenage pregnancy is often referred to as that which occurs within the first two years of gynaecological age (i.e. the time that has passed since menarche) and/or when the teenage girl is still dependent on her original family nucleus. The World Health Organization uses the expression ‘early pregnancy’ to refer to any pregnancy occurring before the age of 20 years and the United Nations defines teenage pregnancies as those in which the mothers are younger than 18 years. The young woman may be dependent on her family at this time in her life or she may become dependent on a third person because of pregnancy.
The body of the teenage girl or mother is not prepared for pregnancy and there is a major risk of dying from factors related to pregnancy, childbirth and post-childbirth, especially if the pregnancy occurs before the age of 15. It is estimated that complications arising from pregnancy and childbirth in girls between 15 and 19 years of age are the second most prevalent cause of death worldwide for this population group [11]. The numbers of teenage maternal psychiatric deaths in the UK and Ireland have increased in recent years (see Chapter 22, ‘Maternal Suicide, Deliberate Self-Harm and Other Mental Health Related Causes of Maternal Death’) and indicate that the mental health of pregnant teenagers has to be addressed rigorously. Furthermore, in addition to the physical consequences, there are psychosocial consequences that will impact the future lives of the mother and her offspring [12, 13, 14, 15] (see Box 1.1). However, the transition to the parenting role has more positive outcomes when there is strong family support.
Factors associated with teenage pregnancies include:
early and forced marriages
low self-esteem
drug and alcohol misuse
mental disorder in the individual and/or her family
lack of sex education
ignorance of, misinformation about and lack of access to contraception
poor access to healthcare
low educational level, interest and expectations
poverty
poor social support and absence of positive stereotypes
Consequences:
complications with childbirth
premature births
underweight babies
poor maternal weight gain
higher maternal mortality
higher rates of mental health problems
economic and psychosocial consequences of single parenthood, lack of educational and occupational opportunities
economic dependency increasing risk of future abusive relationships and sexual abuse
children more likely to live in poverty and to have more accidents and behavioural problems
Lockwood Estrin’s work in an inner-city environment found that young pregnant women under 25 had a very high prevalence of mental disorders, 67.2% versus 21.2% when compared with older women. They were also more likely to be Black and minority ethnic, single, to live in poverty, be homeless or in emergency accommodation, be unemployed or unable to work, and to have an unplanned pregnancy [Reference Lockwood Estrin, Ryan, Trevillion, Demilew, Bick, Pickles and Howard16].
On the other hand, while older motherhood is not new, there is an increasing number of women becoming pregnant through technological means, often for the first time, at the end of their reproductive cycle [Reference Baldwin17]. Childbearing can be postponed for many reasons including higher educational attainment, focus on career, the ability to control fertility, waiting for a perfect partner or not finding a partner. However, there is a gendered anxiety associated with the often-painful reality of age-related fertility decline in women. Older mothers are more likely to be single, educated, use assisted reproductive technologies (ART), and have higher physical and psychiatric morbidity [Reference Pettersson, Nedstrand, Bladh, Svanberg, Lampic and Sydsjö18].
Pregnancy may also be delayed for reasons associated with the woman’s mental health, including:
effects of prescribed medication on ovulation, for example anti-psychotic drugs that raise prolactin levels
fear of effects on the developing fetus of prescribed psychotropic medications
medical advice to avoid pregnancy when taking specific medications, for example sodium valproate
polycystic ovarian syndrome (PCOS) as a side effect of prescribed medication
depression and anxiety affecting capacity to make decisions
fearfulness of becoming a parent in the context of a personal history of child maltreatment, abuse and trauma
sexual trauma
sexual dysfunction
obsessional ideas or compulsions leading to avoidance of sex
fear of relapse, for example for women who have severe mood disorders
stigma including fear she will be regarded as a bad mother or that her infant will be removed
Women with some of the above dilemmas may present for pre-pregnancy advice (see Chapter 24, ‘Pre-pregnancy Advice and Planning’) and many of these conditions can be managed with appropriate interventions. It is also worth noting that many of these issues can be addressed through careful and sensitive exploration of the woman’s sexual health and plans for parenthood as part of routine psychiatric care.
