Response rates
A total of 118 maternity care units (92 %) responded and provided the number of deliveries. Only 10 private clinics failed to respond. All the MF centers and general hospitals responded to the questionnaire. A total of 155 417 infants were born in these maternity care units between 2016 and 2018, and 102 027 (66.7 %) babies were born in private clinics. Further, 19 of the 21 NICUs (90.5 %) responded, and 28 of the 40 ART units (70 %) responded. The NICUs that participated in this survey had a total of 173 beds. The median number of beds in each NICU was 9 (range = 3–18).
Women with worsening mental illness during the perinatal period
A total of 82 women (52.8 per 10 000 births) were admitted to mental health care units during the perinatal period. There was a significant increase in the percentage of admissions across time. The number of admissions (n = 38) in 2018 (74.2 per 10 000 births) was approximately twice the number of admissions in 2016 (n = 19; 36.0 per 10 000 births) (Fig. 2, p < 0.001). Moreover, 32 out of 82 patients (39 %) in maternity care units were referred to psychiatric hospitals without maternity care units for hospitalization. Despite a deterioration in their mental illness, six patients were emergently admitted to maternity care units because they could not be admitted to mental health care units. Additionally, 10 patients had undergone legal abortion because of worsening mental illness across the three years of the survey.
Multidisciplinary perinatal mental health care system
Psychiatrists. Most MF centers and general hospitals had psychiatrists. The distributions were significantly different across the different types of units: MF centers, general hospitals, and private clinics (Fig. 3a, p < 0.01). However, only 4 MF centers (20.0 %) and 2 general hospitals (10.5 %) in Aichi prefecture reported that their psychiatrists were on duty for 24 hours a day to handle emergency admissions.
The 84 maternity care units did not have psychiatrists. Further, only 12 units (14.0 %) reported that they had contacted their patients’ psychiatrists from other medical facilities and provided care during the perinatal period. However, the other units (86 %) reported that they followed a policy that required patients to be referred to MF centers or general hospitals. Additionally, 34 units (43.0 %) reported that they sometimes provided care to patients who were stable and did not require medication.
Social workers.
Most MF centers and general hospitals had hospital social workers, and these distributions were significantly different across the different types of units (Fig. 3b, p < 0.01). The 76 maternity care units did not have any social workers. Further, only 12 units (16.0 %) reported that they collaborated with community social workers as an alternative.
With regard to seamless multidisciplinary collaboration between medical units and community health centers, 58 maternity care units (49.0 %) reported that they had encountered cases that required collaboration with a community health center. The corresponding percentages did not differ significantly across the different types of units (Fig. 3c, p = 0.549). The availability of social workers in these units was unrelated to the experience of seamless multidisciplinary collaboration (61.0 % vs. 52.0 %, p = 0.525). Among the units that had collaborated with a community health center, 57 units (98 %) reported that this approach was adopted seamlessly and without any problems.
Problems within the perinatal mental health care system
The respondents (21/118) provided a wide range of opinions in response to the following question: “What problems exist within the present perinatal mental health care system in Aichi prefecture?” Eleven respondents reported that the available perinatal mental health care resources were not adequate to permit them to emergently refer patients when their mental illness worsens. The other opinions that were shared were as follows: patient rejection of referrals to psychiatrists, poor medication adherence, and a lack of consensus regarding therapeutic protocols among obstetricians and psychiatrists.
Perspectives on psychotropic drug use during pregnancy among obstetricians
Table 1 summarizes the participating obstetricians’ perspectives on psychotropic drug use during pregnancy, when psychotropic drugs not contraindicated during pregnancy are prescribed. This variable was significantly associated with unit type (p = 0.033). Moreover, 5 %, 31.6 %, and 35.4 % of MF centers, general hospitals, and private clinics endorsed the discontinuation of drug use, respectively.
Table 1
Perspectives on noncontraindicated psychotropic drug use during pregnancy across maternal care units
Type of maternity care units
|
Psychotropic drug use during pregnancy
|
p
|
Discontinue
|
Continue
|
Other
|
MF center (n = 20)
|
1 (5.0)
|
18 (90.0)
|
1 (5.0)
|
|
General hospital (n = 19)
|
6 (31.6)
|
13 (68.4)
|
0 (0.0)
|
|
Private clinic (n = 79)
|
28 (35.4)
|
45 (57.0)
|
6 (7.6)
|
0.033
|
Total (n = 118)
|
35 (29.7)
|
76 (64.4)
|
7 (5.9)
|
|
Values represent frequencies (percentages), and the p-value was computed using Fisher’s exact test. MF = maternal-fetal.
