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Chapter 11: Deaths from psychiatric causesdisorder, is the same at conception as in the nonpregnantfemale population. Pregnancy is not protective againstrelapses of pre-existing serious mental illness, particularly ifthe woman has stopped her usual medication at the beginningof pregnancy.Women who have had a previous episode of a seriousmental illness, either following childbirth or at other times,are at an increased risk of developing a postpartum onsetillness, even if they have been well during pregnancy andfor many years previously. This risk is estimated as at leastone in two, that is these women have a 50% chance of itrecurring in a subsequent pergnancy. 5,6 The last threeReports 7–9 also found that over half of the women whodied from suicide had a previous history of serious mentalillness. It is also known that a family history of bipolar disorderincreases the risk of a woman developing puerperalpsychosis following childbirth. 6Specialist perinatal psychiatricservicesSerious psychiatric illnesses in the last few weeks of pregnancyand the first few weeks following childbirth have a number ofdistinctive clinical features including, importantly, the tendencyfor sudden onset and rapid deterioration. Half of allwomen with puerperal psychoses will have presented by dayseven postnatally, and 90% by 3 months postpartum, 4 ashighlighted in the last three Reports. This, together withother distinctive symptoms 10 and the special needs of womenand their infants at this time, has led to national and internationalacceptance of the need for special services for perinatalpsychiatric disorder. 11,12 This includes the recommendationthat new mothers who require admission to a psychiatric unitfollowing birth should be admitted together with their infantto a specialised mother and baby unit and that specialisedcommunity teams are available for those managed at home.The findings of the last three Enquiries underpin the importanceof this strategy, as, with few exceptions, the womenwho died had been cared for by non-specialised psychiatricteams unfamiliar with these conditions.Maternal suicideUntil recently, it had been thought that the maternal suiciderate in pregnancy was lower than would be expected, 13with pregnancy exerting a so-called ‘protective effect’. Thelast three Enquiry Reports found that maternal suicide wasmore common than previously thought and was a leadingoverall cause of maternal death. However, suicide duringpregnancy remains relatively uncommon, and the majorityof suicides associated with pregnancy occur following childbirth.Overall, the suicide rate following delivery is little differentto that among women in the general population, butit may be that for a subgroup of women, those sufferingfrom serious mental illness, the suicide rate is substantiallyelevated. 14 One of the reasons for the misunderstandingabout maternal suicide is that research over the last40 years has consistently shown that rates based upon coroners’verdicts alone are underestimates. For the last four triennia,the Office for National Statistics (ONS) has beenable to link mothers’ deaths up to 1 year after delivery withrecorded births. This revealed that until 2002, around halfof all maternal suicides had not been reported directly tothis Enquiry. Once this under-reporting was corrected, amore realistic estimate of maternal suicide was possible.Impact of previous enquiriesThe findings and recommendations of the last three Enquiries7–9 have influenced national policy and guidelines,including the New Horizons Vision for Mental Health, 11 TheNational Service Framework for Children, Young People andMaternity Services, 15 and the National Institute for Healthand Clinical Excellence (NICE) Guidelines for antenatal andpostnatal mental health. 12 All recommend that womenshould be asked at their early pregnancy assessment abouttheir current mental health and a previous history of psychiatricdisorder. Those at risk of developing a serious mentalillness following delivery should be proactively managed.They also recommend that sufficient mother and baby unitsand specialised community perinatal teams should be establishedto manage women whose pregnancy or postpartumyear is complicated by serious mental illness. The recommendationsfor screening at booking have been widelyimplemented but by no means universally. Specialisedmother and baby units and perinatal psychiatric services arestill not available to women in many parts of the UK.Key findings 2006–08Psychiatric disorder is common in pregnancy and afterdelivery, and this is reflected in this Report. Not all of thedeaths described in this Chapter are counted as Indirectdeaths due to psychiatric illness. As internationally definedand discussed in Chapter 1, the only deaths which fit intothis category are those women who committed suicide duringpregnancy or within 42 days (6 weeks) of the end oftheir pregnancy. There were 13 such women this triennium.Deaths from suicide after this time are classified asLate Indirect. This triennial Report includes only thosedeaths that occurred after 6 weeks and within 6 months(43–182 days) of delivery, of which there were 16. In previousReports these deaths were followed up for a calendaryear after delivery, which makes a direct comparison withearlier Reports difficult. However, it has been possible todeduce some trends, and these are discussed later.ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 133