Trauma, Abuse, Neglect, Adversity
Niall Williams, in his novel Time of the Child, poignantly described a boy ‘whose childhood tasted of tears’ – a powerful image and one that resonates with our familiarity in clinical practice of women who have had jeopardised lives [Reference Williams19]. Childhood adversity is not uncommon, with 67% of the population having at least one adverse childhood event (ACE). However, when individuals have four or more ACEs there are clear effects on both physical and psychiatric morbidity with increased suicide attempts, depression, intravenous substance misuse, lung disease, liver disease and early sexual activity. Childhood adversity’s profound effects on health are mediated through multiple hardships and cumulative stresses and are more common in deprived circumstances [20].
It stands to reason therefore that many of the women seen in perinatal mental health services have been exposed to adversity during their youth and that the effects of this will still be being felt when the woman is herself childbearing and parenting. There is evidence that the cumulative incidence of any postpartum psychiatric diagnosis is increased by the presence of different adversities experienced between age 0–15 years [Reference Metzer-Brody, Larsen, Petersen, Guintivano, Di Florio and Miller21]. Early adversity may also make her more susceptible to abuse and trauma in adulthood. Additionally, parents with multiple ACEs may have post-traumatic stress disorder (PTSD) symptoms or complex PTSD (see Chapter 11, ‘Anxiety Disorders’ and Chapter 15, ‘Complex Post-Traumatic Stress Disorder’) and these are believed to be a key mediator of risk in the intergenerational transmission of ACEs. A history of trauma and abuse may haunt the woman and its viscerality be reawakened during pregnancy, childbirth and on becoming a parent, hence the importance of coming to know what might have happened to her. Work on preventing ACEs in children has begun to examine how children’s risk for ACEs and potential for resilience may be linked to the early child-rearing experiences of their parents carried forward into parenting practices [Reference Narajan, Lieberman and Masten22]. For clinicians this means that direct enquiry needs to be made to elicit the occurrence of ACEs during the mother’s childhood with a view to prevention of breakdown, promptly and effectively treating underlying psychiatric problems and supporting her with parenting to reduce the risk of ACEs for her children, given the evidence that positive childhood experiences may be protective against intergenerational transmission.
Added to ACEs, many women face pregnancy and parenthood with a history of intimate partner abuse and violence [Reference Greenfield, Calcia, McCree, Sahota, Thomas and Kirkpatrick23, Reference Howard, Trevillion and Agnew-Davies24], sexual and non-sexual assault, loss which may be multiple and traumatic, displacement, exposure to war, civil conflict and natural disasters, as well as being victims of stigma and racism. These experiences also need sensitive enquiry though many women may not wish to explicitly recount them in detail. The principles of trauma-informed care (see Chapter 37, ‘Violence against Women’) need to be embedded in perinatal mental health services and practices as it is well established that high rates of trauma exist in women with mental disorders.
Relationships
Relationships are at the heart of the concept of the perinatal frame of mind and are central to all aspects of clinical work with women who have perinatal mental health problems and their families. It is essential to have a thorough understanding of a woman’s experience of relationships with her parents and other key adult attachment figures during childhood as well as subsequent relationships with friends, family and intimate partners. Clinicians need to understand the nature of these relationships, how they may have affected the woman’s mental health, and how any mental disorders have affected her relationships. Understanding what she experienced in her early relationships with parents and siblings and what that might mean for her current relationships with them is important, in order to gauge what support they may be able to provide, what caring responsibilities she has towards them, as well as being able to anticipate what unconscious repetition of early relating and behaviours may occur in her relationships with her family, infant and partner.
Some women may be isolated from family, friends and cultural groups during the perinatal period. There may be many reasons for this from personality-related factors which mean that she may have difficulty establishing or maintaining close relationships, to being a refugee following multiple losses. The lack of a close, confiding relationship is strongly associated with the development of depression [Reference Patten25]. Lack of practical support is hard for any new mother. Therefore, an exploration of the woman’s relationships, her social network and the strengths and stresses associated with these, as well as the well-being of those close to her is vital to understanding her current situation and how to best support her and her family. Mothers and their infants are not alone and are part of families, be they nuclear, with a much wanted and treasured infant or a more complex family that may be extended, blended, broken or dispossessed with above-average stresses and strains.
