This annual report - Taranaki District Health Board

previous involvement with child protection services with older children, for example thosethat have had a child removed through a care and protection intervention.Understanding the Link Between Family Violence and Adverse Pregnancy OutcomeViolence during pregnancy can have direct physical effects, including miscarriage, fetalfractures and rupture of the uterus, and psychological effects including depression, anxietyand post-traumatic stress disorder [139]. Women exposed to violence in pregnancy are atincreased risk of suicide and attempted suicide, severe mental illness, and alcohol anddrug misuse, reflecting the complex nature of the relationship between exposure to thisadversity, and adverse pregnancy outcomes [139].Serious Mental IllnessDefinitions and New Zealand DistributionWomen with serious mental illness, such as schizophrenia and bipolar disorder,experience higher rates of morbidity and mortality, and suboptimal access to healthcarecompared to the general population [205]. Te Rau Hinengaro, the New Zealand MentalHealth Survey, estimated a 12 month prevalence of serious mental disorder (defined bythe level of impairment, and the presence of bipolar I disorder or substance dependence ora suicide attempt in conjunction with any disorder) of 5.4% (95% CI 4.7 to 6.1) for women,compared to 3.9% (95% CI 3.3 to 4.6) for men [206]. The prevalence was higher amongyounger people (16–24 years: 7.2%, 95% CI 5.7 to 9.0; 25–44 years: 5.8%, 95% CI 5.0 to6.6; 45–64 years: 3.8%, 95% CI 3.1 to 4.5; 65 years and over: 1.1%, 95% CI 0.5 to 2.0),suggesting that serious mental disorders are more common among women of childbearingage.Associations Between Serious Mental Illness and Pregnancy OutcomesWomen with serious mental illness appear to be at increased risk of adverse pregnancyand birth outcomes, and subsequent impaired neurodevelopment in the child [207]. Anumber of studies have identified increased risks of perinatal death in babies of womenwith psychiatric illness [205,208]. A Danish cohort study of 1.45 million live births and7,021 stillbirths during 1973 to 1998, identified from national registers, found that risks ofstillbirth and neonatal death were raised for virtually all causes of death for all of thematernal psychiatric diagnostic categories [208]. This lack of specificity suggests that theassociation between maternal mental illness and adverse outcomes is likely to be linkedwith maternal mental illness in general, rather than the illnesses themselves. Women withserious mental illness are more likely to experience a range of other risk factors foradverse outcomes, including smoking, alcohol and illicit drug use, exposure topsychotropic medication, poor compliance with folate supplementation, poor nutrition andfailure to access antenatal care [205,207].Maternal mental illness has also been linked to poorer outcomes for women. The 2012PMMRC report found that in New Zealand between 2006 and 2010, suicide was the mostfrequent cause of maternal death, accounting for 13 of the 57 recorded deaths in this timeperiod [138]. While the small number of deaths makes it difficult to draw firm conclusions,the Maternal Mortality Review Working Group (MMRWG) identified a number of commonfeatures including: a history of mental illness and contact with mental health services in theperinatal period in seven of the women who died, all of whom had experienced worseningpre-existing illness in the perinatal period; the presence of alcohol or drug use in over halfthe women who died; and a known history of family violence in approximately half thecases. Barriers to accessing and engaging with care was the most commonly identifiedcontributing factor (9 of 13 cases) and a lack of coordination and information sharingbetween services was also identified as a contributory cause [138,209].Understanding the Link Between Serious Mental Illness and Adverse PregnancyOutcomesThe links between exposure to serious mental illness and adverse pregnancy outcomesare complex. Research suggests that adverse outcomes are not linked to specific mentaldisorders, but instead represent complex causal pathways involving exposure to a varietyof risk factors linked to mental illness in general [205,207,208]. These pathways suggest aIn-Depth Topic: Adversity in Pregnancy - 285