Pregnancy and the postpartum period is often experienced as a time of great joy and excitement for many women. However, this phase is also associated with vulnerability to mental illness, risk of relapse of pre-existing mental illness, and the development of new psychiatric symptoms. Perinatal mental illness can be defined as psychiatric conditions that manifest during pregnancy and up to one year after delivery (1).
During pregnancy and postpartum, there is an increased incidence of severe mental disorders (SMI), which may include disorders such as schizophrenia, affective psychosis and bipolar disorder. During the post-partum period, there is a dramatic increase in the frequency of psychotic symptoms and psychiatric admissions (2,3). These symptoms may be manifestations of a new illness that develops during the post-partum period, or a relapse of a pre-existing illness. The presence of serious mental illness (SMI) in the perinatal period can have potentially devastating consequences for the mother, infant and family system and may adversely affect the mother’s capacity to parent (4,5).
Factors that contribute to the increased incidence of relapse and new-onset mental disorders during the perinatal period include changes in medication, sleep deprivation, hormonal variation, as well as the physical and psychological demands of pregnancy and infant care (2,6).
Examining the risk factors for relapse of SMI during pregnancy, Taylor and colleagues (7) found a relapse rate of 12% for women with affective psychoses and 24% for women with non-affective psychoses. Risk factors for relapse of SMI included non-affective psychosis, number of recent psychiatric admissions, recent self-harm, substance abuse, smoking and non-white ethnicity. Extending their work to postpartum women, Taylor and colleagues (8) found that 28.3% of women with SMI relapsed within the first three months postpartum. Relapses were associated with smoking, as well as with the recency and frequency of relapses prior to pregnancy.
The presence of serious psychiatric disorders, in particular psychotic disorders, places the mother and unborn infant at greater risk for adverse obstetric and neonatal outcomes (9). The risk of stillbirth or delivering an infant with a low birthweight doubles if the psychotic episode occurs during pregnancy (10). Expectant mothers who have a pre-existing psychotic disorder may be at greater risk for obstetric complications than those mothers who develop postpartum psychotic disorders (11). Pregnancy outcomes of mothers with affective psychoses, such as bipolar disorder, carry double the risk for a preterm birth, low birthweight or small for gestational age babies (12).
Substance use during pregnancy also contributes to the risk for adverse obstetric and child outcomes (13). Zhao and colleagues (14) reported that poorer birth outcomes among women with mental illness were more likely when the mother used substances during pregnancy.The high rates of substance use among South African pregnant women has been recognised by two surveys of women attending Midwife Obstetric Units in Cape Town where alcohol consumption and smoking were found to be especially prevalent (15,16).
Postpartum psychosis in particular is considered to be one of the most severe psychiatric conditions with onset in the postpartum period (17). The phenomenon of postpartum psychosis refers to the sudden onset of manic or psychotic symptoms in the first 6 weeks after delivery (18). The clinical symptoms typically associated with postpartum psychosis include a range of psychotic phenomena (delusions and hallucinations) that often relates to the infant; affective symptoms (elation and depression); and disturbances of consciousness (which may be in the form of confusion, bewilderment, perplexity) (2,19). Sudden changes in the clinical presentation with significant fluctuations in the intensity of symptoms are common and have been described as the “kaleidoscopic picture of postpartum psychosis” (18, p1182).
In general, postpartum psychosis occurs relatively rarely. In a systematic review, VanderKruik and colleagues (20) reported incidence rates ranging between 0.89 and 2.6 per 1 000 women, but noted variations in study methodology, definition and assessment of postpartum psychosis. Although uncommon, postpartum psychosis may place the mother at increased risk for suicide and infanticide (2,18).
There is compelling evidence that women with a history of bipolar disorder are at a significantly increased risk of developing postpartum psychosis (3,21), which places them at a higher risk for psychiatric admission and separation from their infants.
Although women with schizophrenia and bipolar disorder have somewhat lower fertility rates than women in the general population, the majority of these women are parents (2). However, Miller and Finnerty (22) reported a greater likelihood that the pregnancies of women with schizophrenia would be unplanned and unwanted when compared to women without the disease.