The perinatal frame of mind includes exploration and consideration of the partner, father or non-birthing parent and the quality of the relationships between them and the mother. The physicality and uniqueness of childbearing and childbirth, and societal expectations around motherhood, may overshadow the roles and experience of fathers and non-birthing parents, contributing to them being overlooked and neglected (see Chapter 6, ‘Paternal Mental Health in the Perinatal Period’). Asking sensitively but directly about the quality of the couple relationship is vital to determine how they support each other and to detect whether there is abuse within the relationship (see Chapter 37, ‘Violence against Women’) [Reference Greenfield, Calcia, McCree, Sahota, Thomas and Kirkpatrick23].
The questions that need addressing when thinking about the partner in the context of maternal mental disorder are set out in Box 1.2.
How much does the partner know or understand about the mother’s mental disorder?
How do they respond to learning about the disorder and to experiencing their partner’s symptoms? Do they feel able to cope, seek help appropriately, engage with healthcare professionals? Does the woman hide information or minimise her symptoms with them? Do they experience anger, blame, or feel abandoned and rejected and how do they cope with these feelings?
What are their attitudes to mental illnesses and their treatments in general, and in the context of pregnancy and childbirth?
What are the family, cultural or societal factors that affect the way they understand and deal with the illness in their partner?
Does the partner have mental health problems too? If so, how does this interact with the woman’s mental health problems? What support do they have with their mental health? And what does this mean for the infant if both parents are unwell at the same time?
What is the history of the couple relationship? How have they reacted to the pregnancy, childbirth, early parenthood and associated changes to the emotional and physical relationship with the mother? Are there unresolved conflicts within the relationship? Is there intimate partner violence or abuse?
What is their relationship with the infant like? How do they contribute to child-rearing tasks? Are there issues with their own parenting capacity?
Is the current partner the parent of the unborn baby, or infant? If not how do they feel about the pregnancy?
Do either the woman or partner have children from previous relationships and, if so, what is either or both of their relationships with their stepchildren like?
Physical Health
Some women come to pregnancy in optimal health, knowledgeable about diet and supplements and physically fit. Others bring with them physical vulnerabilities associated with their country of origin (infection, untreated congenital cardiac abnormalities, etc.), mental disorders, pre-existing physical conditions, environment, medication, family history, smoking and obesity. There are conditions that occur only in or are exacerbated by pregnancy (see Chapter 3, ‘Physiological Changes in Pregnancy and Common Obstetric Medical Disorders’). More women are presenting to maternity services either overweight or obese and this poses a significant problem for both maternal and infant outcome. Both antipsychotic and antidepressant medication contribute to weight gain, which increases physical vulnerability in women taking these medications [Reference Gill, Gill, El-Halabi, Chen-Li, Lipsitz and Rosenblat26, Reference Dayabandara, Hanwella, Ratnatunga, Seneviratne, Suraweera and de Silva27].
Women with severe mental disorders are particularly vulnerable. Women with schizophrenia have worse physical health, are more likely to smoke and have higher rates of obesity than women in the general community. Symptoms of the disorder, poor diet, lifestyle factors, social isolation, poor self-care and hygiene as well as adverse treatment effects contribute to this. They have more autoimmune disorders, are more likely to die from cancer than men with schizophrenia, miss or are not offered opportunities for screening and routine care and reviews of their physical health, are subject to delays in diagnosis and receive suboptimal treatment. This means that women with schizophrenia are more likely to become pregnant in an unhealthy, malnourished state with consequences for both her and the infant’s outcome (see Chapter 13 on schizophrenia). The combination of antipsychotic use and obesity causes a particular vulnerability in pregnancy. Studies in Canada and Denmark have shown that compared with women in the population who do not have a history of schizophrenia, women with schizophrenia tend to have higher risk outcomes including pre-eclampsia, venous thromboembolism, placental complications and haemorrhage, assisted deliveries such as caesarean sections, inductions of labour and maternal intensive care admissions, and more stillbirths and neonatal deaths [Reference Vigod, Kurdyak, Dennis, Gruneir, Newman and Seeman28]. There is also an increased risk of obstetric near misses during childbirth for women with severe mental illness even when age, ethnicity and socio-economic status are accounted for [Reference Easter, Sandall and Howard29].
Women with bipolar affective disorder also have higher rates of physical comorbidities, obesity, smoking and obstetric complications (see Chapter 12, ‘Postpartum Psychosis and Bipolar Disorder’).