|
NICU admission of infants born to mothers with mental illness
Among the participating NICUs, 18 (95.0 %) had collected clinical data about maternal mental illness to care for their neonates. Among them, only 4 (21.0 %) had a policy that required them to prepare for the resuscitation of neonates born to mothers with mental illness. None of the 18 NICUs (95.0 %) had a policy that required neonates born to mothers who have been prescribed psychotropic drugs to be admitted to NICUs for toxicity evaluation. A total of 158 infants (1.0 per 1000 births; 50, 53, and 55 infants in 2017, 2018, and 2019, respectively) born to mothers with mental illness were admitted to NICUs during the survey period.
Preconception counseling provided by fertility therapy centers
To survey the preconception counseling services provided by fertility therapy centers, a questionnaire was sent to 40 ART units (Table 2). Between January and December 2017, the 28 ART units had recorded 3921 IVF, 7624 ICSI, and 13 192 FET treatment cycles. These treatment cycles accounted for approximately 4.3 %, 4.8 %, and 6.6 % of the total treatment cycles in Japan, respectively.
Table 2
Questionnaire administered to fertility doctors
1. Have you collected any information about prior history of mental illness or associated complications from your patients through interviews (e.g., medical history)?
|
number (%)
|
A. Yes
|
How do you collect them?
|
28 (100.0)
|
|
A-1. Ask clients
|
6 (21.4)
|
|
A-2. Provided by clients
|
22 (78.6)
|
B. No
|
|
0 (0.0)
|
2. Do you consult with psychiatrists before providing fertility treatment to clients who receive care from mental health hospitals or clinics?
|
number (%)
|
A. Yes
|
When do you seek a consultation? (multiple options can be selected)
|
28 (100.0)
|
|
A-1. Every case
|
10
|
|
A-2. Only cases with a prescription for mental illness
|
6
|
|
A-3. Only cases with very poor mental state
|
14
|
|
A-4. Other
|
3
|
B. No
|
|
0 (0.0)
|
3. Do you consult with psychiatrists before providing fertility treatment to a client who has a history of mental illness but is not receiving psychiatric care? (multiple options can be selected)
|
number (%)
|
A. Yes
|
With which psychiatrist do you consult?
|
22 (78.6)
|
|
A-1. Psychiatrist from a hospital that has maternal care and mental health care units
|
5
|
|
A-2. Psychiatrist who has previously provided care to my patients
|
16
|
|
A-3. Other
|
7
|
B. No
|
|
6 (21.4)
|
4. To which obstetric facilities do you refer your clients with mental illnesses when they conceive? (multiple options can be selected)
|
number
|
A. Undecided
|
19
|
B. An MF center
|
4
|
C. A maternal care unit with one or more psychiatrists
|
2
|
D. A hospital with a maternal care unit and a mental health care unit
|
4
|
E. Unknown
|
2
|
5. Are you aware of any hospital in Aichi that has a maternal care and mental health care unit?
|
number (%)
|
A. Yes
|
17 (60.7)
|
B. No
|
11 (39.3)
|
MF = maternal-fetal.
|
All the 28 units that responded reported that they collected clinical information about the presence of mental illness from all patients and consulted with psychiatrists before providing fertility treatment to patients who regularly visited mental health care units. Sixteen institutes (57.1 %) had a policy that required them to refer patients with a history of mental illness to a hospital that had both obstetricians and psychiatrists prior to conception. However, 23.0 % of them did not consider it necessary to consult with a psychiatrist when a patient has a history of mental illness but is not receiving care from any mental health care unit. Some units (37.9 %) reported that they did not have any information about hospitals that have adequate resources to provide appropriate perinatal care to such women (collaborative care provided by both obstetricians and psychiatrists). Further, 19 institutes (67.9 %) reported that they did not discuss where their patients can receive appropriate care during the perinatal period with them prior to conception.
Policies regarding psychotropic drug use during pregnancy were also examined. Six units (21.4 %) endorsed drug use discontinuation, and 18 units (64.3 %) endorsed drug use continuation. The other 4 units selected other options.
The respondents (10/28) provided a range of opinions in response to the following question: “What problems have you encountered until now when you are providing fertility treatment to women with a history of mental illness?” Their responses were as follows: insufficient perinatal mental health care resources (n = 2), patient rejection of referrals to psychiatrists (n = 2), a lack of consensus regarding therapeutic protocols among obstetricians and psychiatrists (n = 2), and insufficient information about prior history of mental illness because it was provided by clients (n = 2).