6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

Oates, CantwellTable 11.5. Maternal suicide: previous psychiatric history,identification and management. UK: 2006–08Past psychiatric history n %Table 11.6. Highest level of psychiatric care of mothers whocommitted suicide; UK: 2006–08Level of care n %No history, first illness 10 34Past psychiatric history 19 66Past psychiatric history identified 9 47Past history appropriately managed 4 21Total 29 100A woman had a history of serious depressive illness, includingan earlier episode of severe postnatal depression; shealso had a family history of the same condition. Althoughshe was being treated for depression by her GP, this informationwas not passed on to her midwife. In later pregnancyshe became acutely depressed and required admissionto a psychiatric unit. She failed to attend for follow up afterdischarge, and it seems that no attempts were made toreach her in the community. Her community midwife wasunaware that she was not receiving psychiatric care afterdelivery. She died by violent means.Women with a significant past history face a 50% riskof recurrence. This should be identified at booking andappropriate management plans should be put in placeeven though the women may be well at the time. Theyalso require close support and monitoring followingdelivery. There is still an apparent lack of understandingby general psychiatric services of the high risk of postpartumrelapse and the need for continuing care in suchwomen.Previous psychiatric history andsuicide: learning pointsThe majority of women who suffer maternal deathsfrom suicide have a past history of serious affective disorder.Women with previous bipolar disorder, otheraffective psychoses and severe depressive illness face asubstantial risk of recurrence following delivery even ifthey have been well during pregnancy.Previous psychiatric history must be identified in earlypregnancy. Psychiatrists should proactively manage thisrisk and, at the very least, frequently monitor and supportthese women in the early weeks following delivery.The psychiatric services providedEighteen (62%) of the women had been involved with psychiatricservices during their last maternity as shown inTable 11.6.Mother and baby psychiatric unit 2 7General psychiatric inpatient 6 21Perinatal psychiatric team 0 0General psychiatric team 9 31Drug and alcohol team 1 3GP only 4 14None 7 24Total 29 100Of the eight women admitted to psychiatric units, onewas admitted to a general adult psychiatric unit duringpregnancy and one was admitted following a terminationof pregnancy. Six of the women who delivered, includingtwo who were eventually admitted to a mother and babyunit, had been admitted to a general psychiatric unit andseparated from their babies. For three of the motherswho had delivered, there was no evidence that admissionto a mother and baby unit had been considered. In onewoman with an early onset puerperal psychosis, followingthe admission to an adult psychiatric unit without herbaby, the request for transfer to an out-of-area motherand baby unit was turned down by her Primary CareTrust.Some of these cases demonstrate the problems withaftercare by non-specialised community care services thatdid not seem to appreciate the continued risks of relapse inthese mothers. They also provide examples of the importanceof GPs communicating with midwives and the needfor direct admission to a mother and baby unit of womenwith a puerperal psychosis. The involvement of a specialisedperinatal service might have improved their engagementwith psychiatric care.Eleven women, including the two who were admitted tomother and baby units, were cared for in the communityby general psychiatric teams rather than specialised communityperinatal teams. There was evidence of delay inobtaining admission to mother and baby units whenrequired, whether through local availability, appreciation ofseverity or, as has been mentioned, a refusal to fund suchcare. All of these cases demonstrate the importance of havingboth specialised perinatal community teams as well asprompt access to mother and baby units with whom theyhave close working links.Substandard careFor the majority of women (69%) known to be involved withpsychiatric services in their current maternity, psychiatric136 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203