Therefore, the guidance offered within pre-pregnancy advice and planning (see Chapter 24, ‘Pre-pregnancy Advice and Planning’) needs to be considered for all women with severe mental disorders, even when they are not actively stating that they want to become pregnant. It affords the opportunity to address physical health problems, obesity and the effects of an unhealthy lifestyle, as it may be too late to address the risk issues once the woman is pregnant.
The woman may experience physical health complications due to new pregnancy and childbirth-related conditions, for example, pre-eclampsia, thrombosis, sepsis, liver disease (see Chapter 3, ‘Physiological Changes in Pregnancy and Common Obstetric Medical Disorders’) or fetal abnormalities may be detected during routine ultrasound scans (see Chapter 4, ‘Fetal Development and Routine Maternity Care’), and require medical intervention, extended hospital stays for the woman or infant and cause considerable anxiety. Traumatic childbirth, previous pregnancy loss and years of infertility treatment (see Chapter 8, ‘Psychological Aspects of Infertility, Assisted Conception and Perinatal Loss’ and Chapter 11, ‘Anxiety Disorders’) can have both physical and psychological consequences for the woman and her partner.
Jardine’s paper indicated that socio-economic and ethnic inequalities were responsible for a substantial proportion of stillbirths, preterm births and births with fetal growth retardation in England [Reference Jardine, Walker, Gurol-Urganci, Webster, Muller and Hawdon30]. The largest inequalities were seen in Black and South Asian women in the most socio-economically deprived quintile and it was recommended that prevention should target the entire population as well as specific minority ethnic groups at high risk of adverse pregnancy outcomes, to address risk factors and wider determinants of health. The Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBBRACE) report finds that the risk of maternal death in 2020–22 was almost three times higher among women from Black ethnic minority backgrounds compared with white women, that women from Asian backgrounds also continued to be at higher risk than white women, and that women living in the 20% most deprived areas continue to have the highest maternal mortality rates, more than twice as high as the maternal mortality rate of women living in the 20% least deprived areas [Reference Knight, Bunch, Tuffnell, Jayakody, Shakespeare and Kotnis31].
This means that the clinician needs to remain alert for the reality that there may be several cumulative risk factors that contribute to physical health problems for particular women in the perinatal period.
Mental Health
Perinatal psychiatry is not defined by a particular diagnosis. This textbook addresses individual disorders in terms of how the perinatal context affects their presentation, course, risks, treatment and care. It is essential however to have an up-to-date understanding of the entire range of psychiatric disorders that occur in adults and their recommended, effective and evidence-based interventions. This then allows for the perinatal psychiatrist/clinician to apply learning to the perinatal context and its effect on clinical practice. Clarification of the diagnosis and the exploration of comorbidities is an essential early task following referral (see Chapter 23 on perinatal assessment and evaluation of risk) and aids care-planning and risk assessment. Diagnoses can change over time and there are very high rates of both physical and psychiatric comorbidities in women with severe mental illness. Anxiety disorders are known to be both under- and mis-diagnosed and may be exacerbated by or arise de novo in the perinatal period.
Diagnosis is, however, just part of the clinician’s task. Understanding what the diagnosis means for this individual woman during pregnancy, in labour and in early parenthood requires exploration of the history of the disorder. Areas that need clarification are set out in Box 1.3.
Is this a first episode or a recurrence of a long-standing mental disorder?
Was there an acute or insidious onset?
Is this an acute illness or is there a chronic condition with impairment of function?
Have there been frequent relapses or has she remained well for many years?
What do her most severe episodes look like?
What treatments and interventions have been tried and what works?
Does she achieve full remission or partial remission?
What have been and what are the current risks to self and to others?
Are there risks from others?
What are the actual and potential effects of the disorder
◦ on level of risk, when severely unwell, when relapsing, when stable
◦ on self-care and daily functioning
◦ on cognitive function
◦ on pregnancy and childbirth
◦ on parenting
◦ on family, social network and health/social care relationships
What may be the effects of pregnancy, childbirth and parenting on the disorder?
