Why Do Women Face Mental Health Issues During And After Pregnancy?

Mental illness is widespread, and the burden of poor functioning and health is still rising globally even with the expansion of resources and treatment options. There is a widespread misconception that the hormones secreted during pregnancy shield women against mental illnesses and promote a period of emotional stability. However, recent research indicates that up to 20% of women experience anxiety or mood disorders throughout pregnancy and the postpartum period. Whether the sickness is new during pregnancy or is a recurrence of a past history, women must make a difficult decision over how to treat their condition.

Understanding Mental Health Risks

Although there is a decrease in self-harm, suicide, and psychiatric admission during pregnancy, mental illness can still develop or worsen. However, there is a higher risk in the early postpartum phase, which has led to a sharp rise in the number of patients in for psychotic illness treatment. Although women with and without a history of mental illness are at risk, women who have a history of serious mental illness are at a notably higher risk. Social trauma may put women at risk for mental illness. Individuals who are marginalized or isolated are more likely to suffer from mental illness, and they are also more likely to experience unfavorable pregnancy outcomes.

The first incident of domestic violence happens to about 30% of women who experience it. Domestic violence is also associated with low care, engagement and some unfavorable pregnancy outcomes. Lastly, underreporting may occur due to the stigma attached to mental illnesses, however, this is reduced in the modern era. People are looking for assistance and treatment as they become more aware of mental health issues, which may be contributing to the surge in diagnoses that are being made these days.

Depressive and Anxiety Disorders

Recent studies show a prevalence of antenatal depression of 20.7% and 15.0%, and a postnatal depression prevalence of 17%. These rates are higher in low- to middle-income countries compared to high-income countries. Anxiety disorders have an overall prevalence of 15.2% in pregnancy and 9.9% in postnatal periods. Panic disorder and obsessive-compulsive disorder may be more common during pregnancy. Risk factors for postnatal depression include genetic factors, prior mental health, adverse life events, and lack of social support.

Significant risk factors for perinatal anxiety disorders include lower educational attainment, living with extended family, multi-parity, family history of psychiatric disorder, comorbid sleep disorders, and antenatal oxytocin exposure. Anxiety disorders can pose challenges for anaesthetic care, such as needle phobia, which can result in poor engagement with care and higher demand for general anesthesia.
Psychological treatment of anxiety and depressive disorders is effective, with cognitive-behavioral or interpersonal therapies being the most effective for postnatal depression. Psychological interventions can prevent the onset of postnatal depression and treat perinatal anxiety disorders.

Postpartum Psychosis (Bipolar Disorder and Schizophrenia)

Research indicates that women with prior mental disorders, such as bipolar disorder or postpartum psychosis, have higher rates of postpartum recurrence. However, those with prior postpartum psychosis are more likely to experience severe illness. Women with bipolar disorder typically recover quickly from the acute phase, but the risk of recurrence in future periods is high. Women experiencing a first episode of postpartum psychosis are at a substantial risk of future bipolar episodes. Bipolar disorder in pregnancy typically requires ongoing management to prevent recurrence, unless there is long-term stability.

Schizophrenia affects fertility rates more significantly in men than women, with women experiencing a greater attrition into illness during the first postnatal year. Women with schizophrenia are more likely to experience adverse pregnancy outcomes, such as pre-eclampsia, thromboembolic disease, preterm birth, and fetal growth alterations. These outcomes may be due to lifestyle factors, comorbidities, social adversity, worse antenatal care, underlying illness, and medication effects.

Other Mental Disorders

Eating disorders are the most fatal mental disorder, with a prevalence rate of 1.47% in UK inner city women during pregnancy. Abnormal eating attitudes may decrease during pregnancy but worsen postnatal. Severe food restriction, malnourishment, and binge-eating behaviors may lead to poor birth outcomes, including low birth weight and miscarriage.

Personality disorders, characterized by inflexible responses to personal and social situations, can affect up to 6% of pregnant women. The emotionally unstable type is most commonly diagnosed in young women, characterized by emotional instability, impulsivity, dysphoric mood, self-image disturbances, and self-destructive behavior. Post-traumatic stress disorder affects 4% to 6% of women during pregnancy, particularly high-risk groups with a history of psychiatric issues or pregnancy complications. Rates are higher among those experiencing stillbirth or neonatal death. Prevalence may increase postpartum and may lead to avoidance of maternity care. Effective interventions include trauma-focused psychological therapies.

Suicide and Self-harm

Suicide rates decrease during pregnancy and postnatal periods, but they are significantly increased in women with underlying mental illness, especially those admitted to psychiatric care in the first three months. Early postpartum mental disorder is also at a higher risk of suicide following deliberate self-harm.

UK Maternal Deaths Enquiries have reported on psychiatric causes of mortality since the early 1990s, with risk factors including rapid progression of severe postpartum mental disorder, under-recognition, and violent methods. Women with a history of psychosis are at higher risk of early postpartum major mental disorder. Psychiatric factors can also contribute to deaths due to other causes, such as underlying physical illness symptoms being misattributed to mental disorders.

Management of Maternal Mental Health Conditions:

• Maternal death enquiries highlight the importance of good communication between professionals, including sharing information on mental health history.
• Women with severe mental illness are less likely to plan their pregnancies, and all women with preexisting mental disorders should have access to information on risk, pregnancy planning, and contraception before any pregnancy.
• Women should be able to make informed choices about medication management. Women at significant risk of early postpartum mental disorder should have an agreed late pregnancy plan, with an anesthetist as a key member.
• Early engagement should be multidisciplinary, including input from obstetricians and psychiatrists, and include anesthetic input. Anaesthetists should have an understanding of the spectrum of psychiatric disease and be familiar with legislation covering medical interventions for patients who lack capacity.