According to Cès and colleagues (23), mothers suffering from psychotic disorders are at greater risk of being separated from their infants. Separations between mother and infant frequently occur when mothers experience SMI and in particular postpartum psychosis and require inpatient psychiatric treatment.
During the first half of the twentieth century, separation of mothers with postpartum psychotic disorders from their babies were considered to be advantageous for both parties (24). The emergence of social psychiatry, changes in psychiatric treatment, as well as research by Bowlby (25) and Spitz (26) on the adverse effects of early separation from attachment figures signaled a questioning of this approach (24). More recent studies have further provided support for the notion that early separation between infants and mothers may have adverse consequences. Separations between the mother and infant occurring during the infant’s first year pose a risk to the development of a secure attachment relationship (27). Furthermore, Howard and colleagues (28) found that mother-infant separation within the first two years of life was associated with child negativity at age three and aggression at ages three and five. In recognition of the benefits of maintaining proximity of mothers and infants during the postpartum period, psychiatric mother-baby units (MBUs) emerged in several developed countries with favorable outcomes for postpartum mothers (29).
The first joint admissions of mothers with schizophrenia and their babies occurred in 1959. Baker and colleagues (30) demonstrated that mothers admitted with their babies had shorter periods of admission, were more likely to care for their babies upon discharge and had lower rates of relapse than mothers treated in an admission ward without their babies. This practice has now become more widespread and is recommended by the National Institute for Health and Clinical Excellence (31). Despite the benefits of joint admissions, mothers with psychotic disorders may still be separated from their infants as reported by Cès and colleagues (23) who analyzed joint admissions of mothers with psychotic disorders and their infants. The authors linked early separation to the placement of the mother in an institution during childhood, being single, early hospitalization of the baby and maternal psychiatric decomposition during pregnancy.
Du Toit and colleagues identified several risk factors contributing to unplanned pregnancies in a sample of South African women with psychiatric illness (32). These include being of younger age, two or more pregnancies in the past, being of mixed ancestry, African or Indian ethnicity, being unmarried, below tertiary level of education, being unemployed, low socio-economic status, substance abuse, previous psychiatric admissions and previous suicide attempts. The presence of maternal mental illness in combination with unplanned pregnancy significantly increases the vulnerability of these mothers to adverse pregnancy outcomes (32,33).
Mothers utilizing mental health services may experience more significant challenges in their roles as parents, which may be of particular significance during infancy, when there is greater dependence on the parent (34). Children in care of mothers with psychiatric illnesses may be more vulnerable to developing insecure or disorganized attachment, particularly when maternal psychopathology is severe and prolonged, and when other risk factors such as parental trauma are present (35). The presence of both maternal psychiatric symptoms and separations may adversely affect the quality of the mother-child relationship, as well as parental sensitivity and capacity (36).
Specific features of psychotic disorders, such as withdrawal, delusional thinking, disorganized behavior and reduced responsiveness, may separately and in combination hamper the mother’s ability to provide a consistent, attuned presence for her infant and may compromise the development of a secure attachment, especially if early separation occurs (4,28).
Nurturing care is defined by the World Health Organization (WHO) as “giving young children opportunities for early learning, through interactions that are responsive and emotionally supportive” (37, p2) and focusses on the importance of the period from pregnancy to age 3. Several components make up nurturing care, including: behaviors, attitudes, knowledge regarding caregiving, stimulation, responsiveness and safety (38). Mothers with peripartum psychosis may require additional support in the provision of nurturing care in order to provide adequate opportunities for learning and development for their infants.
In the South African context of widespread socio-economic risks and limited resources, it is imperative to identify vulnerable dyads for early intervention. To our knowledge, there has not been a study among South African women with experiences of peripartum psychosis. The present study aims to provide a description of the socio-demographic factors and pregnancy outcomes for this group of women to determine areas of focus for intervention. By gaining a better understanding of the potential difficulties that mothers with this severe form of peripartum psychiatric illness face, dyads who may be at particular risk for adverse maternal and infant outcomes may be identified for further treatment.