Residual symptoms and/or prior undertreatment of the disorder, need to be carefully considered by the clinical team, as these may impair maternal function and increase risk. Symptoms that may not have much influence on day-to-day functioning in the absence of parental responsibility may be highly problematic and potentially devastating in the context of child-rearing. Fatigue, low energy, poor drive, agitation, psychomotor retardation, social withdrawal, reduced facial expression and preoccupation will affect how the woman meets the physical and emotional needs of her infant. Comorbid substance misuse will also have potentially serious effects on parenting and attempts need to be made to address this (see Chapter 18, ‘Alcohol and Substance Use Disorders’). Novel symptoms, that occur only within pregnancy (e.g. psychotic symptoms related to the fetus, denial of pregnancy, thoughts of feticide) or postpartum (e.g. estrangement from the infant, psychotic symptoms related to the infant, thoughts of infanticide or filicide), require careful exploration to both identify and assess the associated risks (see Chapter 36, ‘Child Safeguarding’ and Chapter 38, ‘When Mothers Kill Their Children’). Suicide is a rare but devastating consequence of mental illness in the perinatal period, and this is discussed in Chapter 22, ‘Maternal Suicide, Deliberate Self-Harm and Other Mental Health Related Causes of Maternal Death’.
What is unique about the perinatal period is of course the opportunity for early identification, assessment and, with it, prompt treatment and prevention in women who are either currently unwell or at risk of becoming unwell in pregnancy and postnatally (see Chapter 23 on the perinatal assessment and evaluation of risk). National Institute for Health and Care Excellence Antenatal and Postnatal Mental Health guidance recommends that pregnant women are asked identification questions as part of a general discussion about their mental health and well-being at first contact with maternity services and primary care [32] (see Box 1.4). If women are identified as being unwell or at risk of relapse it is imperative that they are guided to the care pathway that meets their needs (see Chapter 29, ‘Effective Working across Health, Peer Support and Third Sector Interfaces’ and Chapter 30, ‘Perinatal Mental Health Service Development and Delivery’), and that plans for monitoring and treatment are developed in partnership with and shared with the woman, her partner/family and teams and services working alongside her.
At a woman’s first contact with primary care or her booking visit, and during the early postnatal period, consider asking the following depression identification questions as part of a general discussion about a woman’s mental health and well-being:
Depression and Anxiety Disorders
During the past month, have you often been bothered by feeling down, depressed or hopeless?
During the past month, have you often been bothered by having little interest or pleasure in doing things?
Also consider asking about anxiety using the two‑item Generalized Anxiety Disorder scale (GAD‑2):
Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?
Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?
At all contacts after the first contact with primary care or the booking visit, the health visitor, and other healthcare professionals who have regular contact with a woman in pregnancy and the postnatal period (first year after birth), should consider:
Severe Mental Illness
At a woman’s first contact with services in pregnancy and the postnatal period, ask about:
Once an assessment has taken place, working in partnership with the woman is essential. Psychoeducation about mental illness in the perinatal context is an important element of the woman’s care. The development of a formulation and the sharing of and discussion with the woman of this can be helpful for her own understanding and self-compassion (see Chapter 23 on the perinatal assessment and evaluation of risk). The formulation and the woman’s understanding of it may also be helpful in explaining to partners and family what is happening and can potentially change attitudes and reduce stigma.
The woman’s previous experience of care needs to be explored, particularly if she has had unpleasant or traumatic experiences of general adult inpatient care. Women who are at high risk of breakdown in the perinatal period will benefit from discussions about what their treatment options might entail. A visit to their local Mother and Baby Unit may help to reduce any anticipatory anxiety they may have about a potential admission. Talking with the woman and her partner about setting out, in advance, plans to address particular issues that arise when she is most unwell may also be beneficial particularly when there are interventions she categorically does not want or if her symptoms negatively affect her relationships and she wishes to avoid the consequences of this (see Chapter 39, ‘Mental Health and Capacity Legislation in the Perinatal Period’).
The perinatal period is a time when women may be very afraid to admit to or to seek help for mental health problems because of fears that they will be judged negatively as a parent and/or that their children will be taken from them. Practitioners working with pregnant and postnatal women need to be aware that a reluctance to disclose and/or minimisation of symptoms might be present and needs careful elucidation. Women may also be reluctant to engage, or have difficulty in engaging, in treatment because of avoidance associated with their mental health problem or dependence on alcohol or drugs and clinicians need to be alert to this.
However, for the majority of women, pregnancy and early parenthood are times of great personal growth and development. The woman is likely to be highly motivated to remain well and to adjust lifestyle and relationship factors that contribute to her becoming unwell.
