Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality

The Confidential Enquiry into Maternal Deaths 1997 to 1999 finds that psychiatric disorder, and suicide in particular, is the leading cause of maternal death. Suicide accounted for 28% of maternal deaths. Women also died from other complications of psychiatric disorder and a significant minority from substance misuse. Some of the findings of the Confidential Enquiry confirm long established knowledge about postpartum psychiatric disorder. The findings highlight the severity and early onset of serious postpartum mental illness and of the risk of recurrence following childbirth faced by women with a previous history of serious mental illness either following childbirth or at other times. These findings led to the recommendation that all women should be asked early in their pregnancy about a previous history of serious psychiatric disorder and that management plans should be in place with regard to the high risk of recurrence following delivery. Other findings of the Enquiry were new and challenged some of the accepted wisdoms of obstetrics and psychiatry. It is likely that the suicide rate following delivery is not significantly different to other times in women's lives and for the first 42 days following delivery may be elevated. This calls into question the so-called 'protective effect of maternity'. The overwhelming majority of the suicides died violently, contrasting with the usual finding that women are more likely to die from an overdose of medication. Compared to other causes of maternal death, the suicides were older and socially advantaged. The Enquiry findings suggest that the risk profile for women at risk of suicide following delivery may be different to that in women at other times and in men. None of the women who died had been admitted at any time to a Mother and Baby Unit and their psychiatric care had been undertaken by General Adult Services. None of the women who died had had a previous episode correctly identified and none had had adequate plans for their proactive care. The conclusion is that there is a need for both Psychiatry and Obstetrics to acknowledge the substantial risk that women with a previous psychiatric history of serious mental illness face following delivery.