The perinatal frame of mind is not just for those working in perinatal mental health services. Clinicians working with women from menarche to menopause in child and adolescent and adult mental health services, that is, those women of childbearing potential, need to ensure that they optimise the treatment of psychiatric disorders from initial presentation and pre-conception so that women with the more severe disorders have the best chance of maintaining function to support their future parenting and caring roles. Clinicians in these services also need to regularly discuss and ask about the woman’s sexual health, relationships and plans for pregnancy and parenthood, with this being embedded as part of routine care within secondary mental health services.
Culture, Ethnicity and Gender
The perinatal frame of mind involves understanding who this woman is and what are her relationships and influences. The contributions of the woman’s culture, ethnicity and gender are of great importance in the perinatal period both on her physical and mental health. In Chapter 7, ‘The Perinatal Mental Health of Racial and Ethnic Minority Groups’, the authors address the striking inequities that persist in health outcomes for women of racial and ethnic minority groups beyond socio-economic and other demographic factors, and in particular what this means for women in the perinatal period.
Perinatal clinicians need to have a good understanding of the communities in which they practise. There is a need to know what, for example, are a particular religion’s beliefs and attitudes to mental illness, mothers and mothers with mental illnesses. This needs to be accompanied by a knowledge of what behaviours may be exhibited towards the woman and her family, and what supports may be provided within her religious community for her as a mother and if she is unwell. In addition, it is important to understand the following within a particular culture:
attitudes to mental health, including any issues to do with stigma, shame and honour
beliefs and knowledge about mental illnesses and their treatment
beliefs and practices regarding pregnancy, childbirth and parenting
health-seeking behaviours
beliefs and expression of these within the disorder
language and words used for mental health symptoms and mental disorders
Watson found in her review of ethnic minority women’s experiences of perinatal mental health conditions that there were problems in relation to healthcare professionals’ attitudes, understanding and perceptions, that Black, Asian and minority ethnic women were less likely to be offered treatment when compared to white women and that there was limited availability of culturally appropriate services [Reference Watson, Harrop, Walton, Young and Soltani33]. Language and interpreting services have a major role to play when working with women who have mental disorders. Ensuring that the options offered to women are of high quality and culturally appropriate is important. Women may lose their capacity to communicate clearly in their second language (English) when acutely unwell and it is better to err by providing an interpreter for these women rather that hoping that communication will be optimal [Reference Tribe and Lane34].
Acculturation is an important factor for people within migrant groups. Having an understanding of women’s identification within their own cultural group or within that of where they reside, helps us determine how this affects their mental health and how support for the woman can be developed within her community. People may acculturate in different ways, for example:
integrated/bicultural: strong identification with host and cultural group
separate: strong own group identification only
assimilated: strong host identification
marginalised: weak identification with host and cultural group
Marginalised women may find it very difficult to access perinatal mental health services, and those with a more separate identification may find it difficult to accept support from services. Women from diverse communities need to be stakeholders in the development of perinatal mental health (PMH) services to optimise access and engagement.
Within a culture there may be gender issues that affect the woman and her mental health in the perinatal period. For example, exploring the following may be critical to understanding her and how to support her:
What is her role and status within the family?
What autonomy does she have, for example access to money, her passport, travel locally, language classes and education, social pursuits, decision-making?
What are the attitudes to fetal and infant loss?
What are the attitudes towards the sex of the infant?
Can she access healthcare (mental health, gynaecological, maternity) independently?
What are attitudes to women seeing male healthcare professionals?
Will male partners take advice from female healthcare professionals?
Do families feel the need to consult either religious leaders, or traditional/faith-based healers before making decisions based on medical advice?
Relationship with the Infant and Safeguarding
The perinatal frame of mind includes holding in mind the infant and the parental relationships with the infant, alongside consideration of the mother (see Section 4, ‘Infant Mental Health in the Context of Maternal Mental Health’ and Chapter 36 ‘Child Safeguarding’). In addition, women worry about how their behaviours, relating and interpersonal difficulties associated with their perinatal mental illness, and their own childhood experiences, may affect the immediate and long-term development and outcome of their children. They may also have fears about the genetic transmission of their illness and the role that other factors associated with their illnesses (e.g. poor housing, poverty, unstable relationships, stigma) may have on their children’s well-being. However, Stein’s review purported that risks are not inevitable and in the absence of severe or chronic maternal disorder or other adversities, the effect sizes are generally small or moderate and that mechanisms underlying associations are complex and include a range of genetic, other biological, and environmental pathways [Reference Stein, Pearson, Goodman, Rapa, Rahman and McCallum35]. Howard and Khalifeh noted that there is a limited understanding of protective factors that account for the large proportion of unaffected children, despite exposure to significant antenatal maternal illness, and that associations are attenuated or no longer evident after adjustment for confounders (e.g. young age, low educational level, interpersonal violence, poor social support, substance misuse) [Reference Howard and Khalifeh36]. They also stated that the woman’s own experience of being parented and early trauma, and the effects of these on her relating and attachment style (low maternal sensitivity and ‘parental mentalisation’) may be more significant influences on outcome for the exposed child. It is reiterated, therefore, that a careful developmental history needs to be undertaken within perinatal mental health services. Mental illness in both parents and inter‐parental conflict are also clearly red flags for adverse child outcomes. Most importantly, the cumulative risk when parental mental illness is combined with other risk factors including domestic abuse and substance misuse may place the infant and other children at great risk of harm (see Chapter 36, ‘Child Safeguarding’). However, positive parenting by a healthy co‐parent (mother or father) can buffer children against the adverse effects of perinatal mental illness [Reference Barker, Iles and Ramchandani37].
It is well established that stigma takes on an extra dimension in the perinatal period where women are afraid to seek help or admit that they have mental health problems as they fear they will be judged negatively as a parent and/or that their children will be taken from them. This contributes to women being fearful of services and can contribute to delays in accessing timely help. In women with the more severe mental disorders these ideas may become delusional and expose both the mother and infant to higher risk of harm. Clinicians need to be constantly aware that these fears may be present and concerning for the woman and seek to explore them in a sensitive and realistic manner.
However, when there are genuine concerns about risk to the infant (see Chapter 36, ‘Child Safeguarding’) difficult, often challenging and painful, conversations will need to take place between perinatal mental health practitioners and the woman and her family. Referral to children’s social services can be alarming [Reference Smithson and Gibson38, 39] for the woman and her family, and the mother is particularly vulnerable to worsening of her mental state or the emergence of new risks when the infant is or might be removed from her care (see Chapter 2, ‘Experiencing Severe Perinatal Mental Illness: The Woman’s Perspective’ and Chapter 22, ‘Maternal Suicide, Deliberate Self-Harm and Other Mental Health Related Causes of Maternal Death’). Having the capacity to hold in mind that the mother, perinatal mental health services and other agencies all want the best outcome for the infant, that is, that they are safe and well cared for, is essential to ensuring that the mother remains supported at a very challenging time despite what might appear to be a perception of conflicting roles, interests and hopes.
What Does the Perinatal Frame of Mind Mean for Practitioners?
Perinatal psychiatrists need to develop their skills as clinicians, leaders (see Chapter 9, ‘The Evolving Leader in Perinatal Mental Health Services’) and as teachers. They also need to be mindful of the evidence base, and open to and able to critically appraise emerging research in the many disciplines which underpin perinatal psychiatry. These include but are not limited to, embryology, genetics, neuroscience, physiology, psychology, sociology, health services research, psychopharmacology, clinical trials and teratology. The clinical tasks are intellectually and emotionally demanding, as is leading a team and engaging with stakeholders to ensure that perinatal mental health services are developed, delivered and maintained. Teaching and training are key to not only the maintenance of optimal delivery of high-quality, effective and compassionate services within PMH teams [40] but also to ensure that primary care, general adult, liaison, home treatment and crisis team, as well as child and adolescent mental health services remain aware of the need to ensure that women of childbearing potential have their physical, sexual and mental health care needs addressed in a timely and holistic way. Health visitors, midwives, obstetricians, early years practitioners, workers in third-sector organisations as well as women and their partners and families, also need access to high-quality and regular perinatal mental health psychoeducation and training. It is vital that perinatal psychiatrists recognise and anticipate the need to deliver training in their local and regional areas to a wide breadth of professionals as well as ensuring high-quality training of medical students and trainee psychiatrists.
The perinatal frame of mind means that we have a number of people, not just the mother, and a range of relationships, to think about and hold in mind within our clinical practice, teams and when developing services. It also commits us to the vital task of working in partnership with women, their families, as well as the many professionals and services involved in a woman’s care. These include maternity services, primary care professionals, universal services, general adult mental health teams, social care and third-sector services. Perinatal mental health clinicians need to work collaboratively, take responsibility and display trust, respect, compassion, transparency and resilience. NHS England’s document Involving and Supporting Partners and Other Family Members in Specialist Perinatal Mental Health Services: Good Practice Guide (2021) sets out practical advice on how to work in partnership with women and their families [41]. The Royal College of Psychiatrists’ (2021) College Report CR232: Perinatal Mental Health Services: Recommendations for the Provision of Services for Childbearing Women outlines how good perinatal mental health services should promote seamless, integrated, comprehensive care across the whole clinical pathway, with clear communication across organisational and professional boundaries [42].
Box 1.5 sets out who we need to consider and Box 1.6 what needs to be considered by the mother and by practitioners.
Who do we need to consider?
the woman
the infant
the partner
the family (older children, grandparents, extended family)
other social relationships
our own role
the PMH team
other mental health teams
primary care
health visiting
children’s social care
other agencies
voluntary and third-sector organisations
What does the woman think about in the perinatal period?
not just one person
conflicts between own needs and those of dependent others
the fetus/infant and older children
partner/co-parent
wider family
concerns about disclosure
understanding of her disorder, insight
how to remain well
treatment/therapeutic issues and decisions to be made
previous experience of care and treatment
risk: what does it mean?
influence of life experience, social and cultural issues
what does it mean and feel like to be ‘looked after’?
fear, shame, stigma, grief, loss
dealing with lots of professionals
What does the practitioner think about in the perinatal period?
the perinatal frame of mind
the concerns of the woman and her family
illnesses may have a different course
interventions may need to be adapted
general principles and decision-making becomes more complex
the unique opportunity for prevention
risk assessment (always dynamic, e.g. stage of pregnancy, stage of illness) for both now and future, and for at least two people
confidentiality – keeping and knowing when to share information
communication
the care to be delivered
the woman’s experience of care: autonomy, being listened to, heard, understood, coercion, helplessness
Women in the perinatal period, as with any other time, deserve to have safe, kind, compassionate, effective, continuous, personalised, co-produced and family-friendly services where they have access to specialist information and choice. Their practitioners need to uphold these values and be thoughtful, well-trained and competent, with access to training, supervision and mentoring. Box 1.7 sets out some of the skills, competencies and attributes the clinician must develop.
Knowledge of mental disorders, the perinatal context, culturally relevant issues
discussing risk
ability to hold difficult conversations
information sharing/governance
relationships and communication with team members and with other teams/agencies
flexibility, compassion, curiosity, understanding
awareness of own strengths and limitations
ability to reflect on own experiences of being parented/parenting and how that affects relationships with patients
knowing how and when to seek help, supervision and mentoring, recognising and managing stress and burnout
The team needs to be responsive, flexible, well-governanced, have clear aims, solid leadership, access to evidence-based interventions, with the skills and ethos of working with, communicating effectively with, working in partnership with, and managing conflict between the woman, partner, family, other teams, services and agencies. Perinatal mental health teams must face the challenges of not focusing exclusively on either the mother or the baby’s well-being, of not excluding from services women with the ‘wrong’ diagnosis and of retaining the perinatal frame of mind, even when the workload is demanding or in the throes of clinical crises. Difficult decisions sometimes need to be made, as for example when a decision is reached that an infant be separated from their mother. Emotions may run high; opinions may become polarised and it may be hard to keep compassion alive. Supervision, mentoring, work-based discussion and striving to remain open and reflective will help at these times, as well as taking steps to avoid personal burnout and exhaustion.
Summary
This chapter shows how the perinatal frame of mind can help ensure that we are aware that women, their children, partners and families, and the relationships between them are of the utmost importance in our clinical work and that we work in partnership with the many professionals and services involved in the woman’s care. Perinatal mental health is one of the most clinically complex areas within the practice of psychiatry. It can be challenging intellectually and emotionally for practitioners but also rewarding and a privilege to work with women and their families at one of the most important and motivated times of their lives. Our tasks are to instil hope, be effective, knowledgeable and compassionate clinicians, leaders and teachers and through this potentially make a huge difference to women and families, both in the perinatal period and the longer term.
